Every finding on record at Mountain View Post Acute

Based on observation, interview, and record review, the facility failed to ensure inventions were implmented to safeguard, protect, and prevent the elopement (an instance where a resident leaves the facility without authorization and/or necessary supervision) for 1 of 3 residents (Resident 1) reviewed for accidents and hazards. This deficient practice placed residents at risk for serious injury and the potential for future elopements.Findings included.Review of the facility policy titled Wandering and Elopements, revised in March 2019, showed residents who were identified as at risk for wandering or elopement would have strategies and interventions to maintain residents' safety on their care plan.Resident 1Review of the medical record showed Resident 1 admitted to the facility, on 01/08/2026, with diagnoses of severe dementia (a loss of memory, language, problem-solving, and other thinking abilities) with agitation (feeling of irritability or mental distress), anxiety (feeling of fear, dread, and uneasiness), and restlessness (the physical or mental inability to relax or sit still).Review of the Elopement Assessment, dated 01/12/2026, showed Resident 1 was a high risk for elopement due to wandering behaviors and cognitive impairment.Review of Resident 1's elopement care plan, initiated on 01/13/2026, showed interventions included placement of a Wander Guard (a device worn on the wrist that interacts with the Wander Guard alarm system installed at all exit doors to alert staff of a potential resident exiting the facility) on Resident 1 and for staff to check its functionality every shift.Review of the comprehensive assessment, dated 04/16/2026, showed Resident 1 had severe cognitive impairment, required set up for dressing, personal hygiene, toileting, eating, and was independent with ambulation.Review of the nursing Progress Note (PN), dated 05/09/2026 at 6:01 PM, showed Resident 1 had been wandering and exit seeking throughout the day, tried to follow families and go out while the door is open, and tried to go out multiple times (nursing assistants) NAs and nurses redirected them.Review of the facility's Incident Report Log for May 2026 showed Resident 1 had an incident of elopement on 05/09/2026 at 10:36 PM.Review of the facility investigation for the elopement incident on 05/09/2026 showed Resident 1 was last seen at 9:00 PM by evening shift staff and was noted to be unaccounted for by night shift staff at 10:30 PM. The investigation showed Resident 1 was located by local Law Enforcement (LE) walking east on Mountain View Avenue (the road the facility was located) and was returned to the facility at 11:01 PM.Review of the nursing PN, dated 05/09/2026 at 10:36 PM, showed Resident 1 was returned to the facility by local LE, was wet and cold, appeared (they) had fallen into a ditch, had a skin tear to right foot, and Wander Guard was in place to right arm and was functional.Review of the medical record, on 05/21/2026, showed Resident 1's Medication Administration Record (MARs) for May 2026 with documentation of their Wander Guard device as functioning and in place.On 05/21/2026 at 12:45 PM, an observation showed a drainage ditch that ran parallel to road between the facility parking lot and the sidewalk on Mountain View Avenue. The ditch had one-and-a-half feet of water and multiple areas of four-foot-tall grass-like brush growing in it.During an interview, on 05/21/2026 at 3:10 PM, Staff A, Administrator, stated the normal process was for the maintenance staff to test the Wander Guard alarms at all the exits weekly, but the Maintenance Director had been out on leave for the past four weeks. Staff A stated the facility had a temporary maintenance employee, but they were unsure if they had been doing the tests prior to the incident on 05/09/2026.During an interview, on 05/21/2026 at 3:30 PM, Staff B, Director of Nursing, stated staff were alerted to the front door frequently throughout the day due to several residents with Wander Guard devices wandering near the front door and the adjacent visiting area. Staff B stated it would have been difficult for staff to see if Resident 1 had exited the front doors or was in the parking lot due to the time of night the 05/09/2026 incident occurred.During an interview, on 05/21/2026 at 4:15 PM, Staff C, Registered Nurse (RN), stated they worked the night shift on 05/09/2026. Staff C stated the Wander Guard alarm at the front door would alarm frequently throughout the day when residents with Wander Guard devices came close to the doors. Staff C stated they were present when Resident 1 was discovered to be missing and there were no Wander Guard alarms activated at any of the facility exits. During a concurrent observation and interview, on 05/21/2026 at 4:30 PM, Staff B, Director of Nursing, demonstrated the Wander Guard system at all five facility exits, the notification panels in the East, West, South hallways and at the Nurse's Station. Staff B showed the Wander Guard exit door testing log for December 2024 and January 2025 and stated it was an example of the tool the Maintenance Director documented their weekly testing on. Staff B stated they were trying to locate the most current testing logs but had not found them yet. Current testing logs were not provided by the facility.Refence: WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to protect the residents' right to be free of abuse for 1 of 3 residents (Resident 1) reviewed for abuse. This deficient practice placed residents at risk for physical injury, psychosocial distress, and feeling unsafe in their home.Findings included.Review of the facility policy, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, revised in January 2025, defined abuse as the willful infliction of injury to another person and defined willful as a deliberate action.Resident 1Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or impaired ability to move) of the right side and Chronic Obstructive Pulmonary Disease [(COPD) a lung disease that makes it difficult to breathe due to damaged, inflamed, and narrowed airways]. Review of the comprehensive assessment, dated 02/10/2026, showed Resident 1 had moderate cognitive impairment and required the assistance of two people for bed mobility, dressing, and transfers.Resident 2Review of the medical record showed Resident 2 admitted to the facility on [DATE] with diagnoses of major depressive disorder (mental health condition characterized by persistent low mood and deep sadness), anxiety disorder (mental health condition characterized by excessive and uncontrollable fear or worry that interferes with daily life), and obsessive compulsive disorder (mental health condition characterized by repetitive intrusive thoughts and urges to repeat certain behaviors). Review of the comprehensive assessment, dated 02/01/2026, showed Resident 2 was cognitively intact and was independent with transfers and mobility using a wheelchair or walker.Review of the facility incident log showed a Resident-to-Resident altercation incident occurred, on 04/20/2026 at 6:55 PM, between Resident 1 and Resident 2 in room [ROOM NUMBER].Review of the facility investigation for the above incident showed Resident 1 and Resident 2 were roommates in room [ROOM NUMBER], and the altercation started with verbal aggression from Resident 2 toward Resident 1 due to Resident 1's television volume. The verbal altercation escalated, Resident 2 ambulated over to Resident 1 who was laying in their bed and physically hit Resident 1 in the mouth. The investigation showed staff intervened, separated the residents, assessed for injuries, and notified local law enforcement.During an interview, on 05/01/2026 at 1:50 PM, Resident 2 stated they recalled hitting Resident 1 in the mouth because Resident 1 was mouthing off and dared me to hit them. Resident 2 stated they knew hitting other people was wrong, but sometimes their (Resident 2's) anxiety caused them to react aggressively. Resident 2 stated they usually just yell when their anxiety was out of control, but this time they (Resident 2) reacted physically. Resident 2 stated they felt they would be less triggered now that they had a private room and more personal space from others.During an interview, on 05/01/2026 at 2:15 PM, Resident 1 stated they were watching television in their room on the day of the altercation when Resident 2 became agitated and was yelling about the volume. Resident 1 stated they got tired of listening to them holler and said they (Resident 2) should do something about it. Resident 1 stated they saw Resident 2 walk over to the side of their bed and then Resident 2 hit Resident 1 on the left side of the face. Resident 1 stated they did not trust Resident 2 and was glad they moved to another room.During an interview, on 05/01/2026 at 4:10 PM, Staff B, Director of Nursing, stated Resident 2 had a history of verbal outbursts when they were triggered by a lack of control in a situation, but had not seen it become physical until now. Staff B stated Resident 2 had been out of the facility earlier in the day for a medical procedure and was likely overstimulated and easily triggered. Staff B stated Resident 2's behavior was not acceptable.During an interview, on 05/01/2026 at 4:40 PM, Staff A, Operations Manager, stated resident abuse of any kind was not acceptable. Reference: WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to implement components of their infection prevention and control precautions regarding, A) the water management program (WMP) control measures (actions or steps taken), identified to reduce the potential growth/spread of Legionella (a bacteria that can cause a severe respiratory disease) in water, when not within acceptable ranges for 1 of 1 WMP reviewed for infection control and, B) respiratory devices were not cleaned/disinfected for 1 of 3 Residents (Resident 30), reviewed for respiratory care. This failure placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included .Review of the facility's policy titled, Legionella WMP, reviewed November 2025, showed that proactive steps were established to provide an .infection-free environments for their residents, staff and visitors . The policy showed the facility would identify water system areas/situation at risk or that could lead to legionella growth like, water storage tanks/filters, tubs, medical devices, presence of biofilm (a community of bacteria that stick together and to a surface forming a protective layer), water temperatures, areas of water stagnation (water that stops flowing for an extended period) or infrequently used equipment, ice machines, and ensure specific measures for maintenance/monitoring was completed. The WMP showed the monitoring of control measures were to be completed; monthly flushing of the hot water heaters and weekly temperature monitoring, monthly cleaning/disinfecting of ice machine with visual inspections for biofilm growth, flushing/cleaning/disinfecting of unused sinks/shower heads every 30 days for areas of water stagnation, cleaning/inspection of a resident Whirlpool bathtub when used, and weekly water temperatures throughout the facility. Additionally, the WMP showed that when control measures were not met for the facility's ice machine, the equipment would be taken .out of service, emptied and sanitized before returning back to service, and the facility's WMP was based on the Center for Disease Control and Prevention (CDC) toolkit. Review of the CDC toolkit titled, Developing a WMP to Reduce Legionella Growth and Spread in Buildings, updated 09/30/2025, showed a facility's WMP should identify areas or devices in the building where Legionella might grow or spread to people so the risk can be reduced. The toolkit showed that parts of a building water system that were a risk for spreading contaminated water included water storage tanks, water heaters, shower heads/hoses, ice machines, and infrequently used equipment like eye wash stations. Additionally, the toolkit showed that water stagnation encouraged biofilm growth, which can protect Legionella from heat/disinfectants and was common in water devices that went unused or infrequently used. Review of the control measures documentation presented by Staff C, Maintenance Director, on 02/20/2026 showed, The ice machine cleaning/disinfecting log had been completed monthly for every month in the year 2025, January 2026 and last completed on 02/10/2026. Additionally, the log showed that a deep cleaning of the ice machine was performed on 06/09/2025 and 12/11/2025. No documentation of monthly flushing of the facility's hot water heaters nor weekly monitoring of temperatures. No documentation for flushing, cleaning or monitoring of the facility's unused sink eye washing stations or whirlpool bath tube had been completed. Temperatures throughout different rooms in the facility had been completed weekly for January 2026 through February 2026, but no documentation showed for February 2025 through December 2025. During observations on 02/18/2026 at 11:58 AM and 02/19/2026 at 3:23 PM, showed multiple eye washing stations throughout the facility that had dirty, stained, partially broken labels with the last inspection date of May 2024. During an interview on 02/19/2026 at 7:35 AM, Staff C, stated they were responsible for cleaning the one ice machine in the facility which was completed monthly and a deep clean was completed two times a year. Observations of the ice machine on 02/19/2026 at 1:48 PM, located in the east hallways dining room showed, that under the main lid of the ice bin was a slimy/wet, spotty, blackish/brown substance, resembling mold, interconnected in patches and noted on the underside of the ice bin's, white/plastic storage retainer plate (to secure or hold different items in place) which span five to six inches (a unit of measure) long by one to two inches wide. Additionally, the ice machine water filter was labeled with the date last changed of 03/24/2025. During an interview on 02/19/2026 at 1:52 PM, Staff C showed the control measures documentation and stated the ice machine was deep cleaned two times a year by the company that serviced the machine and that was also when the ice machines filter would be changed. Staff C stated they were the only staff in the facility that cleaned/disinfected the one ice machine. During a concurrent observation and interview on 02/19/2026 at 1:56 PM, Staff C and the surveyor observed the ice machine located on the east hallway. Staff C stated their process for cleaning and maintaining the ice machine was to check the digital display on the machine for errors, take out the ice from inside the bin and would then place the machine on an internal cycle that cleaned and disinfected itself, which was what Staff C completed on 02/10/2026. Staff C opened the ice machine's storage bins lid and noted the blackish/brown substance and stated the substance was not on the upper storage retainer plate before and that it needed to be .cleaned out . Staff C stated the blackish substance should not be there and that it might be in other parts of the ice machine which would require the staff to take off the upper panel of the ice machine to see. Additionally, after observing the ice machine water filters date of 03/24/2025 written on the filter, Staff C stated they were unaware of the filter not being changed for 10 months and 26 days and the company that serviced the ice machine should have changed it out the filter two times since that date, .they missed changing it out. After observing the ice machines current state, Staff C stated, I don't think that it's serious enough to shut it down, but would reassess after opening the ice machines top hatch further to see if more of the slimy blackish/brown substance was in that section of the ice machine as well. During an interview on 02/19/2026 at 2:12 PM, Staff W, Nursing Assistant (NA), stated they had just started their NA evening shift at 2:00 PM, and the facility had one ice machine in the east hallway dining room which was utilized to fill up other ice chest/coolers on each of the hallways throughout the facility. Additionally, Staff W stated the ice within the coolers was changed once every shift or three times a day. During a concurrent observation of the ice machine and interview on 02/19/2026 at 2:25 PM, Staff A, Regional Nurse, the brown slimy substance had the potential to be biofilm growth, the ice machine was not clean and needed to be disinfected. Staff A stated the facilities WMP legionella control measures would not be within acceptable ranges due to the current state of the ice machine and that Staff C should have taken the machine out of service so that residents were not served ice that could be contaminated. Staff A stated the correct process was not followed. During an interview on 02/19/2026 at 2:54 PM, Staff C stated they did not have documentation of the facility control measures for flushing/temperature monitoring of the hot water heaters, the flushing, cleaning/monitoring of unused sink eye washing stations or whirlpool bathtub, nor logs of the temperatures throughout the facility for 2025. Staff C stated they were aware of the eye washing stations not being monitored or inspected since May 2024. Staff C stated the WMP control measures were not being monitored per the facility's process. Respiratory Devices Resident 30Review of the medical record showed Resident 30 admitted to the facility on [DATE] with diagnoses to include heart failure, obstructive sleep apnea (a chronic disorder where throat muscles relax excessively during sleep, causing the airway to close and breathing to repeatedly stop and start), and the need of assistance with personal care. The 01/11/2026 comprehensive assessment showed Resident 30's cognition was intact, they required a continuous positive airway pressure machine (CPAP, a machine that delivers pressurized air to keep the airway open when asleep by use of mask, and tubing) and required substantial assistance of one staff member for upper body dressing. During an observation and concurrent interview on 02/18/2026 at 11:00 AM, a CPAP machine was sitting on the right side of the Resident 30 on their nightstand. The undated mask and tubing were laid across the nightstand on top of the residents clothing, lotion and paperwork. Resident 30 stated they had not seen staff clean their mask or machine, but that the nurses on shift would place water in the machine before giving the mask to them when using their CPAP while. Review of the physician orders dated 07/05/2025, showed nursing staff were to Clean CPAP mask, tubing, and machine with soap & water, every week. Once a day every Thursday for weekly cleaning and to Check CPAP tubing daily prior to administration for damage/non-function. During an observation and concurrent interview on 02/22/2026 at 3:04 PM, Resident 30 was lying in bed watching television, their CPAP mask and tubing on the floor. The resident stated they have not had a change of mask or tubing; they were unsure if staff had cleaned the reservoir of the machine. During an interview and concurrent observation on 02/22/2026 at 3:12 PM, Staff H, Licensed Practical Nurse (LPN), acknowledged that Resident 30's CPAP mask was on the floor and stated the resident CPAP mask should not be on the floor. Staff H stated Resident 30's CPAP mask and tubing should be cleaned and, in a bag, when not in use to keep it clean for the resident's next use. Staff H stated the assigned nurse would place the CPAP mask on for the resident when they want to sleep, that nursing assistants do not place the masks. During an interview on 02/22/2026 at 3:44 PM, Staff A, Regional Nurse, stated the expectations were care be done for all residents, physician orders and resident care plans be followed. Reference: WAC 388-97-1320(1)(a)(2)(b)

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. The failure to consistently monitor kitchen refrigerator temperatures for 2 of 2 kitchen refrigerators, and the failure to ensure undated/expired foods were discarded for 1 of 1 nutritional refrigerator (resident snack refrigerator), placed residents at risk for ingestion of contaminated food or beverages, cross contamination, and potential of food borne illness. Findings included . Review of the Washington State Retail Food Code dated January 18th, 2023, showed Food must be protected from contamination by preparing and storing food as follows: In a clean, dry location, where it is not exposed to splash, dust, or other contamination. Records must be monitored to verify that the critical limits required for food safety are being met. Normal refrigerator temperature requirements are 41 degrees Fahrenheit to 45 degrees Fahrenheit. Review of the facility policy dated 08/01/2025, titled Resident Food from Outside Source showed Refrigerated food items from an outside source will be stored with the following information on it: Date product was brought in the facility Name of product Resident name and room number Refrigerated foods that are unlabeled or undated, when noted will be discarded. During observation and concurrent interview on 02/17/2026 at 9:32 AM, Staff U, Dietary Manager, acknowledged the inconsistent temperatures logged on the kitchen refrigerators. Staff U stated they had implemented a sign as a reminder for staff but can see they were still having trouble. During an observation on 02/18/2026 at 11:58 AM, the nutritional refrigerator located in the south hall contained unlabeled and expired foods. One opened jar of Tostito cheese with no date when opened, the manufacturers dated had been rubbed off. One opened jar of Marmalade jam, no open date on the jar. One large Ziplock bag that contained a peanut butter sandwich, ensure and cup of canned fruit in a bowl there were no dates on the contents in the bag or on the bag. One piece of a store-bought carrot cake with expiration/sell-by date of 1/23/26 (26 days past the sell-by date). During an observation and concurrent interview on 02/19/2026 at 8:40 AM, Staff V, Cook, stated they were aware the refrigerator logs had multiple days of no monitoring and they tried to remember to check the temperatures daily. Staff V stated it was important to monitor all temperatures to ensure the integrity of the food. Staff V stated as far as they know the kitchen staff were not responsible for cleaning that nutritional fridge. Staff V stated kitchen staff refill the nutritional refrigerator with the snacks. During an observation on 02/22/2026 at 3:12 PM, the nutritional refrigerator located in the south hall contained unlabeled and expired foods. One opened jar of Tostito cheese with no date when opened, the manufacturers dated had been rubbed off. One opened jar of Marmalade jam, no open date on the jar. One large Ziplock bag that contained a peanut butter sandwich, ensure and cup of canned fruit in a bowl there were no dates on the contents in the bag or on the bag. One piece of a store-bought carrot cake with expiration/sell-by date of 01/23/2026 (30 days past the sell-by date). During an interview on 02/22/2026 at 3:44 PM Staff A, Regional Nurse, stated that there was an expectation for the kitchen staff to ensure the nutritional fridge was stocked and cleaned. Staff A stated the food items were everyone's responsibility to ensure dates and names were placed on the food item to ensure staff were aware of when the items were brought into the facility. Reference: WAC 388-97-1100 (3)

Based on interview and record review the facility failed to implement their abuse/neglect policies and procedures to identify allegations of neglect filed as grievances for 10 of 44 grievances from 12/01/2025 to 02/23/2026) reviewed for neglect allegations. The facility did not provide a thorough investigation into the allegations of neglect to determine if further action to protect the residents was required. The lack of recognizing allegations of neglect and taking appropriate action placed residents at risk for a deterioration in their physical and or mental health. Findings included. Review of Nursing Home Guidelines Prevention and protection, Incident Identification, Investigation, and Reporting The Purple Book dated October 2015 (sixth edition), showed the definition of neglect as; an individual or entity with a duty of care fails to provide goods and services that maintain resident's physical and mental health. Record review of the facility grievances from 12/01/2025 to 02/23/2026 showed ten grievances that were not identified as allegations of neglect and not provided a thorough investigation or follow up if indicated as required. 12/2/2025 Resident with risk of skin breakdown, was ignored by staff after requesting assistance for incontinent care. 12/2/2025 The resident was soaked through clothing with a puddle of urine under their wheelchair. Requested assistance four to five times but no assistance was given. 12/15/2025 A resident received no meal when going to dialysis. 12/16/2025 The facility neglected to get the resident to their surgical appointment which resulted in having to wait an additional three months to have surgery. 12/23/2025 Resident's husband requested help as wife was incontinent and did not receive timely assistance. 01/19/2026 Resident did not receive meal tray on four occasions. 01/31/2026 Concerns reported with frequency of wound care and handling of wound care supplies. 02/06/2026 Meal not sent with dialysis resident. 02/09/2026 Resident did not receive lunch meal and does not get assistance from staff with eating. 02/19/2026 resident wanted to get up for meal staff stated would return and assist them however never returned, resident remained in bed. During an interview on 02/18/2026 at 5:15 PM, Staff E, Social Services Director, stated they were the Grievance Officer and after reviewing the initial grievance would be sent to the appropriate department for follow up as indicated. Staff E further stated if the allegation was related to abuse or neglect, the process was to forward to the Director of Nursing to complete an investigation. In an interview on 02/20/2026 at 1:40 PM, Staff A, Regional Nurse, reviewed the grievances and stated the facility should have recognized the grievances as allegations of neglect. The expectation was to escalate allegations made on grievances to an incident investigation. Reference WAC 388-97-0540(2)(a)(b)

Based on interview and record review, the facility failed to ensure investigations were completed and/or thorough for 3 of 5 residents (Resident 22, 4, and 52) reviewed abuse. The failure to initiate and complete thorough investigations placed residents at risk for unidentified accidents, abuse/neglect and serious injuries. Findings include . Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), all incidents of abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property must be thoroughly investigated. A thorough investigation was a systematic collection of a review of evidence/information that describes and explains an event or a series of events to determine what occurred and make necessary changes to a resident's plan of care and services to prevent recurrence. The investigation should include the who, what, when, why and how, of the incident and establish a reasonable cause within 24 hours of the incident. Additionally, evidence of the investigation must be readily available to state licensing and certification staff and others according to their authority. Resident 22 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include dementia with agitation, anxiety, insomnia and need for assistance with personal care. The 12/18/2025 comprehensive assessment showed Resident 22 had moderately impaired cognition and required supervision/touch assistance of one staff member for walking distances of 10 feet (ft.) to 150 ft. During an observation on 02/19/2026 at 1:16 PM, Resident 22 was walking independently, to the East hallway and entered room [ROOM NUMBER]. During an observation on 02/20/2026 at 12:13 PM, Resident 22 was independently walking down the [NAME] hallway looking for their gold cup; the resident stated someone had taken it. Staff J, Activities Director, offered to assist the resident and redirected them back to their room to find their cup. During an observation on 02/22/2026 at 3:07 PM, Resident 22 was sitting on a chair in the East hallway drinking from a covered cup. The resident stated they were doing well, but the person next to them was crazy and getting on their nerves. There was no other resident sitting next to Resident 22. During an interview on 02/22/2026 at 3:09 PM, Staff H, Licensed Practical Nurse, stated the resident had a history of delusions, always wandering and required supervision. Review of the facility's reporting log dated January 2026, showed Resident 22 was involved in a resident-to-resident altercation on 01/16/2026. Resident 22 entered room [ROOM NUMBER], Resident 52 grabbed Resident 22 by the wrist and escorted them out of their room into the East hallway, holding onto the resident until an unnamed staff member intervened. Review of the facilities investigation involving Resident 22 in a resident-to-resident altercation dated 01/16/2026 showed no witness statements to reflect a thorough investigation. Resident 4 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included, diabetes (too much sugar in the blood), recent below the knee amputation and pulmonary fibrosis (scaring of lung tissue which makes it difficult to breathe). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact, had no memory deficits. The resident required total assist for showering and substantial staff assistance for transfers, mobility and dressing. During an interview on 02/17/2026 at 2:43 PM, Resident 4 stated they had a fall on Saturday 02/14/2026. The resident explained staff had assisted them to their wheelchair and placed them too close to the edge of the seat which caused them to slide out and onto the floor. The resident further stated they had not had a fall in a long time and wondered why no one had come to talk to them about the fall so they could tell them what had happened. Resident 4 stated they felt the nursing assistant who had transferred them to their wheelchair needed more training. Record review of a facility incident report dated 02/14/2026 at 1:10 PM documented the resident had slid out of their wheelchair while trying to maneuver in their room. The etiology of the fall was documented as related to the resident's behaviors of wandering and impulsiveness. Continued review of Resident 4's fall incident report showed no interviews with witnesses, or the resident. The resident's wheelchair was not assessed to ensure it was functioning properly and in good working order. Additionally, the residents' environment was not assessed for possible hazards that could be modified and mitigate the risk of additional falls. Review of Resident 4's progress notes from 02/14/2026 to 02/22/2026 showed no documentation of follow up on the fall or monitoring of the resident for possible residual injuries. Review of the care plan dated 11/10/2025 showed no documentation that the resident exhibited wandering or impulsive behavers as identified risks for the fall. During an interview on 02/20/2026 at 11:10 AM, Staff A, Regional Nurse stated that Resident' 4's incident report was not complete or thorough as it had no witness statements and did not adequately establish the cause of the fall. Staff A stated there should also have been alert charting in the resident's progress notes to monitor for further injuries after the fall. Resident 52 Review of the medical record showed the resident was admitted to the facility with diagnoses including heart failure and dementia (a decline in mental ability severe enough to interfere with daily life). The 12/21/2025 comprehensive assessment showed Resident 52's cognition was moderately impaired and required the assistance of one staff member for Activities of Daily Living (ADLs). Further review showed Resident 52 had no behavioral symptoms directed toward others. Review of the facility's reporting log, dated January 2026, showed Resident 52 was involved in a resident-to-resident altercation with Resident 22 on 01/16/2026. After Resident 22 entered room [ROOM NUMBER], Resident 52 grabbed Resident 22 by the wrist and escorted them out of their room into the East hallway. When an unnamed staff member intervened, Resident 52 attempted to bend the unnamed staff members wrist and threatened to punch them in the face. Review of the facility investigation of a resident-to-resident altercation involving resident 52, dated 01/16/2026 showed no evidence of a thorough investigation. The investigation lacked witness statements from staff members and interviews with other residents to determine the circumstances surrounding the incident. During an interview and observation on 02/19/2026 at 4:20 PM, Staff D, Resident Case Manager, stated they were unsure of any witness statements, and would have to speak to the Director of Nursing Services (DNS). Staff D stated the DNS or the Social Services Director (SSD) completed the investigations and would obtain witness statements for investigations. During an observation and interview on 02/20/2026 at 11:42 AM, Staff A, Regional Nurse, reviewed the facility incident report and acknowledged the investigation report as incomplete without witness statements. Reference: WAC 388-97-0640 (6)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure there were sufficient numbers of competent nursing staff to provide care and services for 4 of 4 residents (Residents 5, 2, 3, and 35 ) as evidenced by failures related to Resident Rights, Activities of Daily Living (ADLs), Quality of Care, and Prevention or Decrease in Range of Motion. Additionally, reports in the facility grievance logbook showed allegations of neglect in care and staff interviews provided additional evidence of insufficient staff. This failure placed residents at risk of not having their needs met and potential/actual negative outcomes to their physical and mental health. Review of the 2025 Facility Assessment, updated 01/13/2026, showed on Section A. Function and Mobility for Activities of Daily Living (ADL) excluding bathing which required assistance was 87% of the facility residents. Additionally, ADLs excluding bathing for residents who required maximal assistance of two plus staff was 45.8% of facility residents. Residents that required mobility assistance with contractures (a permanent shortening of the muscle or tendons that leads to stiffness and limits movement of a joint or body part.)F 550 Resident Rights related to Dignity The facility failed to provide an environment that enhanced and prompted a dignified lifestyle. Resident 5 On 02/19/2026 from 2:35 PM to 3:38 PM Resident 5 did not receive timely care for a bowel incontinence episode for 63 minutes despite having their call light on and requesting assistance multiple times. The resident was informed by staff that they had to wait until staff were available to assist them. Resident 5 stated they were embarrassed and upset at having to wait so long for assistance. F 677 Activities of Daily Living Care for Dependent Residents The facility failed to provide care for residents that required assistance in nail care and oral care. Resident 2 On 02/17/2026 at 10:48 AM Resident 2 was observed to have long yellowish jagged fingernails on their left hand. The lack of nail care resulted in harm to the resident's left hand as the un-cut fingernails dug into their left thumb causing injuries to the area. Resident 3 During an observation on 02/18/2026 at 9:07 AM, showed the resident in their room in bed. Their bottom teeth were yellow with a brownish grime substance on them. Additionally, they had foul smelling breath and dried cracked lips. Follow up observations on 02/19/2026 at 8:43 AM, 02/19/2026 at 2:09 PM and 02/22/2026 at 9:28 AM showed the resident with yellow teeth, dry cracked lips and foul breath. During an interview on 02/18/2026 at 9:30 AM an Anonymous Staff stated they did not have time to perform oral care for the residents. F 684 Quality of Care the facility failed to provide care that met professional standards. Resident 35 An observation on 02/18/2026 showed Resident 35 sitting in their wheelchair and their left fourth finger was bent at the knuckle in a fixed position. Review of the record showed the resident had experienced a fall on 07/28/2025 at 12:10 PM which resulted in a fracture to the left fourth finger. A splint was ordered on 08/01/2025 pending follow up with orthopedics. Review of Resident 35's medication administration record showed from 08/01/2025 to 08/26/2025 the resident's left fourth finger was not put in a splint as ordered. Record review of clinic notes from an orthopedic clinic showed the resident's finger was healed in a tilted fixed state and would require surgery to correct. Additionally, the note showed the resident should have been seen earlier at the clinic as the outcome of surgery to fix the resident's finger could have been avoided. F 688 Prevent/Decrease in Range of Motion (ROM)/Mobility The facility failed to ensure staff provided care and services to maintain ROM and prevent contracture. Resident 2 In an observation on 02/17/2026 at 10:48 AM showed the resident lying in bed with their left hand in a clutched fixed position. It was also noted to have a strong odor related to the skin-on-skin contact of the fingers on the palm of the hand. Review of the care plan dated 12/04/2025 showed the resident was not receiving interventions to their left hand with no restorative nursing for splinting or range of motion program to avoid further decline in left hand mobility and worsening contractures. Grievance Logbook Record review of the facility grievance logbook showed five grievances filed by residents and families related to not receiving timely assistance to meet their basic care needs. 12/2/2025 Resident with risk of skin breakdown, was ignored by staff after requesting assistance for incontinent care. 12/2/2025 The resident was soaked through clothing with a puddle of urine under their wheelchair. Requested assistance four to five times but no assistance was given. 12/23/2025 Resident's husband requested help as wife was incontinent and did not receive timely assistance. 02/09/2026 Resident did not receive lunch meal and did not get assistance from staff with eating. 02/19/2026 resident wanted to get up for meal staff stated would return and assist them however never returned, resident remained in bed. Staff Interviews During an interview on 02/18/2026 at 11:47 AM with an anonymous caregiver stated there was not enough staff to provide even basic care for the residents. The caregiver further stated they had reported their concerns related to inadequate staffing however nothing gets done about it. During an interview on 02/22/2026 at 10:06 AM, Staff Z, Nursing Assistant, stated they were alone on the East Hall from 6:00 AM to 8:00 AM because we do not have enough staffing. Saff Z stated they were supposed to provide quality care to the residents but were not able to, related to a pattern of not having sufficient staffing. It is not fair to . the residents. Record review of the day shift daily staffing sheet for the East Hall on 02/22/2026 showed Staff Z had worked alone from 8:00 AM to 10:00 AM and was responsible for providing care to 23 residents. Reference WAC 388-97-1080(1), 1090(1)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 8 of 12 resident rooms (Rooms 3, 4, 5, 6, 9, 18, 21 and 25), 1 of 1 utility room (East hallway) and 1 of 1 kitchen reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment. Findings included . Rooms room [ROOM NUMBER]: observation on 02/23/2026 at 11:15 AM, showed the bathroom door had an area measuring 2 1/2 feet (a unit of measure) by 10 inches (a unit of measure) where the paneling had been removed, exposing bare wood. room [ROOM NUMBER]: observation on 02/17/2026 at 10:27 AM, showed a five-foot scratch extending down the wall to the left of the entry. Multiple areas of paint were missing, and the drywall was exposed. room [ROOM NUMBER]: observation on 02/17/2026 at 10:27 AM, showed a six-foot area of the wall to the left of the entrance missing paint. A metal plate located mid-wall near the floor was pulled away from the surface, leaving sharp edges exposed. The bathroom walls were observed with missing chunks of drywall, exposing the underlying structure. room [ROOM NUMBER] (Bed A): observation on 02/23/2026 at 11:15 AM, showed multiple deep scratches and chipped paint on the wall adjacent to the left side of the bed, leaving the drywall exposed. The bathroom wall surrounding the grab bar was observed with large sections of missing drywall. room [ROOM NUMBER]: observations on 02/17/2026 at 10:55 AM and on 12/18/2026 at 1:13 PM, showed a metal plate located mid-wall near the floor with the corners pulled away from the wall, leaving sharp edges exposed. room [ROOM NUMBER] (Bed B): observation on 02/17/2026 at 1:43 PM, showed a wall on the right side of Bed B had chipped paint, multiple deep gouges with drywall exposed. room [ROOM NUMBER]: observation on 02/17/2026 at 2:34 PM, showed a metal plate located mid-wall near the floor with the corners pulled away from the wall, leaving sharp edges exposed room [ROOM NUMBER] (Bed A): observation on 02/17/2026 at 3:27 PM, showed the room door with multiple scratches leaving splintered wood pieces on the front and back of the door. Closet A had no closet door, clothing protruding out of the closet. The back wall by Bed A had multiple chips of paint and exposed drywall. Utility Room (East Hall) Observation on 02/17/2026 at 10:58 AM, Showed multiple dirty commodes stored from the entry to the back of the room, leaving insufficient space to walk or maneuver. Multiple basins containing yellow and brown substances were observed on the counters and within both the clean and dirty sides of the sinks. The area surrounding the sink faucets were covered in yellow and brownish substances and there was a strong odor of urine. Kitchen During observation and concurrent interview on 02/17/2026 at 9:32 AM, Staff Dietary Manager, acknowledged the ceiling pipes, and the osculating fan had built up of black dirt and dust. Staff U stated they had cleaned the fan the week prior. Staff U stated they were unsure when the last time the ceiling pipes and floors were cleaned. Staff U stated they had stepped into the position three months prior and that kitchen staff completed routine cleaning, but understood maintenance completed the deep cleaning of the kitchen. During an observation and concurrent interview on 02/19/2026 at 12:00 PM, Staff Y, Registered Dietician, acknowledged the kitchen floors dark black/brown grout and missing floor tiles that exposed the concrete underneath. Staff Y stated with the management turnover they were not sure when the kitchen floors were last cleaned. Staff Y stated the flooring had been missing for two years; maintenance began to work on it then stopped, and unsure why. During an interview and concurrent observation on 02/20/2026 at 2:18 PM, Staff C, Maintenance Director, stated they did rounds of the facility and checked on the rooms weekly. Staff C stated all staff communicated any needed repairs for resident rooms verbally and used TELS (an electronic facility system designed for maintenance request). Staff C acknowledged the metal plates and stated they were working on a request to have them removed from the rooms. Staff C stated they did not have a repair schedule for the residents' rooms as it was difficult with a high census. Staff C stated they had no schedule to clean the ceiling pipes/ vents nor the deep cleaning of kitchen floors, as maintenance department was not responsible. During an interview on 02/22/2026 at 3:44 PM, Staff A, Regional Nurse, stated they were aware of the environmental issues of the building. Staff C stated maintenance was also aware and would be working on the facility. Staff A stated the deep cleaning of the kitchen was the responsibility of the maintenance department. Reference: WAC 388-97-3220 (1)

Based on interview and record review, the facility failed to ensure residents/resident representatives (RR) were educated on the potential risk versus benefits when offering the pneumococcal and influenza immunization (specific vaccines that protects against pneumococcal bacteria and influenza viruses that can lead to lung, nose and throat infections) nor documentation that indicated vaccination were offered, accepted or refused for 2 of 5 residents (Resident 22 and 2) reviewed for immunizations with infection control. This failure placed residents at risk of exposure to contagious diseases without the knowledge of the risk/benefits in order to make an informed decision.Findings included .Review of the facility's policy titled, Influenza and Pneumococcal Immunizations, dated 08/01/2024, showed the facility would provide residents with the opportunity to accept or refuse the influenza and pneumococcal vaccines. The policy stated that a resident or RR would complete an immunization informed consent document, were to receive education regarding the benefits/potential side effects of the influenza/pneumococcal immunizations by facility staff and the acceptance or vaccine declinations would be documented in the resident medical record.Resident 22 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include dementia (a progressive disease that destroys the memory and other important mental functions) with agitation, anxiety and insomnia (a sleep disorder). The 12/16/2025 comprehensive assessment showed the resident had a moderately impaired cognition, was offered and declined the influenza/pneumococcal vaccines.Review of Resident 22's immunization informed consent document, dated 12/11/2025, showed the resident had been offered other for the type of immunization, but no documentation of which immunization was noted on the form. The consent document showed that Resident 22's RR had refused the other unknown immunization and was not educated on the potential risk versus benefits or possible side effects regarding both the influenza/pneumococcal immunizations.Resident 2Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or total loss of motor function on one side of the body) of the left side and dementia. The 11/23/2025 comprehensive assessment showed the resident had severe cognitive impairments, did not receive the influenza vaccine and was offered and declined the pneumococcal vaccine. Review of Resident 2's immunization informed consent document, dated 11/17/2025, showed the resident themselves had been offered and accepted/signed to receive the influenza immunization. The consent document showed that no education was completed on the potential risk versus benefits or possible side effects of the influenza immunization with the resident. Additionally, no documentation showed that Resident 2 or a RR had been offered nor educated on the potential risk versus benefits or possible side effects regarding the pneumococcal immunization.During an interview on 02/19/2026 at 12:42 PM, Staff R, Registered Nurse/Infection Preventionist, stated the process for immunization was to offer them to the resident/RR upon admission, obtain history of immunization already received by the resident and have the resident complete an immunization informed consent document which was transferred to an evaluation in the resident medical record. Staff R stated that if a resident was not cognitively intact in order to make the decision, a RR would complete the immunization consent document for the resident. Staff R stated the immunization consent document also showed the resident received education on the potential risk versus benefits or possible side effects regarding both the influenza/pneumococcal immunizations. After reviewing Resident 22's immunizations records, Staff R stated the resident and/or RR were not educated on the potential risk versus benefits or possible side effects regarding both the influenza/pneumococcal immunizations. When reviewing Resident 2's immunization records with the surveyor, Staff R stated they were aware of the resident's severely impaired cognition, and a RR should have completed immunization document and been educated on the influenza and pneumococcal immunizations. Staff R stated the correct process was not followed for offering, educating and documenting resident immunizations. Reference: WAC 388-97-1340(2)

Based on observation, record review, and interview, the facility failed to ensure drugs and biologicals were stored, labeled, and monitored in accordance with professional standards. The facility failed to discard expired or improperly labeled medications on one of three medication carts (East medication cart) and failed to document twice-daily temperature monitoring for 1 of 1 medication refrigerator in medication storage room. These failures placed residents at risk for receiving compromised or ineffective medications and vaccines and negative health outcomes.Review of the Centers of Disease Control and Prevention guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. A review of the temperature logs from 02/01/2026 through 02/16/2026 showed the temperature was being checked once daily on the NOC (night) shift. At the time of the survey, the refrigerator contained the following improperly monitored biologicals: Three vials of Apisol (solution used for tuberculosis sensitivity test) Nine boxes of Fluzone Quadrivalent (a vaccination designed to protect you from the influenza virus), containing 10 single-dose vials per box (Totaling 90 doses). Two vials of Arexvy (a vaccination that helps your body's immune system learn how to fight off the Respiratory Syncytial Virus (RSV- a serious lung infection). During an interview on 02/22/2026 at 12:22 PM, Staff A, Regional Nurse, stated that per regulations, the medication refrigerator must be monitored twice daily if vaccinations are stored within it. Staff A acknowledged this monitoring was not being performed. East medication cart During an observation and concurrent interview on 02/22/2026 at 9:24 AM, with Staff N, Licensed Practical Nurse (LPN), stated they were unsure of when the medication cart had been last audited, they monitored the expiration dates when administering the medications. An observation of the East medication cart on 02/22/2026 at 9:24 AM, showed as follows: 1 bottle of Nitroglycerin (a medication used to treat chest pain) tabs the label was worn off, unable to determine who the medication was for, when it was delivered and when the medication expired. 2 Lantus (a brand of insulin used to control sugar in the blood) insulin pens without a date to show when the medication had been removed from the refrigerator and opened. 1 lispro (a brand of insulin used to control sugar in the blood) insulin pen without a date to show when the medication had been removed from the refrigerator and opened. 1 box of Ferrous sulfate (iron supplement) with an expiration date of 12/2023, there was no label on the box to show who the medication it was, and within the box multiple cards of different medications such as 4 cards (32 tablets) of Ferrous fumarate (iron supplement) 324mg, 4 tablets on a card of anti-diarrhea 2mg, 2 cards (16 tablets) of guaifenesin (cough expectorant medication) 600mg/30mg, and 2 cards (16 tabs) of Ferrous Glutamate (iron supplement). During an interview on 02/22/2026 at 09:30 Staff N, LPN stated the insulin should be dated because the medications were only good for 28-30 days when out of the refrigerator. Staff N acknowledged the box was filled with different medications and stated they did not realize the box had all different medications within it and should be destroyed. During an interview on 02/22/2026 at 9:42 AM Staff B, Director of Nursing Services, stated their central supply staff completed audits on the medication carts, and the pharmacy had just audited the medications carts a month ago. Staff B stated the expectation was that the nurses review dates and ensure insulins are dated when opened. Reference: WAC 388-97-1300 (2)

Based on interview and record review the facility failed to ensure resident grievances were promptly followed up on by coming to a resolution of the grievance for 2 of 5 residents (Residents 5 and 4) reviewed for grievances. Additionally, the facility did not keep the residents updated on the progress of their grievances. This failure placed residents at risk for overall dissatisfaction with their lives and unresolved concerns. Findings included . Record review of a facility policy titled Grievances dated 08/2024 showed, each resident has the right to voice concerns/grievances. The facility will actively seek a resolution to concerns and keep residents updated on the progress. Resident 5 Review of the resident's medical record showed the resident was admitted to the facility with diagnoses which included heart failure (the heart can no longer keep up with the needs of the body), end stage renal disease with dialysis (the kidneys no longer work and require a machine to remove waste from the blood) and diabetes (too much sugar in the blood). Review of the comprehensive assessment dated [DATE] showed Resident 5 was cognitively intact and was dependent on staff for transfers and mobility. Additionally, the resident required substantial assistance for dressing and showers. During an interview on 02/17/2026 at 8:36 AM, Resident 5 stated they did not fill out grievances anymore because no one will follow up on them. The resident stated they had filed a grievance related to not getting enough food when traveling to and from dialysis. They were unable to receive services at the local center therefore had to travel a long way to an alternate center for dialysis services. The resident stated they got really hungry and had requested from the kitchen additional sandwiches to be sent with them instead of just one. Resident 5 stated after filling out the grievance they were approached by Staff B, Director of Nursing, and Staff U, Dietary Manager. Staff B and Staff U had informed them they would only get 'one sandwich, one fruit and one drink to take with them to dialysis.' The resident stated they would not let me explain or listen to me as to why they were requesting additional sandwiches because of the long ride to and from the dialysis center. Record review of a grievance form dated 02/06/2026 showed Resident 5 had filed a grievance related to not getting the sandwiches they had requested from the kitchen for when traveling to and from dialysis. The written follow-up, which was signed by Staff B and Staff U, stated 'met with resident and informed of what they can and can't have.' There was no resolution to Resident 5's concern and the outcome was documented as 'the resident will only receive one sandwich, fruit and a drink, when traveling to dialysis.' During a follow up interview on 02/19/2026 at 8:35 AM Resident 5 stated they did not feel their grievance had been resolved related to their request and were discouraged from filing any additional grievances. Resident 4 Record review of the resident's medical record showed they were admitted to the facility with diagnoses which included diabetes and pulmonary fibrosis (a disease of the lungs when the tissue becomes scarred and damaged). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact, required total assistance for toileting and showers with substantial assistance for dressing. In an interview on 02/17/2026 at 2:34 PM, Resident 4 stated they had filed a grievance related to their meal trays coming out later than usual. Resident 5 stated they had filed the grievance for the whole hall because it had affected all the residents on the south hall who ate in their rooms and some of them had a diagnosis of diabetes and needed to eat earlier to keep their blood sugars stable. The resident further stated it had upset them because no one had explained or asked any of the residents if they wanted a change in their mealtimes. Record review of a grievance form filed by Resident 4 on 12/13/2025 showed the in-room mealtimes had been changed and the residents were receiving their meals approximately one hour later than usual. The grievance form was signed by the dietary department stating 'nursing sets the order of the trays and nursing was responsible to follow up on the concern. Further review showed the form had no additional follow-up comments or actions by the nursing department. In an interview on 02/22/2026 at 10:26 AM Resident 4 stated I still haven't heard anything back about my grievance on late mealtimes. During an interview on 02/20/2026 at 1:40 PM, Staff A, Regional Nurse, stated their expectation was for resident grievances to be appropriately followed up on to resident satisfaction and residents made aware of the outcome. WAC 388-97-0460(2)

Based on interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic (drugs that change brain chemistry to alter a person's mood, thoughts, behavior, or perceptions) medications when they did not consistently attempt non-pharmacological (non-drug, strategies used first to manage mental health symptoms) interventions prior to medication use and failed to adhere to the 14-day limitation for PRN (as needed) psychotropic medications for 1 of 5 residents (Resident 35), reviewed for unnecessary medication. This failure placed residents at an increased risk for falls, medication-related adverse side effects, and unmet care needs. Findings included. Review of the policy titled, Psychotropic Medication, dated 08/01/2025, showed that non-pharmacological interventions would be attempted and documented prior to the use of any PRN psychotropic medication. Orders for such medications would expire in 14 days and would require an in-person assessment by a medical provider, along with supporting documentation, for the order to continue for an additional 14 days. Additionally, any continued use beyond that period would require a physician's justification for a specific timeframe. Review of the medical record showed the resident was admitted to the facility with diagnoses including Parkinson's disease (a condition where the brain gradually loses the ability to control movement properly), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities that were once enjoyable) and panic disorder ( where a person experiences recurrent panic attacks) . The 01/03/2026 comprehensive assessment showed Resident 35's cognition was severely impaired and required the assistance of one-two staff members for Activities of Daily Living (ADLs). Further review showed Resident 35 received antianxiety (a class of drugs used to treat symptoms of anxiety, such as feelings of fear, dread and uneasiness) medication. Review of a physician's order dated 01/02/2026 showed an order for an antianxiety medication to be administered every 24 hours PRN. Review of an order dated 01/21/2026, 19 days after the initial antianxiety medication order, showed instructions to monitor behaviors and to attempt non-pharmacological interventions. Review of the January and February 2026 Medication Administration Records (MAR) showed the PRN antianxiety medication was administered on six occasions in January 2026 and six occasions in February 2026, for a total of 12 administrations with no documentation to indicate that non-pharmacological interventions were attempted or utilized prior to any of the 12 administrations. Review of the physician's orders dated 02/11/2026 showed that the PRN antianxiety medication remained active through February 2026. Further review showed the PRN order was written for 30 days and not limited to 14 days; additionally, there was no documented clinical rationale provided by the practitioner to extend the medication beyond the 14-day regulatory limit. During an interview on 02/22/206 at 12:22 PM, Staff A, Regional Nurse, stated they would expect to see documentation in the Medical Record regarding behaviors and non-pharmacological interventions, or at the very least, a resident's refusal of such interventions prior to the administration of a PRN psychotropic medication. Staff A further stated that for any PRN psychotropic medication lasting longer than 14 days, there should be clear documentation from the physician providing clinical justification for the medication and the extended duration. Reference WAC: 388-97-0620 (1)(a)

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers, incontinent care, oral care, and nail care for 2 of 5 residents (Residents 2 and 3) reviewed for activities of daily living (ADL). The failure to receive adequate showering and grooming care according to the residents' physician orders and care plan placed the residents at risk for unmet care needs, impaired skin integrity, and a potential decline in health. Findings included.Review of the facility's policy titled Activities of Daily Living (ADL), Supporting, revised date March 2018, showed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, elimination, dining and communication. Resident 2 Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including stroke (a loss of blood flow to part of the brain), hemiplegia (severe or total loss of motor function on one side of the body) of the left side, dementia (loss of memory, thinking and the ability to perform daily activities), and need for assistance with personal care. Review of Resident 2's comprehensive assessment dated [DATE], showed the resident had severe cognitive impairment, and was dependent on staff for showering, grooming care, and transfers. Review of Resident 2's physician orders dated 11/19/2025 showed the Licensed Nurse was to check the resident's fingernails and toenails once a week on bath day, trim as needed. Further review of the physician orders showed Resident 2 had weekly skin checks. Review of the nurses' January 2026 treatment administration record (TAR, nurses' documentation of care and treatments given to residents) showed documentation on 01/07/2026, 01/14/2026, 01/21/2026 and 01/28/2026 Resident 2's nail trim was not needed, and they did not have any new skin impairment. Review of the nurses' February 2026 TAR showed documentation on 02/04/2026, 02/11/2026, and 02/18/2026 Resident 2's nail trim was not needed, and they did not have any new skin impairment. Review of Resident 2's January 2026 Nursing Assistant (NA) task flow sheet (nursing assistant documentation of care given to residents) showed the resident had received only one shower that was documented on 01/06/2026. Review of Resident 2's February 2026 task flow sheet showed the resident went six days without a shower. During an observation on 02/17/2026 at 10:48 AM, Resident 2 was lying in bed, kicking their legs up and down in the air, yelling out verbiage difficult to understand. The resident was unshaven with long chin hair; their left hand was in a clutched position. Resident 2 had a foul odor to their left hand; their fingernails were long, jagged, yellow in color. The resident's index and middle fingernails were imbedded (firmly and deeply in a surrounding mass) into their thumb with redness, and scabbing surrounding the fingernails in the thumb. During an interview and concurrent observation on 02/19/2026 at 1:27 PM Staff P, NA, stated Resident 2 yelled out but had never been aggressive with staff. Staff P stated the resident was cooperative with their care. Staff P lifted the resident's left hand from underneath their blanket, the resident's left hand had a washcloth within their clutched fist. Resident 2 had long, yellow, jagged fingernails to their left hand, their index and middle fingernails were imbedded in their thumb. Staff P stated they were unsure how the washcloth was placed in the resident's left hand, that they had not been instructed to do that for the resident. During an observation and concurrent interview on 02/22/2026 at 10:36 AM, with Staff B, Director of Nursing Services (DNS), of Resident 2's left hand. The resident had a washcloth in their clutched fist; there was a foul odor as Staff B lifted their left hand up to assess it. Resident 2 had long fingernails, jagged, yellow in color that were imbedded into their thumb creating reddened indentations and abrasions. Resident 2 had moved to pull their hand away from Staff B with a grimace on their face when their fingernails were pulled out of their thumb. Staff B asked Resident 2 if they had pain when they removed their fingernails from their thumb, the resident had a blank stare and a frown on their face. Staff B lifted the resident's index and middle finger away from their thumb, there were two areas to the thumb. The first area near the second joint of the thumb had an open red area with scabs, the second area near the first joint of the thumb had redness and deep indentation. Staff B stated yes, the fingernails are causing those areas. Staff B stated the resident's fingernails needed to be trimmed, immediately grabbed supplies and trimmed the resident's fingernails. Resident 3 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included history of a stroke (blood flow is cut off from a part of the brain), dementia and diabetes (high blood sugar). Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and required total assistance from staff for all daily care activities. Review of the resident's care plan dated 11/10/2025 showed the resident was to receive daily oral care including applying ointment to their mouth to avoid dry cracked lips. During an observation on 02/18/2026 at 9:07 AM, showed Resident 3 in bed lying on their back. Their lower teeth were yellow with brown colored grime on them, and their lips were dry and cracked. Additionally, their breath had a strong foul odor. In an interview on 02/18/2026 at 9:30 AM an anonymous nursing assistant (NA) stated they were often unable to brush the resident's teeth or provide oral care as they did not have time. During additional observations on 02/19/2026 at 8:43 AM, 02/20/2026 at 8:43 AM, 02/20/2026 at 2:09 PM and 02/22/2026 at 9:28 AM, showed the resident's bottom teeth were still yellow with brown grime, foul breath and dry cracked lips. During an interview on 02/22/2026 at 3:44 PM, Staff A, Regional Nurse, stated that the expectation of staff was that resident care was completed such as brushing teeth, bathing, nail care, and repositioning. Staff A stated the expectation was that nursing staff followed all physician orders and resident care plans. Reference: WAC 388-97-1060 (2) (C)

Based on observation, interview, and record review, the facility failed to ensure a resident received the necessary care and services to maintain their highest practicable physical well-being in accordance with professional standards of care by failing to ensure proper immobilization, and failing to consistently follow physician's orders to oversee the healing process for 1 of 3 resident (Resident 35) reviewed for falls with injury. This failure placed Resident 35 at risk for further injury, impaired healing, and a decline in range of motion (ROM). Findings included. Review of the medical record showed the resident was admitted to the facility with diagnoses including Parkinson's disease (a condition where the brain gradually loses the ability to control movement properly). The 01/03/2026 comprehensive assessment showed Resident 35's cognition was severely impaired and required the assistance of one-two staff members for Activities of Daily Living. Further review of the comprehensive assessment showed Resident 35 had no impairment with their ROM to their upper extremity (hand). During an observation on 02/18/2026 at 9:21 AM, Resident 35 was seated in their wheelchair. Resident 35's left fourth finger was bent at the knuckle in a fixed position. When prompted, Resident 35 was unable to move the finger. During an interview on 02/18/2026 at 9:07 AM, Resident Representative (RR) stated Resident 35 had fallen from their bed, their left arm was trapped underneath them. The RR stated they had to request an x-ray related to Resident 35 complaining of pain to the left hand. The RR stated that Resident 35 sustained a fracture to their left ring finger. The RR further stated they noticed the finger was not healing correctly, which required them to contact the Orthopedic (a medical specialist who focuses on treating injuries of the musculoskeletal system) clinic to schedule an appointment and transport the resident there. The RR stated the Orthopedist was unable to fix the finger because it had healed incorrectly and would require surgery to repair. The RR further stated after discussion with family members they declined the surgery related to the risk factor. Additionally, the RR stated they had noticed a decline in Resident 35's functional ability to the left hand since the fall. Record review of a facility investigation dated 07/28/2025 at 12:10 PM, showed Resident 35 was found on the floor next to their bed lying on their left side. Review of a progress note dated 07/28/2025 at 7:49 PM, showed the provider was contacted to obtain an x-ray per the RR's request. The provider was also updated regarding the finger being swollen with purple discoloration. Order for x-ray was given. Review of a progress note dated 07/29/2025 showed the RR was notified of x-ray results that showed Resident 35's left fourth finger was fractured. Review of a progress note dated 07/31/2025 at 2:36 PM, showed Resident 35 would have a temporary splint placed until a new one arrived. Review of the physician visit dated 08/01/2025 showed an order for splint placement to left fourth finger. Review of the July and August 2025 Medication Administration record (MAR) showed an order to monitor placement of finger splint to left hand every shift. Further review of the MAR from 7/30/2025 to 8/26/2025 showed there were 21 shifts, the splint was not on Resident 35's left fourth finger. Additionally, there were six shifts where no charting was completed to verify placement of the splint. During an interview on 02/19/2026 at 10:54 AM, Staff S, Licensed Practical Nurse, stated they applied a makeshift splint on 07/28/2025. Staff S stated they ordered a splint online. Staff S reported that once the new splint arrived there were specific instructions for correct placement and the components required for use. Staff S stated the splint was frequently placed incorrectly and components required for the back of the finger went missing, rendering the splint ineffective even though nursing staff had been educated on proper placement. Staff S further stated they had updated Staff B, Director of Nursing Services (DNS), regarding these issues, specifically the inaccurate splinting and the finger becoming fixed in position. Review of an office clinical note dated 08/26/2025 (29 days after the fracture was identified) from Kittitas Orthopedics showed Resident 35's left hand had obvious significant deformity of the fourth finger. Further review showed the finger had healed angulated (something that is bent, tilted, or angled away from its normal straight line or position) following the fracture sustained from the 07/28/2025 fall. Additionally, the Orthopedist recommended Resident 35 undergo surgical intervention to correct the deformity. During an interview on 02/19/2026 at 1:41 PM, Collateral Contact (CC1) associated with Orthopedics provider, stated if Resident 35 had been seen earlier the finger would not have been fixed and possibly would not have required surgical intervention. During an interview on 02/22/2026 at 12:22 PM, Staff B, DNS, stated that the facility should try to find something appropriate for the fracture, notify the physician, and obtain an order to see a specialist to prevent the least amount of damage. Staff B stated Resident 35 should have been sent to Orthopedics to weigh the risks and benefits of treatment. Staff B further admitted that a timely consultation may have helped prevent the contracture. Reference WAC: 388-97-1060 (1)(3)(d)

Based on interview and record review, the facility failed to ensure residents and/or resident representative (RR) were offered/educated on the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) immunization (a specific vaccine for the COVID-19 virus) benefits/risks and potential side effects for 2 of 5 sampled residents (Resident 22 and 2) reviewed for immunization status. This failure placed the resident and/or their representative at risk of making an uninformed decision and resident contracting the COVID-19 virus.Findings included .Review of the facility's policy titled, COVID-19, dated 08/01/2024, showed that facility residents were offered the recommended COVID-19 immunization upon admission to the facility. The policy stated that an immunization informed consent would be obtained and education regarding the benefits/potential side effects of the COVID-19 immunization. Additionally, facility staff document resident acceptance or declination of the immunization within the resident medical records.Resident 22 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include dementia (a progressive disease that destroys the memory and other important mental functions) with agitation, anxiety and insomnia (a sleep disorder). The 12/16/2025 comprehensive assessment showed the resident had a moderately impaired cognition and COVID-19 immunization status was not up to date (did not have the current recommended COVID-19 immunization).Review of Resident 22's immunization informed consent document, dated 12/11/2025, showed the resident had been offered other for the type of immunization and not the COVID-19 immunization. Additionally, the resident/RR was not educated on the potential risk versus benefits or possible side effects regarding the COVID-19 immunization.Resident 2Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or total loss of motor function on one side of the body) of the left side and dementia. The 11/23/2025 comprehensive assessment showed the resident had severe cognitive impairments, was not up to date with the COVID-19 immunization.Review of Resident 2's immunization informed consent document, dated 11/17/2025, showed the resident themselves had been offered and accepted/signed to receive the influenza immunization, but no documentation showed that Resident 2 or a RR had been offered nor educated on the potential risk versus benefits or possible side effects regarding the COVID-19 immunization.During an interview on 02/19/2026 at 12:42 PM, Staff R, Registered Nurse/Infection Preventionist, stated the process for immunization was to offer them to the resident/RR upon admission, obtain history of COVID-19 immunizations and complete an immunization informed consent document. Staff R stated the document would then be transcribed onto an electronic evaluation form in the resident medical record. Staff R stated that if a resident was not cognitively intact in order to make the decision a RR would have to complete the immunization consent document for the resident. Staff R stated the immunization consent document also showed the resident/RR receiving education on the potential risk versus benefits or possible side effects regarding both the influenza/pneumococcal immunizations. After reviewing Resident 22 and Resident 2's immunizations records, Staff R stated the residents and/or the RR were not offered nor educated on the potential risk versus benefits or possible side effects regarding the COVID-19 immunization. Staff R stated the correct process for Resident 22 and Resident 2 was not followed with offering, educating and documenting resident COVID-19 immunizations. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure routine and timely dental services were provided and failed to follow through on practitioner-ordered referrals for 3 of 5 residents (Resident 52, 53 and 41) reviewed for dental care. This failure placed the residents at risk for dental pain, nutritional compromise and unmet dental needs. Findings included. Resident 52 Review of the medical record showed the resident was admitted to the facility with diagnoses including heart failure and dementia (a decline in brain functions severe enough to interfere with daily life). The 12/21/2025 comprehensive assessment showed Resident 52 cognition was moderately impaired and required the assistance of one staff member for Activities of Daily Living (ADL)s. During an interview on 02/17/2026 at 10:49 AM, Resident 52 stated they wanted to go to the dentist because they had one tooth in the back on the right side that was worn out. Resident 52 stated they had not seen a dentist since their admission to the facility on [DATE]. During an interview on 02/20/2026 at 10:05 AM, Staff D, Resident Case Manager (RCM), stated the correct process was for all residents to be added to the dental list (the facility's internal tracking system used to ensure all residents receive dental care) upon admission. Staff D stated Resident 52 had not been added to the dental list upon admission and had not seen a dentist while at the facility. Resident 53 Review of the medical record showed the resident was admitted to the facility with diagnoses including heart failure. The 12/21/2025 comprehensive assessment showed Resident 53 cognition was moderately impaired and required the assistance of one staff member for ADLs. Additionally, the assessment showed Resident 53 had upper dentures. Review of a dental encounter sheet dated 12/04/2025, showed a referral for new upper dentures. Review of a progress note dated 01/21/2026, showed Resident 53 returned from an appointment with the denturist with a request for additional paperwork to start the dentures. An observation and concurrent interview on 02/20/2026 at 2:15 PM, Resident 53 stated, I'm missing a whole side there and there, while pointing to missing teeth on both sides of their upper denture. Resident 53 stated the facility had told them they were getting them new dentures, but they had not heard anything since. Resident 53 further stated they were missing a front tooth, and it was hard for them to eat because the dentures were broken. Resident 53 stated, I was eating bacon this morning, and another piece fell off the denture. Resident 53 stated they were told by Staff D, RCM, that the facility did not have the referral and needed to get another one. Resident 53 further stated requesting dental care was a long process and they did not like missing a front tooth because it affected their appearance. During an interview on 02/20/2026 at 2:32 PM, Staff D stated they needed to fill out the paperwork they had on their desk. Staff D stated that as soon as they completed the paperwork, they could schedule the appointment for Resident 53. Staff D stated they had just received the paperwork and would have followed up sooner if they had been aware of it, but they did not know the paperwork was needed. Staff D further stated the facility did not have a set process for tracking such requests (two months and 18 days from the date of the initial referral request). Resident 41 Review of the medical record showed the resident was admitted to the facility with diagnoses including stroke (happens when the blood supply to part of the brain is suddenly blocked or a blood vessel in the brain bursts). The 1/13/2026 comprehensive assessment showed Resident 41's cognition was moderately impaired and required the assistance of one-two staff members for ADLs. Additionally, the assessment showed resident 41 was edentulous (without any natural teeth). Review of a dental encounter sheet dated 12/04/2025, showed abnormal findings on Resident 41's tongue and included an order for a referral to evaluate those findings, as well as an order for new upper and lower dentures. During an observation and concurrent interview on 02/20/2026 at 2:09 PM, Resident 41 was lying in bed and stated they had requested new dentures because their current ones were loose. Resident 41 demonstrated the looseness of the bottom denture, showing how they could move it around with their tongue. Resident 41 stated it was sometimes hard to chew. Resident 41 stated it had been a long time since the dentist visited and they would like to receive the new dentures. Observation of Resident 41's tongue revealed a red, raised area on the left lateral border. During an interview on 02/20/2026 at 2:32 PM, Staff D, stated they were not aware of Resident 41's referral or the orders for new dentures from the 12/04/2025 dentist visit. Staff D stated they did not review the dental orders form that visit, even though the facility's practice was to review any such orders during the first week the dentist visits. Staff D stated the review of any new orders did not occur this time and acknowledged they did not complete it. During an interview on 02/22/2026 at 12:22 PM, Staff B, Director of Nursing Services, stated they would expect all dental visits to be followed up promptly and documented in the electronic health record with appropriate follow through. Staff B stated the process was not followed and the referrals were not completed in a timely manner. Staff B further stated they would expect all new admissions to be seen during the next scheduled dental visit and for all residents to be seen on a routine basis. Reference: WAC 388-97-1060 (1),(3)(j)(vii)

Based on observation, interview and record review, the facility failed to ensure care and services were provided for 1 of 4 residents (Resident 2) reviewed for positioning. There were no assessments, specific interventions to mitigate the risk of contractures (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) or Restorative nursing for Range of Motion (ROM) services to prevent further decrease in range of motion and hand contracture. This failure placed the residents at risk for a decrease in mobility, development/worsening of contractures and inability to maintain their current level of functioning. Findings included. Resident 2 Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including hemiplegia (severe or total loss of motor function on one side of the body) of the left side, dementia (loss of memory, thinking and the ability to perform daily activities), and need for assistance with care. Review of Resident 2's comprehensive assessment dated [DATE], showed the resident had severe cognitive impairment, and functional limitation of the upper and lower extremity on one side. Review of Resident 2's care plan dated 12/04/2025, showed no care plan had been developed for Resident 2's left hemiplegia to prevent further decrease in ROM, mobility and /or development of contractures. During an observation on 02/17/2026 at 10:48 AM, Resident 2 was lying in bed, their left hand in a clutched position with nothing in their hand to prevent contact between skin and fingernails. There was a strong foul odor to Resident 2's left hand. During an interview and concurrent observation on 02/19/2026 at 1:27 PM, Staff P, Nursing Assistant (NA), stated Resident 2 was cooperative with their care. Staff P lifted the resident's left hand from underneath their blanket. Resident 2's left hand had a washcloth within their clutched fist. Staff P stated they were unsure how the washcloth was placed in the resident's left hand, that they had not been instructed to do that for the resident. In an interview on 02/19/2026 at 2:12 PM, Staff I, Restorative Nursing Assistant (RA), stated Resident 2 was on a restorative program for meals. Staff I stated they did not have a restorative program for ROM for Resident 2 nor placed a device on their left hand. In an interview on 02/20/2026 at 11:04 AM, Staff G, Director of Rehab, stated they wrote restorative programs for the facility residents. Staff G stated the restorative program was run by the nursing department and overseen by Staff B, Director of Nursing Services (DNS) and Staff D, Resident Care Manager (RCM). Staff G stated their tracking system had been streamlined on the computer and the orders for the residents' restorative programs went directly to the nursing department for processing. Staff G stated when they were alerted to a residents' decline in mobility/function, they address the resident's decline with the nursing department and obtain orders for evaluations. Staff G stated they reevaluated residents' when decline in mobility/function was identified. Staff G stated they would then re-write the restorative program after they evaluated the resident to address their needs. Staff G stated they were not aware that Resident 2 had a contracture and should have been notified by the nursing staff. In an interview on 02/20/2026 at 11:30 AM, Staff D, RCM stated they and the DNS oversaw the restorative program. Staff D stated they met once a month with the RA's who provided the program, discussed residents on the program, the refusals and resident who were unable to perform a certain task. Staff D stated for a contracture, first thing they would obtain was a referral for therapy to evaluate the resident. Staff D stated they were not aware of Resident 2's left hand contracture. Staff D reviewed the resident's care plan to verify the resident had a restorative program and acknowledged the resident did not have a care plan specifically for ROM to their left hand. In an interview on 02/22/2026 at 2:46 PM, Staff B, DNS, stated the RA program was new and just implemented a binder with all resident programs. Staff B acknowledged Resident 2 was on a RA program for meals but not range of motion. In an interview on 02/22/2026 at 3:44 PM, Staff A, Regional Nurse, stated the expectations were that staff follow the care plans as they delivered the care as ordered, monitor the residents for decline/deficits and document all care done for all residents. Reference: WAC 388-97-1060 (3)(d) This a repeat citation

Based on interview and record review, the facility failed to provide required liability notices for 1 of 3 residents (Resident 78) reviewed for liability notices. Failure of the facility to issue a Notification of Medicare Non-Coverage [NOMNC] or Advanced Beneficiary Notice [ABN] (required notifications informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) before discharge from the facility placed Resident 78 at risk for not fully understanding their Medicare benefits and appeal rights. Findings included. Resident 78Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnosis of a surgical repair to their left lower leg. Review of the 09/19/2025 discharge assessment showed Resident 78's cognition was intact. Review of Resident 78's Medicare documentation showed Resident 78 was not issued NOMNC or ABN notifications prior to their discharge from covered services on 09/29/2025. During an interview on 02/20/2026 at 3:03 PM, Staff A, Regional Nurse, stated they reviewed Resident 78's medical records and the notifications had been missed all together, and not given to the resident prior to their discharge on [DATE]. Reference: WAC 388-97-0300 (1)(e)

Based on observation, interview and record review the facility failed to ensure that a resident who required assistance with incontinence received timely care to maintain their dignity for 1 of 2 residents (Resident 11) reviewed for dignity. Resident 11 requested assistance with an incontinence episode however staff told them they would have to wait until other staff were available to help them. This failure placed the resident at risk for unmet care needs, embarrassment, potential skin injuries and a deterioration in their quality of life. Findings included . Record review of a facility document given to residents on admission to the facility titled [NAME] Specific Residents Rights stated, the nursing home must protect the rights of the resident to have a dignified existence and promote and protect their rights. Resident 11Review of the resident's medical record showed the resident was admitted to the facility with diagnoses which included heart failure (the heart is unable to keep up with needs of the body), chronic obstructed pulmonary disease (an incurable lung disease that causes breathing difficulty) and diabetes (high blood sugar). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact, was incontinent of bowel and bladder, and required total assistance for incontinent care. During an observation and concurrent interview on 02/22/2026 at 2:35 PM showed Resident 11's call light on over the door of their room. The resident stated they needed assistance as they had a bowel movement and had been waiting for a while. On 02/22/2026 at 2:38 PM Resident 11's concern and request for assistance was reported to Staff N, Licensed Practical Nurse, who was standing in the hall at a medication cart several doors down from Resident 11's room. Staff N stated they would take care of it. During an observation on 02/22/2026 at 2:58 PM showed Resident 11's call light still on. Resident 11 stated that Staff L, Nursing Assistant (NA), came into the room and told them they would have to wait for assistance until other staff were available to help them. During an observation 02/22/2026 at 3:38 PM, showed Staff L, going into the resident's room with Staff M, NA, to assist Resident 11 with their bowel incontinence care (63 minutes after the resident had requested help). During a interview on 02/22/2026 at 3:52 PM, Resident 11 stated they felt very embarrassed and upset because they had to wait so long for incontinent care. In an interview on 02/23/2026 at 10:20 AM, Staff B, Director of Nursing Services, stated it was not appropriate for staff to have left Resident 11 laying in their bowel movement. Additionally, Staff B stated their expectation was for staff to assist residents with incontinent care in a timely manner. Reference WAC 388-97-0180(1)-(4)

Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to maintain Range of Motion (ROM) for 3 of 3 residents (Residents 1, 3, and 2) reviewed for Restorative Nursing programs. The lack of consistent processes in place for implementation of splints and providing ROM services placed residents at risk for not maintaining ROM in the affected areas of contractures (tightening of tendons and muscle), decreased function and pain.Findings included .Resident 1 Review of the medical record showed the resident was admitted to the facility with diagnoses including history of a stroke (blood flow to a part of the brain is interrupted) with paralysis (loss or impairment of voluntary movement) on the left side and heart failure. Review of the comprehensive assessment dated [DATE] showed the resident was severely cognitively impaired and was dependent on staff for dressing, grooming and mobility. During an observation on 09/29/2025 at 1:17 PM, Resident 1 was in the dining room sitting in their wheelchair. The resident's left arm was hanging limply in their lap and their fingers were bent tightly against their palm in a fixed position. Resident 1 had a splint positioned upside down on their hand with the blue foam designed to keep the palm and fingers separated was on top of the resident's hand and not in their palm. Review of Resident 1's Kardex for September 2025 (a care plan used by Nursing Assistants [NAs] to give care directives for residents), showed the resident had a Restorative Nursing program which included ROM to be completed daily on their left arm and hand (there were no directives or information on the use of the blue splint which had been observed positioned incorrectly in their hand). Review of the daily signatures which indicated completion of the ROM program showed 14 missed days on 09/04/2025, 09/05/2025, 09/07/2025, 09/08/2025, 09/14/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/21/2025. 09/22/2025, 09/26/2025, 09/28/2025, and 09/29/2025. Resident 3Review of the medical record showed the resident was admitted to the facility with diagnoses which included history of a stroke with paralysis on the left side of their body, diabetes (too much sugar in the blood) and dementia (cognitive loss). Review of the comprehensive assessment dated [DATE] showed the resident had severe cognitive impairment and was dependent on staff for dressing, grooming, mobility and required a mechanical lift for transfers. During an observation on 09/30/2025 at 12:51 PM, Resident 3 was resting in bed. The resident's left hand was bent tightly against their palm in a fixed position. Staff B, NA, attempted to open the resident's hand, however it was position firmly against their palm, and the resident was uncooperative with Staff B attempting to open their hand. Staff B further stated the Restorative Nursing Assistant (RNA) was responsible for Resident 3's ROM program. Review of Resident 3's September 2025 Kardex showed they had a daily ROM program related to their left sided paralysis. Review of the daily signatures to signify the program had been completed showed 14 out of 30 days on 09/04/2025, 09/05/2025. 09/07/2025, 09/08/2025, 09/14/2025, 09/15/2025. 09/16/2025 09/17/2025, 09/18/2025, 09/21/2025, 09/22/2025, 09/26/2025, 09/28/2025 and 09/29/2025 the ROM program had not been signed as completed. Resident 2Review of the resident's medical record showed they were admitted to the facility with diagnoses which included a history of a stroke with left side paralysis and dysphagia (difficulty swallowing). Review of the comprehensive assessment dated [DATE] showed the resident had impaired cognition and was dependent on staff for grooming, eating, dressing, mobility and transfers. Review of the residents September 2025 Kardex showed they had a daily ROM and left-hand splinting program to prevent stiffness and contractures. Further review of the programs showed 14 of 30 days without signatures to indicate completion of the programs on 09/04/2025, 09/05/2025. 09/07/2025, 09/08/2025, 09/14/2025, 09/15/2025. 09/16/2025 09/17/2025, 09/18/2025, 09/21/2025, 09/22/2025, 09/26/2025, 09/28/2025 and 09/29/2025. During an interview on 09/29/2025 at 10:30 AM, a Collateral Contact stated Resident 2's left hand splint was often dirty and the palm of their had had an odor related lack of care to the area. Review of Resident 2's September 2025 Kardex showed the resident had a restorative nursing program which included ROM to the left arm and hand, and a splinting program to include placing the resident's hand and placing a soft splint on daily in the morning and removing it at bedtime to replace it with a full splint with finger separators worn at night. Further review of the record showed the restorative nursing programs were not completed on 09/04/2025, 09/05/2025. 09/07/2025, 09/08/2025, 09/14/2025, 09/15/2025, 09/16/2025, 09/17/2025, 09/18/2025, 09/21/2025, 09/22/2025, 09/26/2025, 09/28/2025 and 09/29/2025 (14 out of 30 days were missed). During an interview on 09/30/2025 at 1:24 PM, Staff B, RNA, stated I do my best to get them done. Staff B stated the reason the programs were not done daily was because they were often pulled to the floor to work and were unable to complete the restorative programs. Additionally, they stated on their days off or when they were on vacation there was no one to cover the programs. During an interview on 09/30/2025 at 2:40 PM, Staff A, Director of Nursing, stated they were aware that the ROM programs were not being consistently completed related to not having enough staff, and that the facility was working on it. Reference WAC [PHONE NUMBER]60(3)(d)

Based on interview and record review, the facility failed to accurately assess/reassess and provide adequate supervision and safety monitoring for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1, who had moderately impaired cognition and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently found by a bystander outside the facility, lying on the ground and sustained a head injury, left elbow fracture, and multiple bruises that required a hospital evaluation and intervention. Findings included .Review of a policy revised on March 2019 titled, Wandering and Elopement, showed the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the residents care plan will include strategies and interventions to maintain the resident's safety.Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include a broken right shoulder, anxiety (a feeling of worry, nervousness, or unease), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cognitive decline. The resident's comprehensive assessment dated [DATE], showed Resident 1's cognition was moderately impaired and required one-to-two-person assistance with activities of daily living ([ADLs] self-care tasks people do every day).Review of Resident 1's progress notes dated 09/10/2025 through 10/21/2025 showed: 09/10/2025 titled admission summary showed the resident had confusion and moments of hallucinations (a sensory experience where someone perceives something that isn't there) during the evening hours. 09/30/2025 at 6:41 PM, Resident 1 had refused cares. 10/02/2025 at 10:32 AM showed Resident 1 had exhibited anxiety behaviors. 10/18/2024 at 7:17 PM, showed Resident 1 had demonstrated exit seeking behavior, anxiety, and wanting to go home. Further review showed a physician's order dated10/18/2025 for lorazepam (antianxiety medication) 0.5mg for anxiety. 10/18/2025 showed at 7:19 PM the resident was placed on a 1:1 supervision (one caregiver provides undivided attention and support to a single individual). Further review showed the 1:1 supervision was provided by staff until family arrived at 7:30 PM to sit with Resident 1. The 1:1 supervision was re-initiated at 10:00 PM on 10/18/2025 when family had left and the resident continued to exhibit exit seeking behaviors. Staff G, Registered Nurse (RN), stated Resident 1 was taken off the 1:1 supervision when they had calmed down the morning of 10/19/2025. 10/19/2025 at 12:51 PM showed Resident 1 was drowsy and continued with confusion frequently asking, where am I? 10/21/2025 at 10:43 AM, showed Resident 1 had increased confusion, walking into the hallways and looking for their family who were not in the facility.Review of Resident 1's elopement risk assessment dated [DATE] showed Resident 1 was at a low risk for elopement. Further review showed there were no updated elopement risk assessments or care plan updates completed for Resident 1 related to their change in behaviors. Review of the facility's incident report dated 10/24/2025 showed Resident 1 was last seen by night shift staff at approximately 4:30 AM on 10/24/2025, and again when Resident 1 had exited the facility by way of the window in their room into the back courtyard at approximately 6:15 AM. The resident was found by staff from a neighboring facility (Assisted Living Facility, ALF); the ALF staff stated the resident was peeking through their windows, so they came out to help the resident. The ALF staff stated Resident 1 was very agitated and would not let anyone assist them. The nursing home facility staff noticed the resident was out of the facility at 6:40 AM and found the resident at the ALF with scrapes to their knees and complaints of pain to their back and arm. Staff placed a blanket on the resident, called 911 and sent Resident 1 to the local hospital for evaluation and treatment related to the residents increased pain, agitation and anxiety.During an interview on 10/29/2025 at 12:24 PM Resident 1's collateral contact (CC) stated they had received a call from the facility on 10/24/2025 at about 6:45 AM. The CC stated they were asked if they had dropped Resident 1 off the day before after their outing (10/23/2025). The CC stated that they had not, their niece had dropped off the resident the prior evening. The CC stated the facility informed them that they were unable to locate the resident The CC stated they had to call the facility back for an update and were told Resident 1 was found lying on their back outside. The CC stated the facility had called an ambulance to send the resident to the ER. The CC stated when they arrived at the hospital Resident 1 had a goose egg above the left eye and had pajamas on with no socks or shoes. The CC stated Resident 1 had scrapes to their that were new. The CC further stated Resident 1 had sustained a hairline fracture to their left elbow, a head injury, and was concerned about the lack of supervision and care not provided for Resident 1. Review of the local hospital discharge notes dated 10/24/2025, showed Resident 1 had sustained a head injury, a left elbow fracture, and multiple bruises. During an interview on 10/29/2025 at 12:45 PM, Staff L, Nursing Assistant (NA), stated they had worked with Resident 1 on 10/19/2025. Staff L stated they recall the resident being anxious and sat in the hallway to make themselves feel better. During an interview on 10/29/2025 at 2:30PM Staff K, NA, stated they had been assigned as a caregiver for Resident 1, and had done every 15-minute checks during their shift on 10/19/2025. Staff K stated their understanding of the 15-minute checks were due to Resident 1 exit seeking. Staff K stated that Resident 1 had been 1:1 supervision the day before due to the resident exit seeking.During an interview on 10/29/2025 at 2:03 PM, Staff M, NA, stated information of a resident being an elopement risk would be on the Kardex (NA task guide for a resident's care) or care plan, or they would be in the elopement book (a book located at the nurses station with pictures of residents and information to help identify residents who are a risk). Staff M stated a resident was assessed as high risk when they were constantly seeking (a way to exit the building unsupervised) the exit. Staff M stated they were unaware of elopement risk levels for residents in the facility. Staff M stated there had been an elopement last Friday, 10/24/2025, and was told a resident had pushed the screen out and went out the window of their room. Staff M stated, I was just coming to work that morning and seen Resident 1 in the back of the facility, lying on their back on the grass next to the gas pump. Staff M stated it was early, around 6:30 AM to 7:00 AM. Staff M stated Resident 1 was cold, and complained of hip, back and arm pain. Staff M stated Resident 1 was in their pajamas without shoes, very scared saying someone was trying to kill them and their family just very panicked and scared. Staff M stated staff from the ALF found Resident 1, they stated the resident was looking in the windows. Staff M stated the day shift nurse came out to assess the resident and they waited with Resident 1 outside until the Emergency Medical transport services showed up and took them to the local hospital.Review of a binder used to communicate with staff any residents with elopement risks on 10/29/2025 titled Elopement Book, showed no identification of Resident 1 in the binder.During an interview on 10/30/2025 at 9:52 AM, Staff O, NA, stated they had been assigned to Resident 1 on 10/23/2025 night shift. Staff O stated they were not aware of an elopement, there had not been an overhead call of code white (emergency code to alert staff of a missing person), for the elopement. Staff O stated Resident 1 had been in isolation and they had been instructed to keep the door closed. Staff O stated Resident 1 had come out of their room into the hallway around 4:15 AM, they were confused and asked about their spouse. Staff O stated they redirected Resident 1 back to their room and back to bed. Staff O stated Resident 1 came out to the hall again, around 5:20 AM, they were still confused and a bit harder to redirect. Staff O stated Resident 1 went back to their room but would not go back to bed, so they assisted the resident to their chair and left the room. During an interview on 10/29/2025 at 11:22 AM, Staff C, Licensed Practical Nurse (LPN), stated they had received report around 6:40 AM from the night shift nurse and began their day. Staff C stated Resident 1 was on COVID-19 precautions, so they went to their room first with their medications and the room was empty. Staff C stated a staff member had stated Resident 1 had gone with family the day before and may still be with them. Staff C stated they had checked the sign out book and started looking in every room. Staff C stated one of the NA's stated Resident 1's window was open, and the screen was on the ground bent. Staff C stated the NA went out the window to look for Resident 1. Staff C stated staff from another facility (neighboring ALF) had found Resident 1. Staff C stated they assessed Resident 1 and found they were warm to touch, had an abrasion to their nose, pain to their right arm, was moving their head, and not moving their right arm. Staff C stated Resident 1 was not willing to go back into the facility, but they allowed an aide to place a coat and blanket on them. Staff C stated the night shift nurse had called 911 and sent Resident 1 to the local emergency room for evaluation.During an interview on 10/29/2025 at 3:05 PM, Staff E, Resident Care Manager (RCM), stated upon admission they assessed residents for elopement risk, fall risk, reviewed their diagnoses, and their medications. Staff E stated Resident 1 had scored a low elopement risk on admission. Staff E stated, Resident 1 had exhibited behaviors such as crying, being sad, and wanting to die. Staff E stated Resident 1 had been in isolation and their behaviors escalated quickly. Staff E stated a re-evaluation/assessment for elopement was done for certain behaviors such as signs of elopement (exit seeking, anxiousness, and wanting to go home). Staff E stated a re-evaluation for elopement was not completed for Resident 1 when they exhibited anxiety and exit seeking behaviors.During an interview on 10/30/2025 at 10:47 AM, Staff F, RN, stated they checked residents every couple of hours or more often if needed during their shift. Staff F stated the last time they had seen Resident 1 had been around 4:30 AM rounds, and they had started at 5:00 AM with their medication pass. Staff F stated Resident 1 had been asleep most of the night snuggled in covers, when they had seen them last. Staff F stated the morning of 10/24/2025 they gave report to the oncoming nurse (Staff C) and they began their medication pass with Resident 1's room first. Staff F stated Staff C came to the nurses' station and asked where Resident 1 was. Staff F stated, I told them they were in bed the last time I seen them. Staff F stated they went into Resident 1's room and seen that the window had been opened, the screen was pushed out and bent on the ground. Staff F stated another staff member from the ALF had seen Resident 1 peeking through the windows just after 6:30 AM. The ALF staff member stated when they went out to help them, Resident 1 ran away from them. Staff F stated they went back into the building and called 911. Staff F stated, I'm shocked that they could open that sticky (difficult to open) window. Staff F further stated they did not know about Resident 1's mobility status or any behaviors they had been having, I really didn't know Resident 1. Staff F stated no code was called for the elopement we were all shouting the resident was missing, it was during shift change, so everyone was aware Resident 1 was gone. During an interview on 10/30/2025 at 1:25 PM, Staff G, RN stated that on Saturday 10/18/2025 Resident 1 had become agitated rushing the exit door, saying they were going home and that family were waiting outside for them. Staff G stated Resident 1 kept insisting on going outside so, 1:1 supervision was placed for Resident 1. Staff G stated they had notified the family and asked if they were picking the resident up or not because Resident 1 had continued to go to the door to leave. Staff G stated they (the family) were not coming to pick up the resident but would come in to help. In the same interview Staff G stated they had called the on-call physician and explained what was going on with Resident 1 exhibiting behaviors of increased anxiety and agitation. Staff G stated they had received an order for lorazepam 0.5 milligrams (mg) dose prn (as needed) every 12 hours (antianxiety medication). Staff G stated family came in to sit with Resident 1 and it was after 10:00 PM when the family left. Staff G stated after the family had left Resident 1 started heading towards the door so a 1:1 supervision was reinitiated and had placed them on alert charting. Staff G stated then the next day, Sunday 10/19/2025, Resident 1 continued with agitation and so they had the aide assigned to the resident to do every 15 min checks on them. Staff G stated, no I did not have the aide document at those times, I should have. Staff G stated the Lorazepam medication really did not help Resident 1. Staff G stated the 1:1 supervision was placed until Resident 1 had calmed down. During an interview on 10/29/2025 at 4:00 PM, Staff B, Director of Nurses, stated the expectation for an assessment/re-evaluation for elopement risk was to be done on admission, quarterly, and/or if someone was exhibiting behaviors such as exit seeking, agitation or wanting to go home to keep the resident safe and in the least restrictive environment. Staff B acknowledged Resident 1 required an updated assessment for elopement and one had not been completed.Reference WAC: 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure a resident was free from neglect for 1 of 3 residents (Resident 1), reviewed for neglect, when they failed to perform consistent skin assessments as ordered and failed to obtain and implement wound treatment orders when Resident 1 developed a new skin concern. Resident 1 experienced harm when they developed a necrotic (death of tissue) area to the right foot and fifth (little) toe which required hospitalization and surgical intervention of a partial amputation of the right foot (side of foot) including the little toe. Findings included . Review of the facility's policy dated 08/2024, titled, Abuse -screening, training, identification, investigation, reporting and protection, showed the definition for neglect is the failure to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015, showed neglect may result from an inaction by an individual or entity with a duty of care for nursing home residents, including the failure to provide goods and services necessary to avoid physical harm. Review of the facility's policy, dated 09/2020, titled, Skin at Risk/Skin Breakdown showed a full body skin evaluation was completed weekly by the licensed nurse. Completion of the skin audit was to be documented. Review of Lippincott Manual of Nursing Practice, Eleventh Edition, showed signs of necrotic tissue in wounds clinically manifest with increased pain, redness, swelling, and warmth to the area, development of bullae (fluid filled sac or lesion), drainage and foul odor. <Resident 1> Review of Resident 1's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include a fractured right hip, right side hemiplegia/hemiparesis (partial and complete loss of strength to one side of the body) and need for assistance with personal care. Review of the resident's comprehensive assessment dated [DATE] showed the resident's cognition was severely impaired. Review of Resident 1's physician's orders showed the resident had an order dated 09/13/2024, for weekly skin checks every day on Fridays. Review of a nursing progress note, dated 11/07/2024, showed the resident had two new lesions to the outside of the right foot which involved the little toe. Review of a Wound Consultant progress note, dated 11/21/2024, showed wound had closed but remained high risk with direction for nursing to continue the daily wound dressing for extra protection. Review of the nursing progress note, dated 01/19/2025 at 3:30 PM, showed Staff E, Licensed Practical Nurse (LPN), was notified by Staff J, Restorative Assistant (RA), of Resident 1's right foot having a strong, foul odor. Staff E assessed Resident 1's outer right foot to have loose and removed skin, black colored tissue in the wound bed, the little toe (closest to the wound) was dark in color, and the wound had a foul odor. Staff E transferred Resident 1 to a local hospital for evaluation and treatment. During an interview, on 01/22/2025 at 3:04 PM, Staff D, Resident Care Manager (RCM), stated they completed weekly skin assessments on the residents, and the last time they assessed Resident 1's right foot was on 01/05/2025 (14 days prior to significant change). Staff D stated Resident 1 had a callous (a hard, thickened area on skin) to the outer portion of their right foot near the little toe and the surrounding skin was intact. Staff D stated the floor nurses were responsible for completing weekly skin assessments on the residents, and that they tried to routinely monitor pressure wounds and surgical incisions. During an interview on 01/22/2025 at 4:58 PM, Staff O, LPN, stated they worked with Resident 1 on 01/14/2025 and completed the dressing change to their outer right foot. Staff O stated they noted a small open area that was bleeding but the area looked at its baseline otherwise. Staff O stated they did not notify anyone or document the change in skin integrity. During an interview, on 01/22/2025 at 2:30 PM, Staff E, LPN, stated the last time they assessed Resident 1's right foot wounds was on 01/11/2025 (eight days prior to significant change), the area was at baseline with no open areas, and a protective dressing was applied as ordered. Staff E stated when they worked with Resident 1 on 01/15/2025, Resident 1 had refused the dressing change to their right foot due to significant pain and discomfort to the right foot. During an interview, on 01/23/2025 at 12:27 PM, Staff L, Nursing Assistant (NA), stated they worked with Resident 1 on 01/17/2025 and noticed when they assisted the resident to get dressed, the resident's right foot had re-opened. Staff L stated the right foot was swollen, red and warm and they notified Staff F who applied a new dressing. During an interview, on 01/22/2025 at 1:46 PM, Staff F, LPN, stated they worked with Resident 1 on 01/17/2025 and completed the dressing change to their outer right foot. Staff F stated they observed dried serosanguinous [contains both blood and serum (the liquid part of blood)] fluid on the old dressing and a small slit where the drainage was coming from. Staff F stated resident weekly skin assessments were completed by the RCMs. During an interview, on 01/23/2025 at 10:47 AM, Staff H, LPN, stated they usually worked double shifts (two consecutive shifts to equal 16 hours) on the weekends, and they worked with Resident 1 on 01/18/2025 during the day shift (6:00 AM to 2:00 PM). Staff H stated they passed medications for the assigned hall, and did not complete any treatments or dressing changes. Staff H stated the treatments were completed Monday through Friday as they did not have a treatment nurse on the weekends. Staff H stated Resident 1 had a dressing to their right foot, but they never saw the wound. Staff H stated they recalled Resident 1 complained of pain to their right foot during the shift, and the NAs repositioned the resident frequently to keep them comfortable. During an interview, on 01/22/2025 at 2:16 PM, Staff J, RA, stated they worked with Resident 1 on 01/19/2025, after breakfast in their room. Staff J stated Resident 1's right foot did not have a dressing or a sock on it and they observed a bad sore on the outer part of the foot. Staff J stated the wound was on the outer part of the right foot, including the little toe, was dark in color, and there was a foul odor coming from it. Staff J stated they reported it to Staff E. During an interview, on 01/22/2025 at 12:47 PM, a Collateral Contact (CC) at the local hospital stated they had received Resident 1 from the facility, but they had transferred Resident 1 to a hospital in Seattle for further evaluation and treatment by a Podiatrist (medical specialist who help with problems that affect the feet and lower legs). The CC stated the local hospital physician was concerned about potential osteomyelitis (a bone infection that causes inflammation and swelling in the bone) in Resident 1's right foot. During an interview, on 01/23/2025 at 12:57 PM, Staff C, Assistant Director of Nursing (ADNS), stated their investigation regarding the change in condition to Resident 1's right foot showed Staff F assessed the wound on 01/17/2025 to be open, macerated (a breaking down of the skin resulting from prolonged exposure to moisture), and had a piece of loose skin. Staff C stated it did not appear Staff F documented the change to Resident 1's right foot wound nor notify the physician. During an interview, on 01/23/2025 at 4:19 PM, Staff A, Administrator, and Staff B, Regional Nurse, stated that there is indeed a deficiency in the assessment of the resident. During an interview on 01/27/2025 at 10:16 AM, Resident 1's RR, stated Resident 1 was in the hospital and had a partial amputation of their right foot on 01/25/2025. Reference: WAC 388-97-0640(1)

Based on observation, interview, and record review the facility failed to ensure residents received physician ordered medication, had necessary laboratory values (labs) drawn as ordered, and received timely treatment for abnormal labs for 4 of 4 residents (Residents 1, 2, 3, and 5) reviewed for quality of care. This failed practice resulted in harm for Residents 1 and 2 when their treatment was delayed, conditions worsened, and required hospitalization . Residents 3 and 5 were at risk for their condition to worsen and experience inaccurate or a delay in treatment. Findings included . <Resident 1> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include removal of the left leg below the knee and kidney failure. The 04/19/2024 comprehensive assessment, showed the resident's cognition was intact and required one staff assistance for bed mobility and transfers. Review of Resident 1's 04/12/2024 hospital notes, showed the resident was admitted to the hospital, from the facility, for diagnoses to include hyponatremia (decreased level of sodium [salt] in the blood) and an infected abscess (a painful lump filled with pus that can form anywhere on your body due to an infection or injury) to the left buttock. The discharge notes on 04/18/2024 showed the resident was to have weekly blood draws completed to monitor the hyponatremia and the infection, the first one to be drawn on 04/25/2024. Review of Resident 1's April 2024 Medication Administration Record (MAR) showed orders as follows: 04/18/2024, obtain weekly labs. Scheduled to be drawn every Thursday morning, first one scheduled for 04/25/2024. The box on the 25th was documented with a 5 (a five means see progress notes, progress notes on 04/25/2024 showed need supplies). 04/19/2024, obtain weekly labs. Scheduled to be drawn every seven days, first one scheduled for 04/24/2024. The box on the 24th was blank. (No nursing note to show why the lab had not been obtained). 04/24/2024, obtain a Basic Metabolic Panel ([BMP], a blood test that measures eight different substances in your blood [sodium is one of them]). Scheduled to be drawn on 04/27/2024. Lab was drawn. (sodium lab value was low and no documentation to show notification to the provider). 05/02/2024, obtain labs on 05/03/2024. Lab was drawn. (no documented notification to the provider for the low sodium level). 05/02/2024, Sugar free Gatorade at bedside every shift for hyponatremia (ordered for the low sodium level from 04/27/2024, five days after lab drawn, when provider reviewed abnormal lab results on rounds 05/01/2024). 05/06/2024, Sodium Chloride (a fluid that provides sodium replacement), given intravenously ([IV], administered through the veins) for hyponatremia. Review of Resident 1's completed sodium lab draws showed on 04/27/2024 sodium result was 126 milli-equivalents per liter ([mEq/L, a unit of measure], a normal sodium result is 136-145 mEq/L), on 05/03/2024 sodium result was 122 mEq/L, and on 05/07/2024 sodium result was critical at 117 mEq/L. Review of Nursing progress notes showed as follows: 04/28/2024 at 6:33 AM (one day after labs obtained on 04/27/2024), lab will fax BMP results. (no further notes to show the labs were received or provider was notified, sodium was low at 126 mEq/L). 05/06/2024 at 10:21 PM, provider called facility after review of 05/03/2024 low sodium level and ordered IV hydration and a follow up BMP lab in the AM. (the orders showed no order had been processed for the BMP lab in the AM on 05/07/2024). 05/07/2024 at 3:24 PM, resident was observed to be lethargic and pale, called provider, since labs had not been drawn in the AM as ordered, the provider added additional labs. Labs sent to lab at 3:15 PM. 05/07/2024 at 4:39 PM, lab called facility with critically low sodium results and provider gave an order to send resident to the hospital. 05/07/2024 at 8:21 PM, call placed to hospital and Resident 1 had been admitted for hyponatremia and would require replacement therapy. During an interview on 05/17/2024 at 1:39 PM, Staff K, Licensed Practical Nurse, stated their process for lab draws were to draw the blood, drive the labs to the hospital to be processed, review the results when they returned to the facility, and update the provider with any abnormal lab values. Additionally, on 05/21/2024 at 12:54 PM, Staff K stated I do not know for sure if the labs ordered on 04/25/2024 were obtained because they needed additional blood drawing supplies from the lab. Staff K assumed the evening nurse would have obtained the supplies and completed the blood draw if it had not been completed prior to their shift ending. Further, Staff K stated they did not recall why the BMP lab was not obtained until late evening on 05/07/2024 and verified there was no lab order for the morning of 05/07/2024. During an interview on 05/20/2024 at 3:25 PM, Staff Q, Resident Care Manager (RCM), stated they did not process the order for Gatorade (a brand of drink used to replace fluids and minerals such as sodium in the body) that was given on 05/01/2024 until the following day on 05/02/2024 when they reviewed the provider's notes. Additionally, Staff Q stated they did not recall why they did not obtain the labs on 04/24/2024 and usually would keep notes as to why something was not done during their shift but could not find any. Staff Q could not recall why the labs on 04/27/2024 were not followed up on. Staff Q did not receive or review the labs obtained on 05/03/2024 and on 05/04/2024 they called the provider with the lab results for the infection but not for the abnormal sodium level. During an interview on 05/16/2024 at 2:38 PM, Staff E, Advanced Registered Nurse Practitioner, stated they would expect nursing to call them for any abnormal lab results. Staff E further stated they received the results as well but did not prioritize reviewing them because they presumed if they were abnormal, the facility would have called. Staff E stated the low sodium lab result for Resident 1 on 04/27/2024 was not called to them and did not review them until their visit with Resident 1 on 05/01/2024 (four days after labs were obtained). Staff E gave new orders to start Pedialyte (a brand of drink used to replace fluids and minerals such as sodium in the body) for oral rehydration and gave the okay to use Gatorade if Pedialyte was unavailable, I can see that didn't happen. Staff E stated follow-up labs were drawn on 05/03/2024 and they did not receive any calls or results until they reviewed the labs themselves late in the evening on 05/06/2024 when the sodium level had dropped to 122 mEq/L. Staff E stated they called the facility on 05/06/2024 in the evening, and gave orders to start IV hydration and repeat labs on 05/07/2024 in the AM. The provider further stated they were not aware the follow up sodium lab had not been drawn until the evening of 05/07/2024, when they received the call that the resident had become lethargic and pale. Additionally, the provider stated the hydration with the drink and IV solution would have presumably corrected the hyponatremia had they been given timely and as ordered. <Resident 2> Review of the resident's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include asthma (a lung disorder characterized by narrowing of the airways, the tubes which carry air into the lungs, that are inflamed and constricted, causing shortness of breath, wheezing and cough) and low blood pressure. The 04/29/2024 admission assessment showed the resident's cognition was intact and required one to two staff assistance for bed mobility and transfers. Review of Resident 2's 04/30/2024 hospital notes, showed the resident experienced a fever and productive cough at the facility and was sent to the hospital to be evaluated, one day after admission. Resident 2 was diagnosed with an infection in their urine, ([bacteremia], the presence of bacteria in your blood, which can be serious and require antibiotics), and pneumonia (an infection that inflames the air sacs in one or both lungs, causing cough, fever, chills, and difficulty breathing). Upon discharge from the hospital on 05/03/2024, the resident was ordered Fluconazole (a brand of antifungal medication) for the pneumonia (next dose on 05/04/2024) daily for seven days and Vancomycin (a brand of antibiotic) IV antibiotics to be given every 12 hours for 11 days (22 doses) for the bacteremia. Review of Resident 2's May 2024 MAR, showed an order for Fluconazole 100 milligrams daily by mouth to start on 05/04/2024. The MAR showed the Fluconazole had not been given on 05/04/2024, 05/05/2024, and 05/06/2024. Three doses were missed. Additionally, the MAR showed an order for Vancomycin IV antibiotics to be given every 12 hours to start on 05/03/2024 in the evening, with no duration noted. Review of Nursing progress notes showed as follows: 05/04/2024 at 2:20 PM, and 05/05/2024 at 3:23 PM, Fluconazole had not arrived from pharmacy. Resident 2 experienced trouble breathing at rest and had labored breathing. No oxygen required. 05/06/2024 at 10:00 AM, Fluconazole was on order, at 12:54 PM, no oxygen was required, and lung sounds clear. 05/07/2024 at 12:40 PM, continuous oxygen required, no breathing issues, and lungs sound clear. First dose of Fluconazole given. 05/08/2024 at 9:30 AM, Staff H, LPN, documented, Resident 1 does not look well, they were pale, had chills, heart rate at 110 (normal heart rate at rest is 60-100) and respirations at 32 (normal is 12-20). Received orders to send resident out to hospital. Review of the 05/08/2024 hospital admission records, showed the resident had diagnoses of pleural effusions (an excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs) and worsening fungal pneumonia (a lung infection caused by fungal spores. It occurs when these spores mix with the air and are inhaled, or when an inactive infection is reactivated). Additionally, the hospital documented Resident 2 had received treatment with Fluconazole since discharged back to the facility on [DATE]. (Resident only received two of the five doses that should have been received). Upon discharge on 05/12/2024, Resident 2 was to continue the IV Vancomycin that was ordered on 05/03/2024. During an interview on 05/17/2024 at 1:39 PM, Staff K stated their process for receiving new medications from the pharmacy would be to input the orders, the orders then go directly to the pharmacy once inputted, and if it was not too late in the day, they would come in that evening or the next day. Staff K stated if the medication did not come in, they would call the pharmacy and they would let them know if the medication was on back order. Staff K stated they would normally call the provider and request a different medication that was available or ask if it was okay to wait to give the medication until it was delivered from the pharmacy. Staff K stated they did not recall why the Fluconazole did not come in until three days later, and they did not recall notifying the provider. During an interview on 05/17/2024 at 12:33 PM, Staff E stated they were unaware Resident 2 had not received three of the four doses of Fluconazole prior to being sent to the hospital. Staff E presumed if all doses had been given as ordered the infection may not have worsened. Staff E stated the hospital should have been made aware of the missing doses upon transfer, this could have changed Resident 2's treatment plan during their hospital stay, but considering the hospital's documentation, that was not done. Staff E further stated Vancomycin should have been continued to complete the 11 days (22 doses) that was ordered. Staff E was informed at that time that only 15 doses of the 22 doses had been administered and stated, that would be a perfect reason why Resident 2 is running fevers. Staff E further stated their expectation was for staff to report timely lab results and administer medications as ordered. <Resident 3> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including hypothyroidism (the thyroid gland cannot make enough thyroid hormone to keep the body running normally) and end stage renal disease (kidney function has declined to the point that the kidneys can no longer function on their own). The comprehensive assessment dated [DATE] showed the resident had moderately impaired cognition and required assistance of one-two staff members for activities of daily living (ADLs). Record review of a nursing progress note dated 05/13/2024, showed Staff B, was advised by Staff E to send Resident 3 to the hospital for evaluation of a thyroid crisis (when the thyroid gland releases a large amount of thyroid hormone in a short amount of time) after Staff E had reviewed the critical thyroid stimulating hormone (TSH) lab results obtained on 05/10/2024. The lab results showed an elevated TSH level at 45.5 milli-international units per liter ([mIU/L], a unit of measure) (normal range is 0.5-5.0 mlU/L). Record review of the hospital discharge instructions dated, 05/13/2024, showed Resident 3 had been discharged back to the facility with new orders to change Levothyroxine (a brand of medication used to treat hypothyroidism) from 88 micrograms ([mcg], unit of measure) every morning to 122 mcg every morning. Record review of the May 2024 progress notes showed no documentation of the discharge instructions, or the dose change on the Levothyroxine order from the hospital visit on 05/13/2024. Record review of Resident 3's May 2024 MAR showed Levothyroxine 122 mcg was not started until 05/17/2024 (four days after the medication change was ordered). During an interview on 05/17/2024 at 12:34 PM, Staff E stated they did not receive any notification from the facility of a critical lab value for Resident 3 on 05/10/2024. Staff E stated they noted the lab in the office on 05/13/2024 and immediately called the facility for a transport out to the hospital for evaluation of a thyroid crisis. Staff E further stated their expectation was for staff to update them with any critical lab values as soon as they received them. During an interview on 05/17/2024 at 3:08 PM, Staff B stated the TSH lab for Resident 3 was drawn on 05/09/2024 and was not called into Staff E when the critical results came back on 05/10/2024. Staff B stated their expectation was for staff to immediately notify the provider with critical labs/change in conditions and document in the resident's medical record. Staff B stated when a resident returned from the hospital it was the Resident Care Managers (RCM) responsibility to review hospital discharge instructions if they were in the building. Additionally, Staff B stated if the RCMs were gone during the time of readmission, it would be the responsibility of the nurse on the floor to review for any changes, that did not get done. Staff B further stated staff did not follow the correct process for resident 3. <Resident 5> Review of the resident's medical records showed the resident admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to stroke, heart failure and other complications) and a fracture of the right leg. The 05/03/2024 comprehensive assessment, showed the resident had severe cognitive impairment and required assistance of two staff with bed mobility, toileting, and transfers. The assessment further showed the resident received Coumadin, an anticoagulant (a high-risk medication that prevents or breaks down blood clots). Review of the resident's 05/15/2024 hospital discharge summary, showed the resident was sent to the hospital due to an unwitnessed fall out of their bed. During the hospital visit, Resident 5 was found to have an elevated international normalized ratio ([INR], a test that measures how long it takes for your blood to clot and monitor if the anticoagulant was working], when elevated, it indicates that your blood is taking longer to clot and there is an increased risk of bleeding). Review of Nursing progress notes specific to the Coumadin orders, showed on 04/30/2024 at 11:27 AM, the order was to give Coumadin 2.5 mg every evening and recheck INR on 05/03/2024 (should have received Coumadin on 04/30/2024, 05/01/2024, and 05/02/2024). A note on 05/03/2024 at 11:57 AM showed, hold the Coumadin for two days (hold on 05/03/2024, and 05/04/2024, and resume 2.5mg ([mg] a unit of measure) on 05/05/2024) and recheck INR on 05/06/2024. Review of Resident 5's April 2024 through May 2024 MARs, showed no Coumadin was administered on 05/02/2024, 05/03/2024, 05/04/2024, and 05/05/2024. The MAR further showed there were no Coumadin orders entered for 05/03/2024. During an interview on 05/21/2024 at 12:54 PM, Staff K stated their process was to draw the INR's the morning they were due, call the provider with the results, and obtain new orders. The provider's order would be documented under the nursing progress notes titled Coumadin note. Staff K verified they obtained the Coumadin orders on 04/30/2024 and 05/03/2024 and processed them. When Staff K was questioned about the accuracy of the orders, Staff K reviewed the order from 04/30/2024 and confirmed they had entered the order incorrectly and Resident 5 should have had a dose of Coumadin on 05/02/2023. Staff K continued to review the order for the 05/03/2024 INR and confirmed they did not process an order for Coumadin, and they should have, causing the resident to miss a 2.5 mg dose that should have been given on 05/05/2024. Staff K further stated the INR results were accurate but the information the provider was given from previous orders, for ordering the next dosing of Coumadin, would have been inaccurate. During an interview on 05/17/2024 at 3:10 PM, Staff B, Interim Director of Nursing Services (IDNS), stated their expectation would be for the nurses to give the medications as ordered and if that was not possible, they would expect the nurses to call the provider for additional directions. Staff B stated when medication orders were input into the system, they did not go directly to the pharmacy, the orders needed to be printed and faxed over to the pharmacy. Staff B stated they were unaware the nurses were not following the correct process. Additionally, Staff B would expect the nurses to process the orders correctly and right when they were received. Staff B further stated if the nurses had issues in obtaining medications timely, they would expect that communication from the nurses . Reference: WAC 388-97-1060(1) 48368

Based on observation, interview, and record review, the facility failed to ensure care and services that addressed skin infections and accurate blood pressure treatments were provided in accordance with professional standards of practice for 2 of 5 residents (Residents 44 and 13) reviewed for quality of care. This failure resulted in actual harm to Resident 44 when they experienced unnecessary pain, emotional distress and a decline in their medical condition, and caused unmet care needs and placed Resident 13 at risk for negative health outcomes. Findings included . <Resident 44> Review of the electronic medical records, showed Resident 44 was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial infection of the deep layer of skin) of the right lower leg, lymphedema (swelling caused by a blockage of the drainage of lymph fluid) of the right and left lower legs, heart disease, obesity, and depression. Resident 44's most recent comprehensive assessment, dated 10/31/2023, showed they required extensive assistance of one to two caregivers for bed mobility, transfers, dressing and toileting and were cognitively intact. During an observation and interview with Resident 44 on 12/13/2023 at 11:08 AM, the resident showed their right leg to be significantly larger than their left leg. The right lower leg from the knee down was disfigured with red rough, dry, scaly skin and fluid was draining from many breaks in the skin. The top of the foot was covered with a gauze wrap bandage and the ankle area was dark brown in color with areas of thick hard lumps and multiple thick folds in the skin. Resident 44 stated the lymphedema had gotten worse in the right leg after the foot got a bad infection which required a hospitalization and intravenous antibiotics prior to coming to the facility. The resident stated, under the bandage on the top of the right foot, there were several large deep wounds from the cellulitis and the nurses were changing the dressing on it every day. During the same interview, Resident 44 stated they were being seen by a United Wound Healing (UWH) consultant physician assistant (PA-C) who was supposed to come that day to assess the wound and lymphedema but was told they were ill and would not be coming. Resident 44 stated they were worried that the right leg had yet to be wrapped with bandages for the lymphedema to help with the pain and swelling since they were admitted , and felt the right foot was getting much more swollen, hard, and painful every day. During an interview with Resident 44 on 12/19/2023 at 12:10 PM, they stated their right foot was bothering them because of the lymphedema pain and began crying. They stated their lower right foot and leg felt like a brick and they could hardly move the right foot because it was painful and heavy feeling. They stated it was getting more and more difficult to move and participate in therapies because of this. Resident 44 stated, I just don't understand why no one has done anything yet to decrease this fluid and swelling with lymphedema wraps. Resident 44 stated the wound consultant had told them they had ordered vascular studies, x-rays and blood work ups on their previous visits and needed the results of those before they could safely order the lymphedema wrap treatments. During an observation of a dressing change to the right foot with Staff K, Licensed Practical Nurse (LPN), on 12/19/2023 at 1:05 PM, showed the top of the right foot open in many areas with multiple stages of healing ranging in colors from red to yellow to black and covered the whole top of the foot. Staff K took off the old dressing, cleansed the wounds with saline spray, placed a Xeroform dressing (a petrolatum based fine mesh gauze that has antimicrobial properties) over the wounds, covered them with an absorbent dressing and a gauze wrap. Resident 44 questioned Staff K about the current treatment orders, stating the last nurse who changed the dressing told them they were just following what the treatment order was in November, because there were no current orders on the December Treatment Administration Record (TAR) sheets. Staff K responded, yes there is, it's still the every other day treatment with the xeroform dressing as before. Review of the December 2023 TAR for Resident #44 on 12/19/2023 at 2:00 PM showed there were no orders written for a dressing change to the right foot and lower leg for the licensed staff to follow. Review of the Physician Assistant Certified (PA-C) wound consultant's documentation on 12/20/23 at 2:30 PM, showed they first assessed the wounds on 10/31/2023 and were to assess and treat the wounds once a week after that until healed or the resident was discharged . Review of the PA-C's wound consultant's notes, dated 10/31/2023, showed Resident 44 had a history of lymphedema to both their legs since a motor vehicle accident many years ago with fractures and crushing injuries to the lower back and right lower extremity. The wound provider measured both the right and left lower legs which showed a significant increase in size to the right leg and found four areas of concern identifying them as wounds 1 through 4. Wound 1 was identified as lymphedema to the bilateral lower legs and described the lower right leg as swollen with the hard [NAME] raised areas and fissures (splits and cracks in the skin) seen with severe chronic lymphedema. Wound 2 was described as the right back to front of the foot and ankle, measured as 24 centimeters (cm) width by 16 cm length by 0.1 cm depth. The wound was described as full thickness involvement (damage extends below all layers of the skin into the subcutaneous tissue or beyond, (into the muscle, bone and tendons) with the wound base showing 51-75% slough (yellow/white material of dead tissue separating from living tissue) and 11-25% eschar (brown/black dry dead tissue within a wound). Wound 3 was described as the right lower leg, full thickness involvement, measured as 24 cm x 18 cm x 0.1 cm with the wound base as 26-50 % eschar and 26-50% epithelial (pink or pearly white healing skin tissue). Wound 4 was described as the right side of the foot, full thickness involvement, measured as 4 cm x 4 cm. x 0.1 cm with 51-75% slough and 11-25% eschar. On 10/31/2023, the consultant PA-C ordered the following for the facility to follow through with until their next weekly visit. * Baseline vascular studies for appropriate compression for central lymphatic dysfunction and bilateral lower leg lymphedema. Bilateral lower extremity (BLE) venous ultrasound and arterial ultrasound with ankle/brachial index (ABI) (analyzes the quality of blood flow in the ankle arteries). * Imaging CT scan (computed tomography scan) (an imaging test that helps detect diseases and injuries) CT anterior and posterior (A/P) vascular assessment/baseline for central lymphatic dysfunction/lymphedema (a CT scan with an injection of dye to produce pictures of blood vessels and tissues). * Treatment orders, cleanse wounds with wound cleaner, apply skin prep (a protective barrier to protect the skin from adhesive dressings) to the peri wound (the tissue surrounding a wound) and allow to dry, apply xeroform gauze to open areas, cover with super absorbent dressings, change the dressings every other day and as needed. * Pain control 30 minutes prior to wound treatment, please administer as needed (PRN) pain medication and/or topical anesthetic. * Apply lotion to all areas of dry skin. * Pressure relief, offloading repositioning per facility protocol. * Protein supplement with meals twice daily until wound closure. Review of physician visit notes, nursing progress notes, Medication Administration Records (MARs) and TARs from 10/31/2023 through 11/07/2023 showed no documentation that appointments were made for either ultrasound vascular studies or CT scan imaging for baseline studies as ordered by the PA-C contracted wound care consultant for appropriate compression of the lower extremity lymphedema. Resident 44's TAR's showed from 10/25/2023 through 10/30/2023 the facility nursing staff followed admission orders to clean the right lower leg blisters and open areas with normal saline, apply Xeroform over open wounds and cover with absorbent dressings and wrap with Kerlix (a gauze bandage roll) every day and as needed (PRN). These treatment orders continued from 10/31/2023 through 11/04/2023, though did not show to apply skin prep to the peri wound and did not change to every other day dressing changes from every day as ordered by the PA-C on 10/31/2023. Review of the PA-C wound consultant notes dated 11/07/2023, showed after assessing and treating the wounds the following were ordered for follow up by the facility staff. * To obtain an x-ray of the right foot to rule out concerns of osteomyelitis in the muscle/tendon level wound on the right foot. * Continue to pursue vascular studies for baseline evaluation to manage the bilateral lower extremity lymphedema. Review of the PA-C wound consultant notes dated 11/14/2023, showed after assessing and treating the wounds the following were ordered for follow up by the facility staff. * An X-ray of the right foot was done on 11/07/2023 and stated there was a non-specific notation about concerns of bone infection and it was negative for any fractures. The nursing staff were to contact radiology for an addendum to ensure there is no bony involvement. * Vascular studies, bilateral lower extremities venous ultrasound and arterial ultrasound with ABI's. * Imaging. CT scan A/P vascular assessment/ baseline for central lymphatic dysfunction/lymphedema. * More aggressive pain control routinely and topical (top of skin) and systemic (medication by mouth) pain control prior to dressing changes and UWH visits. Topical lidocaine 4% to the wound bed of right foot prior to dressing changes. Dressing treatment continues with every other day dressing changes and PRN. Review of Resident 44's physician visit notes, nursing progress notes, MAR's and TAR's from 11/07/2023 through 11/21/2023 showed no documentation that appointments were made on the third week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered by the PA-C wound consultant for appropriate compression of the lower extremity lymphedema. In addition, the review did not show that the nursing staff contacted the radiology department for an addendum to ensure osteomyelitis (infection of the bone) was found in the x-ray. Review of the November 2023 TAR's showed from 11/05/2023 through 11/28/2023 wound treatment orders remained the same as the previous orders. There were no orders written to apply the topical lidocaine 4% to the wound bed prior to dressing changes for pain relief, to apply skin prep to the peri wound and again did not change the dressing change order to every other day. Review of the PA-C wound consultant notes dated 11/21/2023, showed after assessing and treating the wounds, they found the wounds to be healing the past three weeks, but the resident was having increased pain during dressing changes. The following were ordered for follow up by the nursing staff. * Imaging x-ray right foot and inflammatory lab work up to rule out osteomyelitis. * Unknown if the CT scan has been obtained for medical necessity of lymphedema management. * Skin care treatment every day and as needed. Cleanse legs with warm water and mild soap. Massage a thin layer of A&D ointment (a Vaseline based ointment) to legs and non- covered areas on the feet. Ensure no moisture gets between the toe web spaces. After cleansing and drying the legs, apply a thick layer of unscented shaving foam to BLE. Soak with warm towels for 15/20 minutes. Wipe away the cream and scaling skin. Pat dry and complete wound treatment. * Systemic and local pain control (topical lidocaine 4% to wound bed right foot prior to dressing changes. Same treatment orders as previous every other day and as needed order. * Offloading with right foot footwear. * Consider a lower dose of systemic pain control prior to dressing changes and wound discomfort. Review of physician visit notes, nursing progress notes, MARs and TARs from 11/14/2023 through 11/28/2023 showed no documentation that appointments were made on the fourth week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered for appropriate compression of the lower extremity lymphedema. In addition, the review did not show that the nursing staff had contacted radiology for an addendum to the 11/07/2023 x-ray or ordered a new x-ray of the right foot to rule out osteomyelitis. Review of Resident 44's November 2023 TARs from 11/05/2023 through 11/28/2023 showed there were no changes to the treatment orders and none of the PA-C wound consultant orders to cleanse the legs, apply the A&D ointment to the legs and feet, apply the shaving cream or soak the legs for 15/20 minutes and wiping away the scaling skin were present. In addition, there were no orders to apply the topical lidocaine 4% to the wound bed prior to dressing changes for pain relief, to apply skin prep to the peri wound and again did not change the dressing change order to every other day. Review of a facility Registered Nurse (RN) Staff O, wound evaluation note, dated 11/28/2023, showed new orders were received to treat the top of the right foot cellulitis area by cleaning with an antimicrobial wound cleaner, apply skin prep to peri wound and allow to dry, cover with super absorbent dressings and change the dressing every other day and PRN. Review of the PA-C wound consultant notes, dated 12/05/2023, stated unable to locate any repeat x-ray or inflammatory lab work ordered for osteomyelitis rule out. Unable to locate any pain control med changes from recommendations made on last visit from hospital in western part of state. Lymphedema assessment of a chronic skin condition that is stalled. The following orders were again requested for follow up by the nursing staff. *Ensure pain control is in place routinely and when doing dressing changes. *Ensure vascular studies are done at the earliest convenience to ensure most appropriate lymphedema management is initiated. Vascular studies BLE arterial ultrasound BLE venous ultrasound ABI's- baseline lymphedema evaluation. *Skin care treatment every day and as needed the same as ordered on 11/21/2023. *Systemic and local pain control (topical lidocaine 4% to wound bed right foot prior to dressing changes. Same treatment orders as previous every other day and as needed order. *Offloading Right foot footwear The 12/05/2023 PA-C documentation further stated, based on today's evaluation, wound healing potential is guarded, and may be delayed. Overall, this patient is at a high risk for complications related to the problems addressed today. Review of physician visit notes, nursing progress notes, MAR's and TAR's from 11/28/2023 through 12/20/2023 showed no documentation that appointments were made on the fifth week request for ultrasound vascular studies and CT scan imaging for baseline studies as ordered. In addition, the review did not show that the nursing staff had ordered a new x-ray of the right foot to rule out osteomyelitis. Review of a wound evaluation note written by Staff O, dated 12/12/2023, showed new orders were received to treat the top of the right foot cellulitis area by cleaning with an antimicrobial wound cleaner, apply skin prep to peri wound and allow to dry, cover with super absorbent dressings and change the dressing every other day and PRN. Review of Resident 44's November 2023 and December 2023 TAR's showed from 11/28/2023 through 12/20/2023 there were no orders written to treat the wounds on the right leg. Review of Resident 44's (MAR's) from 11/01/23 through 12/20/2023 showed an order for two Tylenol, eight hour extended release tablets (1300 milligrams (mg) twice a day as needed for pain. The record showed the resident recieved the Tylenol 19 times from 11/01/2023 through 11/30/2023 and 11 times from 12/01/2023 through 12/20/2023. Review of the MAR showed an additional order was added on 12/05/2023 for Oxycodone (a narcotic pain medication) 5 mg every 12 hours as needed for pain, and to administer one tablet every Tuesday morning at 6:00 am prior to UWH providing treatments. One dose was documented as given on 12/12/2023. Review of Resident 44's care plan, dated 10/25/2023, showed a problem listed for acute pain related to left lower extremity cellulitis with wound infection and an actual skin impairment to the right lower extremity related to cellulitis. There were no interventions listed for the treatments provided including use of a topical pain medication for dressing changes, off-loading of the right foot for comfort, or providing a nutritional supplement with meals to promote healing. During an interview with Resident 44 on 12/21/2023 at 10:12 AM, they stated the wound consultant PA-C had not been in to see them for the past two Tuesdays, 12/12/2023 and 12/19/2023, and they were really worried about the lymphedema getting worse and being so painful. Resident 44 stated they continued to get the dressings changed to the right foot about every day, though no other type of treatment such as leg soaks or any type of lotion or cream had been applied. Resident 44 stated they had not been out of the facility for any vascular studies and could only remember having one x-ray of the foot and one blood draw since admission. Resident 44 stated staff had not been elevating the right foot or providing any type of footwear for protection of the foot. During an Interview with the Director of Nursing (DON) on 12/21/2023 at 10:40 AM, when asked about the PA-C wound consultants orders, they stated they would locate them and provide them to the survey team. At approximately 11:30 AM, the DON provided information on the last orders written on 12/12/2023 by Staff O. The information provided showed no further evidence that the PA-C's orders were followed up on for the 11/07/2023, 11/14/2023, 11/21/2023 and 12/05/2023 consultant orders for treatments and diagnostic studies. <Resident 13> Review of the facility policy titled Drug Regimen Review Policy and Procedure, dated 04/2019, showed the pharmacy was to review each resident's medication regime to ensure that risk and problems were identified and acted upon in a timely manner. Review of the electronic medical record showed Resident 13 was admitted to the facility on [DATE] with diagnoses including heart failure and hypertensive chronic kidney disease (high blood pressure caused by damage to the kidneys). The 09/21/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for dressing, toileting, bed mobility, and transfers. The assessment also showed the resident had a severely impaired cognition. Review of Resident 13's medication orders showed an order, dated 07/25/2023, for amlodipine besylate (a medication that lowers blood pressure) oral tablets, give 7.5 mg by mouth one time a day, please hold for SBP (systolic -the top number of the blood pressure - measures the pressure in the arteries when the heart beats, blood pressure) < 100 (less than 100 millimeters of mercury [mmHg] - a measurement to record blood pressures). Review of a pharmacy recommendation, dated 07/26/2023, showed a pharmacy recommendation to add blood pressure readings to Resident 13's MAR for the amlodipine order. There was no documentation that the recommendation was completed. A second pharmacy recommendation dated 11/30/2023 showed the same recommendation with provider in agreement (signed 12/01/2023). Review of Resident 13's MARs showed the following: August 2023: Amlidopine was given 24 times, held four times. There were three documented blood pressure readings in the medical record - the documented readings did not correspond to the held medication dates. September 2023: Amlidopine was given 26 times, held four times. There were nine documented blood pressure readings in the medical record - the documented readings did not correspond with the held medication dates. October 2023: Amlidopine was given 24 times, held three times. There were four documented blood pressure readings in the medical record - the documented readings did not correspond with the held medication dates. November 2023: Blood pressure readings were added to the MAR on 11/8/2023. Amlidopine was administered 11/1/2023, 11/2/2023, 11/3/2023, and held on 11/6/2023 with no blood pressure readings recorded in the medical record. During an interview on 12/20/2023, Staff H, Licensed Practical Nurse, stated prior to the addition of the blood pressure readings to the MAR in December, the blood pressure was recorded by the nursing assistants and Resident 13 was administered the medication based off that reading. During an interview on 12/20/2023 at 2:36 PM, Staff G, Resident Care Manager, stated the licensed nurse should have documented a blood pressure reading somewhere in the medical record if they had held or administered the medication. During an interview on 12/20/2023 at 2:56 PM, Staff C, Senior Regional Support Nurse, stated they expected the licensed nurse to document the blood pressure in the medical record. Staff C stated they expected the Director of Nursing would have addressed the first pharmacy recommendation in July 2023. WAC-388-97-1060(1) 45117 46722

Based on observation, interview and record review, the facility failed to provide adequate supervision and interventions to ensure the safety of 1 of 2 residents (Resident 26) reviewed for falls. This failure resulted in actual harm to the resident who experienced two falls within 10 hours, that resulted in a major injury; the first fall resulted in a head trauma with a laceration; the second fall resulted in a pelvic fracture. Findings included . Review of the facility's policy titled, Accident/Incident, revised 10/2022 showed a plan to prevent re-occurance is initiated at the time of the incident. <Resident 26> Review of the medical record showed Resident 26 was admitted to the facility on [DATE] with diagnoses including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), delirium (a serious change in mental ability that causes confused thinking and lack of awareness), kidney failure, and muscle weakness. The 09/22/2023 comprehensive assessment showed the resident required physical assistance of one staff member for toileting and transfers. The assessment also showed the resident had a severely impaired cognition. An observation on 12/18/2023 at 9:04 AM, showed Resident 26 asleep in their bed, lying on their right side. The resident had their glasses on and there was a laceration on the top of their forehead. The resident's hair was observed with thick bloody flakes. During an interview on 12/18/2023 at 12:24 PM, Staff I, Nursing Assistant (NA), stated the resident had two different falls with injuries the night before. Review of the nursing progress note, dated 12/17/2023 at 12:12 AM, showed Resident 26 was found in their room, lying on the floor by their roommates' bed and bathroom door. The resident had two lacerations, one to their forehead and the other on the left side of their head. The resident yelled out when they moved their right-side lower extremity. Staff received an order to send the resident to the hospital for evaluation. Further review of the nursing progress notes at 4:03 AM, showed the resident returned from the emergency department (ED), at 3:40 AM with four staples to the top of their head. Review of the hospital ED report dated 12/17/2023 at 3:19 AM, showed Resident 26 had a head injury and scalp laceration. The hospital discharge instructions titled Head Injury, Adult, showed complications after a head injury may occur within the first 24 hours after the injury and an adult should stay with them to observe and monitor for any changes in condition. Review of nursing progress notes dated 12/17/2023 at 9:12 AM, showed Resident 26 experienced a second fall. The Resident was found in their room, on the floor, lying on their left side, between their wheelchair and bathroom. The resident told staff they fell , and their arm and head were hurt. Staff called 911 and Resident 26 was transferred to the ED. Additional review of the nursing progress notes at 1:39 PM, showed the resident returned from the ED and had a right pelvic fracture and a possible hip fracture. Review of the resident's Neurological (pertaining to the brain, spinal cord and nerves) Assessment flow sheet (a form used to assess, monitor, and record neurological signs and symptoms following a head trauma) showed instructions to complete neurological checks every 15 minutes, four times, then every 30 minutes, four times, then hourly, four times, followed by every four hours, four times, then every shift for 72 hours. The assessment consisted of the resident's level of consciousness (level of alertness and awareness), pupil response (pupil size and reaction to light exam to evaluate brain activity), motor functions, to include hand grasps and extremities, pain response, vital signs, and observations. The first entry was recorded on 12/16/2023 at 11:10 PM at the time of the first fall, with level of consciousness, vital signs and pain response documented. The next eight entries were documented as Hospital. On 12/17/2023, the three remaining hourly checks at 3:55 AM, 4:55 AM, and 5:55 AM, showed Refused. Documentation at 9:55 AM and 1:55 PM showed Hospital; 5:55 PM and NOC (night shift) showed Refused. On 12/18/2023, Dayshift showed Refused. The 12/18/2023 Evening shift showed resident vital signs were documented. The 12/18/2023 NOC showed no documentation. The 12/19/2023 Day and Evening shifts showed Refused. The 12/19/2023 NOC and 12/20/2023 Day and Evening shifts showed resident vital signs documented. Out of 25 opportunities for complete neurological checks there were four entries for level of consciousness, four entries for pain response, six entries for vital signs and no documentation of pupil responses, motor functions, or observations of Resident 26. During an interview on 12/18/2023 at 12:42 PM, Staff H, Licensed Practical Nurse, (LPN), stated the resident had two different falls over the weekend. Staff H stated they were to resume the original plan of care, the resident was not to bear weight, and required supervision. Staff H stated the resident was a high fall risk and the resident has fallen in the past when they self-transferred from their bed to their wheelchair or from their wheelchair to their bed. Staff H stated the fall preventions put in place for the resident were a fall mat and staff were to remind the resident they were to use their call light. Staff H stated that they would glance into the resident's room when they walked by to see if they were attempting to get out of their bed. An observation on 12/18/2023 at 12:49 PM, showed Resident 26 was lying on their right side in their bed. Their privacy curtain was closed, and they were not visible from the hallway. During an interview on 12/18/2023 at 2:09 PM, Staff F, NA, stated they were working when Resident 26 returned from the ED after the resident's second fall. Staff F stated they were to redirect the resident to not get out of their bed. Staff F stated the resident requested to use the bathroom and Staff F advised the resident to use their brief and to stay in their bed. Staff F stated the fall preventions they used were a fall mat, bed in the lowest position, privacy curtain left open, and kept the resident's wheelchair away from them. During a follow-up interview on 12/21/2023 at 9:14 AM, Staff F stated on the morning of 12/17/2023 at 8:00 AM, Staff L assisted them with providing care to the resident and placed the resident into their wheelchair for breakfast by their bedside tray table. Staff F stated that they left the room and 15 minutes later they found the resident on their floor. Staff F stated prior to this fall, they had checked on the resident twice since 6:00 AM. Staff F further stated they should have stayed with the resident during their breakfast; it was not safe to leave the resident. During an interview on 12/18/2023 at 3:28 PM, Staff N, NA stated they were informed the resident had two falls over the weekend. Staff N stated the new fall interventions were to observe the resident more often. An observation on 12/18/2023 at 3:30 PM, showed Resident 26 was lying in their bed and their privacy curtain was pulled closed and they were not visible from the hallway. During an interview on 12/19/2023 at 9:09 AM, Staff G, Resident Care Manager (RCM), stated that prior to the falls, the resident would be in their wheelchair in the hall. Staff G stated since the fall with the pelvic fracture, the resident had been declining. The resident was now on bedrest and was eating less. Review of the physician orders dated 12/17/2023 at 2:00 PM, showed the resident was non-weight bearing to their right lower extremity. There was no physician order for bedrest. During an interview on 12/19/2023 at 1:09 PM, the Resident's Representative stated they were informed the resident experienced two falls over the weekend after they slipped out of their wheelchair. The Resident's Representative stated they received a call every few weeks or so that the resident had fallen. They stated the resident received staples to their head from the first fall and then a second fall in the morning resulted in a fractured pelvis. The Resident's Representative stated these were the most severe injuries the resident experienced during a fall. During an interview on 12/20/2023 at 12:33 PM, Staff M, LPN, stated they were the nurse on shift when Resident 26 had their first fall on 12/16/2023. Staff M stated they were alerted by Staff W, NA, that the resident was found on their floor between their roommate's bed and the bathroom door. Staff M observed the resident on the floor with a gash on their forehead and a large puddle of blood on the floor. They rolled the resident onto their back and the resident yelled out that their right leg was in pain. 911 was called and the resident was taken to the ED. Staff M stated they were not sure how the resident came to be on the floor with the injuries. Staff M stated when the resident returned from the ED they were placed into their bed and went to sleep for the night. Staff M stated the resident did return with staples to their forehead from the fall. Staff M stated upon their return to work the following night, 12/17/2023, they were informed the resident had a second fall during the morning that resulted in a pelvic fracture. Staff M stated when a resident returned from the hospital, the protocol included completing an assessment, obtaining vital signs, and performing neurological checks. Staff M stated that neither shift completed an assessment for the resident. Staff M stated the fall prevention that was in place was the fall mat. An interview on 12/21/2023 at 8:24 AM, Staff L, Registered Nurse (RN), stated they were notified Resident 26 had a fall during the night. Staff L stated they and Staff F, NA proceeded to get the resident dressed and into their wheelchair for breakfast on the morning of 12/17/2023. Staff L stated the resident was afraid of falling and stated don't let me fall, when they were getting them ready in the morning. Staff L stated the resident's bedside tray table was up against the wall, with the resident in their wheelchair for breakfast. Staff L stated they left the residents room at 8:25 AM and they were alerted by Staff F at 8:45 AM that they had found the resident on their floor in their room. During an interview on 12/20/2023 at 2:33 PM, Staff B, Interim Director of Nursing (DON), stated that the expectation for staff when a resident returned from the emergency department, were to review the emergency department paperwork, perform neurological checks and assessments, obtain vital signs, review orders, and notify family and providers. During a second interview on 12/21/2023 at 9:48 AM, when asked if the resident was left in a safe position, alone in their wheelchair without supervision, and a known head injury, Staff B declined to answer. Reference WAC: 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to notify the provider (physician or nurse practitioner) following a resident's complaint of new onset chest pain for 1 of 2 residents (Resident 22) reviewed for change in condition. The failure to notify the provider in a timely manner resulted in harm to Resident 22 when they experienced distress, delay in treatment, and prolonged pain. Findings included . Review of the facility policy titled, Managing Acute Condition Change (MACC), revised on 02/2018, showed the Resident Care Manager (RCM) or charge nurse would assess the resident experiencing an acute change. The facility would notify the physician and family/responsible party without delay when a change in condition had been identified. <Resident 22> Review of the electronic medical records showed Resident 22 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm) and a history of a heart attack. The 09/15/2023 comprehensive assessment showed the resident required extensive assistance of two staff members for transfers, dressing, and toileting. The assessment also showed the resident had an intact cognition. A concurrent observation and interview on 12/12/2023 at 9:44 AM, showed Resident 22 in their room, sitting hunched forward in their motorized wheelchair. Resident 22, with grimaced expression, complained of constant, stabbing chest pain that radiated to their right side, mid-back area. Resident 22 stated several years ago they experienced a heart attack that presented as pain in the right shoulder and was concerned that their current pain was a heart attack. They stated their pain started three to four days ago, but the pain during the previous night was excruciating. Resident 22 stated the pain was so intense during the night, that they put their call light on for help. A nurse answered the call light and looked at their back. Resident 22 stated the nurse told them there was a red spot on their back and it was probably from the belt that was used with the sit to stand mechanical lift (used for transfers). The night nurse put a pad over the red spot, but that did not help the pain. The resident stated they spoke to Staff H, Licensed Practical Nurse (LPN), that morning and was told the night nurse left a note for the Nurse Practitioner to see the resident the next day (12/13/2023). Resident 22, with tears in their eyes, stated they wanted to see a doctor right away because they suffered so much in bed that previous night but didn't want to go against what Staff H had told them. Resident 22 stated they requested pain medication during the night and again that morning but was told there was nothing else to give them, just their scheduled Tylenol (a medication used to treat minor aches and pains). During an interview on 12/12/2023 at 10:07 AM, Staff H stated Resident 22 had complained of pain that morning. They stated the night nurse felt it was from the sit to stand belt and put a dressing over a red spot on their back. Staff H stated they were monitoring Resident 22 and had put them on the schedule to see the Nurse Practitioner the following day - if the resident was still complaining of pain. Staff H stated the resident was not placed on alert charting and no vital signs (measurements of the body's most basic functions, including body temperature, blood pressure, respirations, and pulse) were obtained. Staff H stated the last blood pressure was taken on 12/10/2023. An observation on 12/12/2023 at 1:35 PM, showed Resident 22 in bed, lying on their back with a washcloth over their eyes. Resident 22 did not respond when spoken to. An observation on 12/13/2023 at 10:47 AM showed Resident 22 sleeping in bed, curled into the fetal position on their left side. Resident 22 did not respond when spoken to. During an interview on 12/14/2023 at 10:26 AM, Collateral Contact 1 (CC1), Nurse Practitioner (NP), stated the facility should have notified them on Tuesday (12/12/2023), when Resident 22 first complained of chest pain, especially with their history of a heart attack, I should have gotten a phone call. CC1 stated they were not notified of pain, just a request for nausea medication, and when they saw Resident 22, late afternoon of 12/13/2023, they had no complaints of nausea, but I absolutely should have been notified by phone regarding the chest pain. CC1 stated knowing now that Resident 22 had shingles, they would still have expected to be notified; the resident only had Tylenol for pain and the type of pain caused by shingles would not have been relieved by Tylenol. CC1 stated, had the facility notified them of the complaints of chest pain, the resident would have been seen at the emergency room and would have received treatment and pain management for the shingles. During an interview on 12/19/2023 at 12:10 PM, Resident 22's Representative, Collateral Contact 2 (CC2) stated they had received a text message from the resident stating they were having pain that felt like their heart attack in the past. CC2 stated it was more concerning that Resident 22 would state that, as it was usual for them to complain of that type of pain. Review of Resident 22's care plan, dated 09/28/2023, showed an intervention for pain as Anticipate the resident's need for pain relief and respond immediately to any complaint of pain, initiated on 06/14/2023. Review of the December 2023 Medication Administration Record (MAR), showed Resident 22 had an order for Tylenol 1000 milligrams (mg) three times a day, initiated on 11/06/2023. Additional review showed Resident 22 had new orders dated 12/14/2023 for Ibuprofen (an anti-inflammatory medication used to treat mild to severe pain) 400 mg twice a day as needed for five days, Lidocaine HCL External Gel 2% (a topical medication used to treat pain), apply to right upper back/chest topically as needed for shingles pain, may use twice a day. The MAR showed an order was placed on 12/15/2023 for Lidocaine External Patch 1.8% (a patch containing medication used to relieve the pain caused by shingles [a viral infection that causes a painful rash]). During a follow up interview on 12/19/2023 at 1:44 PM, Resident 22 stated I wasn't afraid to have a heart attack, I was afraid the staff wouldn't chase that (possibility that chest pain was a heart attack) .I wanted to be sure I wasn't having a heart attack. During an interview on 12/20/2023 at 4:03 PM, Staff B, Director of Nursing, stated that if a resident complained of excruciating pain, and the nurse felt an SBAR (a communication tool to provide prompt and appropriate communication to a provider) was needed for additional pain medications, there should have been a phone call to the provider at that time. Staff B further stated their expectation was to notify the provider with a change in a resident's condition. Reference: WAC 388-97-0320(1)(b)(c)

Based on observation, interview, and record review the facility failed to ensure that 1 of 3 residents (Resident 1) reviewed for indwelling urinary catheters (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag), was referred to a urologist for evaluation of the continued need for the urinary catheter. Resident 1 experienced harm when after nine months of use, they experienced a urethral (a tube that connects the urinary bladder to an opening for the removal of urine from the body) erosion (a place where surface tissue has been gradually destroyed) pressure injury (localized damage to the skin as well as underlying soft tissue sometimes related to medical devices). Findings included . Record review of the facility's policy titled, Indwelling Urinary Catheter, dated 02/2019, showed that: - residents who enter the facility without a catheter will not be catheterized unless medically necessary, - a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates catheterization is necessary. Conditions may include urinary retention that cannot be treated or corrected medically. Record review of the facility's policy titled, Skin at Risk/Skin Breakdown, dated 09/2020, showed that newly identified skin impairment (abrasion, excoriation, pressure sore, rash, or skin tear), the licensed nurse will notify the physician, notify the resident representative, document findings in the resident's record and identify interventions to promote healing and or resolution the skin impairment. Review of a December 2010 Wound Management and Prevention article titled Indwelling Urinary Catheter-Associated Urethral Erosion in Elderly Men, showed that medical devices such as indwelling urinary catheters have caused pressure injuries called urethral erosion. Urethral erosion in men ranges from a partial-thickness wound involving a small area of the glans (tip) penis to a full-thickness pressure injury, or erosion, cleaving (splitting) the glans or penile shaft. <Resident 1> Review of Resident 1's medical record showed they were admitted from another long term care nursing facility on 03/09/2022 with diagnoses to include Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), benign prostatic hyperplasia (BPH, a condition where benign (non-cancerous) nodules enlarge the prostate gland (the gland that produces the liquid in which sperm are expelled from the penis), and obstructive uropathy (a condition where urine cannot flow normally through the urinary tract). Review of the 03/15/2022 comprehensive assessment showed Resident 1 was cognitively intact, was incontinent of bladder and bowel and did not have an indwelling urinary catheter. Review of a discharge summary from the previous nursing facility dated, 03/08/2022, showed that Resident 1 had BPH with urinary retention, was medicated with tamsulosin (a medication that works by relaxing the muscles in the prostate and bladder so that urine can flow easily), and would need to see a urologist (a medical provider that specializes in diagnosing and treating diseases of the urinary system) for follow up on a yearly basis. Review of Resident 1's physician orders from 03/09/2022 to 09/22/2023 showed no orders or referrals for a urology consult. Review of an acute physician exam, dated 10/02/2022 at 11:10 AM, showed Resident 1 was observed in no acute distress, comfortable and the resident denied any problems with urination. The plan for Resident 1's BPH was to continue with the tamsulosin medication. Review of a provider progress note, dated 12/22/2022 at 8:42 PM, showed Resident 1 was sent to the hospital for a change in condition. Review of a post hospital physician exam, dated 12/27/2022 at 12:53 PM, showed Resident 1 was readmitted to the facility on [DATE] after an acute hospital stay for a urinary tract infection (UTI, an infection of any part of the urinary system) with an indwelling urinary catheter. Review of a 12/29/2022 at 8:50 PM nursing communication to the physician showed that Resident 1 returned from a hospital stay with a foley (a type of urinary catheter) catheter and recommended a physician order to discontinue the foley catheter with a voiding (the act of urinating) trial and post void residual (the amount of urine that remains in the bladder after urination) assessment. Review of a 01/04/2023 at 12:59 PM nursing progress note showed the physician talked to Resident 1 about their catheter and void trial today and the resident wanted to keep the catheter. Review of a physician progress note, dated 01/04/2023 at 1:07 PM, showed Resident 1 refused to have their foley [catheter] removed, the resident said they felt better with the catheter; the resident was educated on the increased risk for recurrent UTI's secondary to the continued use of the foley [catheter] and [Resident 1] stated they would take the risk. Review of the medical record showed no order/referral for Resident 1 to see a urologist (a physician who specializes in the study or treatment of the function and disorders of the urinary system). Review of a 09/03/2023 at 4:11 PM nursing progress note showed documentation that no urine was collected in the resident's catheter bag between 6:00 AM and 12:00 PM and a scan of Resident 1's bladder showed 390 milliliters (ml) residual urine in the bladder (a volume of less than 50 ml is considered adequate bladder emptying; in the elderly, between 50-100 ml is considered normal. In general, a volume greater than 200 ml is considered abnormal and could be due to incomplete bladder emptying). The catheter was changed and after removal thick, light green discharge came from the urethra and a urine sample was sent to the lab for analysis. The resident was diagnosed with a UTI on 09/06/2023 and antibiotics were ordered. Review of a nursing progress note, dated 09/15/2023 at 6:33 AM, showed Resident 1 was sent to the hospital for a change in condition, was diagnosed with a UTI, sepsis (a bacterial infection in the bloodstream or body tissues) and respiratory failure. The resident was admitted to the intensive care unit. Review of an in-hospital wound report with photo, dated 09/15/2023 at 5:29 PM, showed Resident 1 was assessed to have a pressure injury on their penis from the chronic indwelling foley catheter. The photo showed a 2-inch split in the penis tip from the urethra on the inferior (low or lower in position) aspect of the glans penis. Medical record review showed no documentation of the pressure injury to Resident 1's penis. Review of a nursing progress note, dated 09/19/2023 at 12:54 PM, showed Resident 1 was readmitted to the facility. During a concurrent interview and observation on 09/19/2023 at 3:05 PM showed Resident 1 in their bed, alert and oriented. There was a covered urinary catheter bag secured on the left side of the bed frame. Resident 1 stated they got the catheter sometime after they moved to the facility and was not aware of any injury to their penis. Staff E, Nursing Assistant (NA) and Staff F, NA, provided catheter care (a process to clean a urinary catheter tube where it exits the body) for Resident 1. The injury was observed and the resident denied any discomfort in the area. During an interview on 09/19/2023 at 3:45 PM, Staff B, Interim Director of Nursing, stated they had not read Resident 1's hospital report yet nor were they aware of a pressure injury to the resident's penis. During an interview on 09/21/2023 at 10:30 AM, Staff G, Physician Assistant-Certified (PAC)/Contracted Wound Specialist, stated they consulted on Resident 1's skin in June 2022 and had not received a referral from the facility to assess a pressure injury on the resident's penis. Staff G stated that chronic foley catheter use can cause a mucosal membrane pressure injury to the male urethra. During an interview on 09/22/2023 at 11:45 AM, Staff J, NA, stated they had provided catheter care for Resident 1 and the injury to their penis had been there for several months. During an interview on 09/22/2023 at 12:05 PM, Staff D, Licensed Practical Nurse, stated that Resident 1 had no erosion on the top of their penis when they were admitted . Staff D recalled that when Resident 1 returned from the hospital with the foley catheter, the resident refused to let the physician have it removed. [Resident 1] probably should have gone to a urologist at that time. Staff D stated they were aware of the injury to the resident's penis but did not remember when it happened, and it should have been documented in the resident's record. Staff D stated they were not sure if a physician had been notified about the injury either. During an interview on 09/22/2023 at 12:34 PM, Staff H, Registered Nurse /Resident Care Manager (RCM), stated when residents were admitted with a foley catheter they would need an appropriate diagnosis and we would do a voiding trial to see if the resident still needed the catheter. Staff H stated residents with chronic urinary catheters were usually referred to a urologist. Staff H stated they started the RCM position recently, had Resident 1 on their case load and was not aware if they had been seen by a urologist. During an interview on 09/22/2023 at 1:00 PM, Resident 1's Representative (RR1) stated they did not think the resident needed the catheter because it increased the risk of infections, and the resident was urinating just fine before the catheter was placed. RR1 stated Resident 1 told them they wanted to keep the catheter because it was easier that way and they would not have to wait for staff to change their brief. RR1 stated Resident 1 had been to a urologist in the past, but not since admitted to this facility. RR1 was asked if they were informed by the facility of Resident 1's pressure injury to their penis and stated, No. I had no idea. How horrible, that just makes me sick. RR1 was crying and appeared very upset. During a telephone interview on 09/22/2023 at 1:50 PM Staff I, Medical Doctor, stated they completed a readmission evaluation for Resident 1 earlier that day. They stated they were not aware of a pressure injury to the resident's penis as he was not informed and did not see the pressure injury. Reference WAC 388-97-1060(3)(c)

Based on interview and record review the facility failed to assess the increased risk of skin breakdown and implement interventions necessary to prevent the development of pressure injuries for one of two residents (1), reviewed for pressure injuries. This failure caused harm to the resident when they developed two facility-acquired, unstageable pressure injuries on their right foot. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Stages include: *Stage II: Partial thickness loss of dermis (middle layer of skin in your body) presenting as a shallow open ulcer with a red pink wound bed. *Unstageable: full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown material in the wound bed) and/or eschar (tan, brown or black dead tissue that sheds or falls off from the skin) in the wound bed. Resident 1. Per the medical record, the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's most recent comprehensive assessment, dated 04/05/2022, showed they were cognitively intact and required extensive assistance of one to two caregivers for bed mobility, transfers, dressing and toileting. Additionally, Resident 1 received physical and occupational therapy services daily for strengthening, mobility and fall prevention while in the facility and discharged to their prior lesser care setting on 04/29/2022. Review of Resident 1's 03/30/2022 admission transfer orders to the facility showed they were to wear a right leg brace walking boot for stabilization of the distal fibula fracture and could bear weight on the right foot as tolerated. Review of Resident 1's admission assessment, dated 03/30/2022, showed they had no skin breakdown present. Further review of facility assessments to predict the resident's risk to develop pressure injuries (Braden Scale), dated 03/30/2022 and 04/06/2022, showed the resident was at a moderate risk for the development of skin breakdown. During a phone interview with Resident 1 (they had discharged back to their Assisted Living Facility) on 05/06/2022 at 9:50 AM, they stated they obtained two deep pressure injuries to the right foot under the walking boot they had to wear for the fracture while in the facility. They stated one wound happened to the right second toe because a nurse put the brace on wrong one morning. Resident 1 stated they informed the nurse and several others that day that the boot was on wrong and caused a lot of pressure on their toes. The boot was never removed and staff did not look at the resident's foot until after they were in bed that evening. The resident stated by that time there was an open sore on it that was very painful. Resident 1 then stated that a few days later their right heel began hurting and was throbbing in pain under the boot. They informed facility staff and was told by a nurse that they had a black pressure injury on the heel. Resident 1 stated they called their family to report the pressure areas and asked to see their physician as they were very worried because of their diabetes, the wounds would be difficult to heal and could quickly worsen. Review of the facility's nursing progress notes showed on 04/16/2022 at 9:37 PM, Staff B, Registered Nurse (RN) wrote, 1.4 centimeter (cm) by 0.5 cm abrasion found on the top of the right foot index pointer toe. Deep red in the center, lighter red around the edges. Monitor for signs and symptoms of increased tissue damage, infection or pain. There were no further nursing notes showing Resident 1's physician or a facility provider was notified of the injury to the toe. Additional review of the nursing progress notes showed on 04/20/2022 at 10:50 AM, Staff B wrote, Resident voicing pain in right heel, site assessed and new nonstageable wound found at right heel. Practitioner notified and new orders given for care. Review of a practitioner's visit note, dated 04/20/2022, showed Resident 1 was seen for evaluation of their new wounds on the right second toe and the right heel. The note stated, per the resident's report, the brace to her right lower extremity was ill placed and cut into the toe and it was unknown how the heel injury happened. The practitioner described the right second toe as an unstageable pressure wound with hard eschar present in the wound bed. Orders to paint the toe with [MEDICATION(S)] (an antiseptic skin cleanser) daily were given and requested a referral to an outside wound specialist for continued management. The right heel wound was described as a partial thickness wound that was unstagable. Orders were given to cleanse the wound with a no sting cleanser then cover it with an absorbent foam dressing and change the dressing every other day. Referral to the wound specialist was also made for this wound. During an interview with Resident 1 on 05/10/2022 at 9:26 AM, they stated they were having pain and drainage from both of the wounds on the right foot and just began to have a home health nurse come to the apartment three times a week to change the dressings and monitor the wounds. During a telephone exit conference with the facility Administrator and Staff A, the Director of Nursing (DON), on 05/10/2022 at 11:06 AM, the DON stated they were aware Resident 1 developed two pressure injuries on their right foot while in the facility and none were present on admission. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review the facility failed to assess, monitor, and appropriately treat the development of pressure injuries for one of four residents (#1) admitted to the facility without pressure injuries. This failure caused harm to the resident when he developed avoidable unstageable pressure injuries to his buttocks which resulted in hospitalization for infected pressure injuries. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer (Injury) Stages include: * Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate at risk persons. * Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed. * Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown material in the wound bed) and/or eschar (tan, brown or black dead tissue that sheds or falls off from the skin) in the wound bed. Resident #1. Per the medical record the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's most recent comprehensive assessment, dated 08/18/2021, showed he was cognitively intact and required extensive assistance of one to two caregivers for transfers, bed mobility, dressing, toileting, and personal hygiene. Review of the hospital's discharge form, dated 08/12/2021, showed no wounds were present to Resident #1's buttocks at the time of discharge to the facility. Review of the facility's admission assessment. dated 08/12/2021, showed the resident had no skin problems noted to his buttocks. Further, review of a facility assessment to predict the resident's risk to develop pressure injuries (Braden Scale), dated 08/12/2021, showed he was at a high risk for the development of skin breakdown. Review of the facility's nursing progress notes showed on 08/19/2021 Staff D, Licensed Practical Nurse (LPN), wrote Resident has a 2.5 (by) 2.5 centimeter (cm) open area on the left side of buttocks. On the right buttock is a 2.5 (by) 2.0 cm fluid filled blister, area cleaned, no drainage, barrier cream applied. There were no further nursing notes that showed Staff D notified Resident #1's physician or a facility provider of the skin breakdown. Further review of the progress notes showed later in the evening on 08/19/2021 and on 08/20/2021, Staff E, LPN, wrote the resident had worsening skin issues though the notes did not indicate the location of the skin issues or that a provider was notifed of the worsening. On 08/21/2021 Staff F, Registered Nurse (RN), wrote in the nursing notes, Resident blisters on both side of his coccyx (tailbone) are open and he now has several moisture associated open areas. The note did not show the size, stage or location of the open areas or note that a provider was notified of the multiple open areas. On 08/22/2021 a nursing note showed Resident #1's Nurse Practitioner (NP) called the facility to check on the resident and at that time Staff F informed the NP of the development of the open areas to the buttocks. On 08/23/2021, a Physician Assistant Certified (PA-C) wound treatment consultant from an outside wound provider, assessed Resident #1's wounds in the facility and recorded five different areas of concern to the buttock region as follows: 1. a proximal (situated nearer to the center of the body) sacral (area at the bottom of the spine) blister measuring 6.1 cm (length) x 5.6 cm (width) x 0.1 cm (deep) 2. a left proximal buttock blister measuring 8.3 cm x 3.3 cm x 0.1 cm 3. a right proximal buttock blister measuring 4.2 cm x 2.2 cm x 0.1 cm 4. an unstageable sacral pressure injury measuring 6.8 cm x 5.2 cm with 90% slough present in the wound bed. 5. an unstageable right buttock pressure injury measuring 3.8 cm x 2.2 cm with 80% slough present in the wound bed. The PA-C ordered the following treatments to the wounds on 08/23/2021. Collagen (a wound healing powder) to the wound beds every other day and as needed and to cover the wounds with a superabsorbent (multilayer wound covers with highly-absorptive layers) dressing for wounds #4 and #5. Treatment orders for wounds #1, #2, and #3 were to apply [MEDICATION(S)] (a topical steroid cream for skin problems), [MEDICATION(S)] cream (a topical cream used for fungal skin infections) and A&D ointment (a topical ointment used for skin protection) to the wound beds every day and as needed and to cover the wounds with a protective dressing. On 08/30/2021, the PA-C from the outside wound provider, assessed Resident #1's buttock region wounds again and stated in her progress notes that the buttock and sacral wounds had increased maceration (wet,weak skin surrounding the wounds) and increased slough in them. The PA-C changed the treatment orders at that time to a different type of ointment for wounds #1, #2, and #3, kept the orders the same for wound #4, and changed orders to a [MEDICATION(S)] ointment (removes damaged tissue from a wound) for wound #5. Review of Resident #1's nursing treatment administration records (TARs) showed from 08/25/2021 through 09/03/2021 there was only one treatment listed which read, Apply [MEDICATION(S)] (a topical ointment to treat or prevent minor skin irritations) to buttocks every shift until healed. The TAR showed that facility nurses documented they performed this treatment each shift through the above time period. The PA-C treatments for healing for Resident #1's buttock wounds were not processed as ordered on 08/23/2021 or on 08/30/2021 and were not placed on the TAR record for the nurses to provide the ordered treatments. Review of Resident #1's care plan did not show that the buttock wounds had been added as an actual skin impairment problem and no interventions or treatments were put into place to treat the current pressure injuries or to prevent others from developing. During an interview with Staff G, RN/Resident Care Manager (RCM), on 10/12/2021 at 4:00 PM, she stated she accompanied the PA-C on the wound rounds once a week and she was the one who was supposed to assure that any new orders given for treatments were processed and put on the TAR's for the nurses to provide the treatments. During the same interview, Staff G stated that she was behind on getting the wound round treatment orders caught up because she was the only RCM currently working. She stated I know that things have fallen through the cracks and orders have not been implemented as they should have been. During a telephone interview with Resident #1 on 09/30/2021 at 1:14 PM, he stated that he had discharged himself from the facility against medical advice (AMA) on 09/03/2021 because the facility caused a pressure injury on his bottom and he didn't feel like they were doing anything they were supposed to do to heal it. He stated he was scared as he had never had a pressure wound before and called a friend and previous caregiver to take him home and assess his wound. Review of a Social Services progress note, dated 09/03/2021, showed, Resident leaving for home AMA, set up his own ride. AMA form signed. During an interview with a previous caregiver of Resident #1 on 09/30/2021 at 12:50 PM, she stated Resident #1 had asked her to look at a wound on his bottom after he got home. She stated she saw a huge, deep sore on his bottom with gauze stuffed up inside of the wound. She stated she felt it was infected and called an ambulance to transport him to the hospital. Review of Resident #1's hospital records showed a stay from 09/04/2021 through 09/09/2021. Records showed he was admitted for an infected pressure injury where he was treated with antibiotics and recieved wound care to his buttock region. Discharge hospital records, dated 09/09/2021, described the wound on discharge in part as, .sacral area with pressure injuries which are all grouped together as there are more than 4 open areas. Wound measures 16 cm (by) 11 cm (by) 0.3 cm, 30% of wound Stage 1, 30% epitheleal tissue (pink healing tissue) 35% slough and 5% granulation (red healing tissue). The patient was discharged home from the hospital with home health services for wound care. During an interview with the Director of Nursing and the Facility Administrator on 10/13/2021 at 4:05 PM, both stated understanding that Resident#1's pressure injuries to his buttocks were avoidable and treatable if appropriate assessments and treatments were done following his admission to the facility. Reference WAC 388-97-1060(3)(b)

Based on interview and record review the facility failed to ensure one of three residents (Resident #1) reviewed for falls, was transferred safely utilizing a mechanical lift. The failure to have sufficient staff in place while using the mechanical lift caused Resident #1 to fall from the mechanical lift, sustaining actual harm with fractures of the spine. The fractures of the spine required immediate hospitalization with surgical intervention. Findings included . Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/04/2020 comprehensive assessment showed the resident required extensive assistance of two staff with all mechanical lifts for transfers. The resident had some impairment with memory, but was able to make his needs known. The 12/01/2020 care plan showed the resident was at high risk for falls and the resident required two staff when transferring with a mechanical lift. During an interview on 12/10/2020 at 1:15 PM with Staff C, Registered Nurse (RN), she stated the resident was compromised medically and used a mechanical lift when he was at the hospital as the resident was not able to support his weight. According to Staff C, the resident was assessed for use of the Hoyer lift, (full body mechanical lift) which always required a two person protocol. Staff C stated that occupational therapy evaluated Resident #1's transfer status on 12/03/2020 and changed to a sit-to-stand mechanical lift so the resident would be lifted from a sitting to a standing position with a sling under their arms. During an interview on 12/10/2020 at 1:28 PM, Staff H, Occupational Therapist (OT), stated that she assessed the resident for use of the sit-to-stand mechanical lift and on 12/03/2020 was with Staff D, Nursing Assistant (NA), when the assessment for the use of the sit-to-stand mechanical lift was being conducted. Staff H stated the assessment on 12/03/2020 for the sit-to-stand was successful and stated that the resident could be transferred with it. A review of a 12/04/2020 Fall Incident Report showed at 10:00 AM, Staff D, NA, transferred Resident #1 by herself with the sit-to-stand lift and wheeled the resident in the mechanical lift to the bathroom. The sit-to-stand which used a battery to operate the lift up and down, lost power as Staff D started to lower the resident in the lift. Resident #1 was stuck in the lift with the sling under the resident's arm and connected to the lift. Staff D left the resident alone in the bathroom on the sit-to-stand at this time, and went to get some help. The resident fell against the wall by the commode and still had the sling under his arms. During an interview on 12/10/2020 at 1:40 PM with Staff E, Registered Nurse (RN), she stated that Staff D ran out of the resident's room and asked her to help. Staff E stated the resident was on the floor against the bathroom wall and stated he hit his head and complained of right hip pain. Staff I, Physical Therapist (PT), and a physician that was currently in the facility, assessed Resident #1. Staff I and other staff moved the resident to a bedside commode and called the ambulance. Resident #1 was transported to the local hospital. During an Interview on 12/10/2020 at 1:50 PM, Staff I stated that she was in the facility when the incident occurred and assessed the resident and helped move the resident. Staff I stated that she had one therapy session with the resident and that he was very weak. A review of the 12/04/2020 undated statement from Staff C, showed she spoke to Staff D and explained that the incident that occurred with the resident should not have happened and that safety was first. According to Staff C, Staff D did not follow the two person transfer policy or the resident's care plan for mechanical lifts as required. Staff D agreed that she required more training using equipment properly. Staff D was suspended pending final investigation. During an interview with Staff D on 01/04/2021 at 11:15 AM, Staff D stated she transferred Resident #1 by herself with the sit-to-stand and the lift became non-functional when she transported the resident to the bathroom. Staff D stated she panicked and left the resident on the lift and tried to get someone to help. By the time staff returned to the bathroom, Resident #1 was on the floor against the wall. Staff D stated that she knew she was wrong for trandferring the resident by herself with the sit-to-stand lift, and leaving the resident connected to the lift when it lost power. Review of Staff D's personnel record showed she was a new nursing assistant (registered) and employed by the facility on 09/09/2020. The 09/15/2020 Nursing Assistant Employees Skills Checklist showed that Staff D was checked off as completed and demonstrates transfer of resident from bed to chair .by use of hydraulic/mechanical lifts. This included storage and location, battery/recharging the battery. A review of the 12/04/2020 hospital report from Virginia Mason Medical Center-Seattle showed the resident sustained [REDACTED]. There was also significant bruising around the ankle. The resident's medical record also showed he had a previous hospitalized from [DATE] to 12/01/2020 at another hospital and he was discharged without a fracture. During an interview on 12/24/2020 at 11:00 AM, the Director of Nursing Services (DNS) stated she thought the resident had a previous fracture from a previous hospitalization on [DATE] but that was not the case according to the 12/04/2020 hospital admission and discharge records. The DNS also stated it was a poor transfer and safety situation for the resident. Staff D did not follow the safety protocol for transfer with the sit-to-stand. Reference WAC - 483.25(d)(1)(2)-1060(3)(g) This is a repeat citation from 08/14/2019.

Based on interview and record review, the facility failed to fully develop a process for notifying residents, their representatives each time a confirmed COVID-19 laboratory test result was identified as positive for two of three residents (Resident #s 2 and 3), reviewed for COVID status. The facility failed to inform the representative of Resident #2's positive COVID status and the resident passed away without representative notification. The facilty also failed to notify Resident #3's representative about the current COVID status (positive staff) in the facility prior to the resident's discharge. This failure put residents and their representatives at risk of not being fully informed of COVID-19 activity in the facility, and at risk of spreading COVID into the community. Actual exposure to COVID-19 to the resident and potential exposure of representatives when the facility had knowledge of a positive COVID-19 staff member before the resident discharged for which they failed to inform the resident or representative, placed them at a potential risk of spreading COVID out into the community. The deficiency occurred during the July 2020 COVID-19 outbreak. This failure caused psychological harm to residents and representatives who lost a resident without the ability to have face-to-face contact due to the facility's lack of notification to the representatives. Another resident was discharged home with their representative and there was no notification by the facility that the resident was exposed to COVID-19 and then later tested positive for COVID-19. Findings included . Resident #3. Review of the medical record showed the resident was admitted to the facility on [DATE] with a closed [MEDICAL CONDITION] left leg, high blood pressure, and a stroke. He required extensive assistance with transfers. A review of the 07/19/2020 comprehensive assessment showed the resident had a cognitive decline but could make his needs known. During an interview on 09/16/2020 at 10:00 AM, the resident's representative stated the local Health Jurisdiction, (LHJ), called her on 07/14/2020 and stated the resident had tested positive for COVID-19. The physician called the representative on 07/15/2020 and asked if the do not resuscitate order was current for the resident. She stated the only other phone call was when the facility's previous Director of Nursing Services, (DNS), called the resident's representative on 07/21/2020 at 8:30 AM to inform them the resident passed away, (less than one week later.) According to the representative, there was a time when she was unable to talk to the resident when he became nauseated. A review of the progress notes from 07/10/2020 through 07/21/2020 showed the following by licensed nurses and physician: 1. On 07/15/2020 at 3:43 PM the physician Discussed with daughter and son, affirmed patient wishes for do not resuscitate. 2. On 07/21/2020 at 10:17 AM, the resident passed away at 8:30 AM and Director of Nursing Services notified the family. During the 09/24/2020 interview at 11:46 AM, Staff A stated the physician called the representative and verified the do not resuscitate order, and thought she notified the representative but there was no documentation as to notification of the representative that the resident had COVID-19 positive test result. Resident #2. Review of the medical record showed the resident was admitted to the facility on [DATE] and discharged to home on 07/09/2020. The resident's [DIAGNOSES REDACTED]. Review of the 07/09/2020 comprehensive assessment showed the resident was cognitively impaired but able to make needs known. He required some supervision but mainly independent with transfers, toileting and ambulation. During an interview on 12/21/2020 at 1:56 PM, a representative stated the resident was discharged from the facility without notification to the resident or the representative that a staff member at the facility was positive for COVID-19. The representative stated a neighbor who currently had a representative at the same facility received a notice on 07/10/2020 that the facility had a positive staff member. The representative for the resident that was discharged on [DATE] didn't receive a letter or notice. She then called the facility and spoke to numerous people who stated they didn't know about the positive COVID-19 staff. She stated she also spoke to the previous DNS who stated she could not help her. During a 12/22/2020 interview at 1:35 PM, with Staff L, representative from the LHJ, she reviewed the facility's positive COVID-19 results and their timeline of where they received results from the local laboratory, who processed the results. The documentation showed that Staff N, Nursing Assistant (NA), tested positive for COVID-19 and results were called to the LHJ on 07/09/2020 at 4:59 AM. She stated that they called the facility as soon as they received the results. During an interview on 12/22/2020 at 12:57 PM, Staff A, RN/DNS, stated that the results from the LHJ were called to the previous DNS the morning of 07/09/2020 and that she had full knowledge that Staff N was positive and other staff that tested positive prior to the resident's discharge. Review of the COVID-19 positive staff laboratory result documentation noted there were two additional staff with signs and symptoms. Staff O, NA, tested for COVID on 07/08/2020 with positive results called on 07/08/2020 to the LHJ at 2:45 PM. During an interview on 01/04/2021 at 10:00 AM, Staff K, Licensed Practical Nurse/ Resident Care Manager, stated she coordinated the discharge with the resident and their representative. The resident was discharged at 1:27 PM with all appointments and home health appointments. She was unaware on 07/09/2020 of any positive COVID -19 staff in the building as it was not communicated to her by the previous DNS. During an interview on 01/04/2021 at 10:10 AM, Staff Q, Payroll/ Benefit Coordinator, for the facility stated she took the message from the LHJ that there were staff that tested positive for COVID-19. She stated the former DNS took the call from the LHJ on 12/09/2020 at 11:00 AM (almost 2.5 hours before Resident #2 was discharged ). The facility implemented the following interventions by 07/26/2020, which corrected the noncompliance of the harm: 1) Ensured the new notification process met Centers for Disease Control and Prevention (CDC) recommendations and Federal regulations 2) A COVID Resident Representative Notification Log 3) Trained staff on communication/notification of residents, families to include newly discharged residents and families. 4) Monitored the new process to ensure sustained compliance Reference WAC 388-97-1780(1)((2)(a)(i)(b)(c)(d)

Based on interviews and record review, the facility failed to develop and implement an effective infection control program related to Centers for Medicare and Medicaid Services (CMS) guidance for required screening of healthcare personnel for COVID-19 (a highly communicable respiratory infection). Failure to implement interventions to mitigate the risk for the spread of COVID-19 by screening all individuals placed all residents and staff at risk for exposure to COVID-19. This failed practice potentially resulted in 52 residents (tested between 07/08/2020 to 07/30/2020), and 43 staff (tested between 07/01/2020 to 07/23/2020) with positive COVID-19 results. The facility was determined to be in Immediate Jeopardy from 06/23/2020, when Staff F, Cook, reported to her immedidate supervisor symptoms of COVID-19, and despite the symptoms the supervisor instructed Staff F to remain at work, until 07/26/20 at which time review of staffing schedules showed designated staff were assigned to be the COVID-19 screeners. Findings included . Review of the CMS April 02, 2020 guidance titled, COVID-19 Long-Term Care Facility Guidance showed the following: Long-term care facilites should immediately implement symptom screening for all - In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside health care workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked - Any healthcare professional who develops fever or symptoms consistent with COVID-19 should immediately notify and make arrangements for medical evaluation and testing. Review of the facility's undated form titled, Employee Screening Log showed all staff were required to disclose any risk factors and/or symptoms of COVID-19 and have their temperature taken prior to starting work. At the top of the form documentation stated to notify supervisor for further guidance for any Yes responses. Review of the Employee Screening Log for COVID-19 consisted of the following questions which required a yes/no response from staff: Travel and Work: International or cruise ship travel in the last 14 days Travel to any location with COVID-19 transmission in the last 14 days Reside in a community where community - based spread is occurring Worked in a setting with confirmed COVID-19 and did the work require proximity to positive or suspected cases Any known contact with someone with or being tested for COVID-19 in the last 14 days Symptoms Evaluation (Yes or No): Temperature (if above 100.0 - contact supervisor) Shortness of breath Presence of Cough Sore throat New/sudden change in taste or smell New or worse diarrhea Runny nose New fatigue New nausea or vomiting New headache New abdominal pain or muscle aches 1) Staff A, Registered Nurse (RN). Review of Staff A's COVID-19 screening form, dated 07/06/2020, showed she lived in an area with COVID-19 community spread was occurring, traveled to areas in the past 14 days with COVID-19 transmission, body temperature was elevated to 99.4 degrees, and cough was present. During an interview on 10/14/2020 at 8:30 AM and telephone interview on 10/21/2020 at 1:50 PM Staff A stated, that she had worked a double shift on 07/04/2020, returned home, and started to feel sick at 1:00 AM on 07/05/2020. She alerted Staff B, Director of Nursing/Infection Control Preventionist, on 07/05/2020 (Staff A's day off) about not feeling well and was scheduled for work the following day, Staff B responded, You were already there, damage done, have to come in. When she reported to work at approximately 8:00 AM on 07/06/2020 she stated she had a sore throat, lost her voice, and had no sense of taste or smell. At 10:00 AM on 07/06/2020 she was told to go home by Staff C, Medical Director. She stated she went to the clinic on 07/06/2020 and was tested for COVID-19 with positive results obtained the following week. Staff A stated that despite Staff B being the ICP there was no oversight on the screening process as staff was doing their own screening for COVID-19. Staff B had provided no instructions/communication to staff regarding steps to follow if they had symptoms for COVID-19. She stated Staff B was on vacation from 06/19/2020 to 07/07/2020 and no one was assigned to perform the duties of an ICP during that time. Staff B then returned to work on 07/07/2020 and her last day was on 07/23/2020. 2) Staff D, Nursing Assistant (NA). Review of Staff D's COVID-19 screening form, dated 06/25/2020, showed she had traveled to locations with COVID-19 transmission in the past 14 days, and had a new/sudden change in taste or smell. Review of her time card showed she worked in the facility the entire evening shift (2:00 PM to 10:00 PM) on 06/25/2020. She was not scheduled to work on 06/26, 27, and 28/2020. On 06/29/2020 her time card showed she worked 6:00 AM to 2:00 PM. Review of her screening form that day (06/29/2020), showed in the past 14 days she had traveled to locations with COVID-19 transmission, had a sore throat, and runny nose. Review of lab results showed Staff D was tested for COVID-19 on 07/01/2020 with reported positive results on 07/09/2020. During a telephone interview on 10/16/2020 at 8:36 AM Staff D stated, that no staff evaluated her on 06/25, 29/2020. She stated one of her friend's parents had tested positive for COVID-19 and she had some symptoms so she went and got tested at the hospital. Staff D stated the screening process was variable as sometimes she screened herself and other times she was screened by another staff member. 3) Staff E, NA. Review of Staff E's COVID-19 screening form, dated 07/10/2020, showed she resided in a community where the spread of COVID-19 was occurring, had shortness of breath, cough, sore throat, and new symptoms of nausea/vomiting. During an interview on 10/14/2020 at 1:30 PM Staff E stated, that when she completed the above screening form at approximately 6:00 AM on 07/10/20 she let the nurses know the results and they stated they would check her out in a couple of hours to determine if she still had symptoms. She left the facility at 7:20 AM as she received a phone call that a family member had fallen and was taken to the hospital. She stated at the time she left the facility she still had not been evaluated by the nursing staff. Staff E stated between the time she started work at 6:00 AM on 07/10/20 until she left at 7:20 AM she had gotten a couple of residents out of bed. Staff E stated the beginning of July 2020 staff were doing their own screening but since the outbreak (middle of July) they had a designated staff member that did the screening. Review of facility records showed Staff E was tested for COVID-19 on 07/13/2020 with negative results obtained. 4) Staff F, Cook. Review of Staff F's COVID-19 screening form, dated 06/23/2020, showed she resided in a community where the spread of COVID-19 was occurring, cough present, sore throat, new fatigue, new nausea/vomiting, and new headache symptoms. Review of the COVID-19 screening form, dated 06/26/2020, showed Staff F resided in a community where the spread of COVID-19 was occurring, traveled to a location with COVID-19 transmission, and had symptoms of abdomnal pain or muscle aches. During an interview on 10/14/2020 at 1:10 PM Staff F stated, that when she entered the facility on 06/23/2020 there was no one at the desk to screen her, thus she completed the screening process herself. She stated there were no instructions given or procedure if staff were displaying any symptoms of COVID-19. When she informed her supervisor of her symptoms the supervisor stated to her, You're not going to be around residents, you're OK to work. Staff F stated she also informed Staff A of her swollen glands and pounding headache, who told her to go home, which she did. Staff F also stated that after three days she was pressured by her supervisor to report to work after three days (which she did), despite still feeling ill. During an interview on 10/14/2020 at 2:20 PM Staff A stated, that she had immediately sent Staff F home after seeing her screening form and told her to get tested for COVID-19. Staff A stated Staff F's supervisor was not happy with the decision to sent Staff F home. Review of Staff F's time card showed she reported to work on 06/23/2020 at 12:55 PM and left at 1:14 PM. She then returned to work on 06/26/2020 at 3:00 PM and worked until 7:01 PM. 5) Staff G, NA. During a telephone interview on 10/20/20 at 4:05 PM Staff G stated, that when she started employment with the facility on 06/08/2020 staff was doing their own self screening for COVID-19 (with the exception of a few days per week but nothing consistent), including temperature checks, until the outbreak occurred in mid July. 6) Staff C, Medical Director. During a telephone interview on 10/13/2020 at 3:22 PM Staff C stated, that there was a designated staff member performing the screening process for COVID-19 at one point in time, and then later staff were on their own, good faith measures. It was either the second or third week of July 2020 when the facility got a designated person to do the screening process. Staff H, Regional Licensed Nurse, was very frustrated regarding the screening process so she then changed it to have a designated staff member. Staff C stated that when the facility began getting positive cases they could have done a better job as there was no one doing the job of ICP until Staff H came to the facility and enlisted the help of an ICP from another facility. 7) Staff H, Regional Licensed Nurse. During an interview on 10/13/2020 at 4:45 PM Staff H stated, that she had been on vacation for three weeks prior to arriving at the facility on 07/13/2020. She stated when she arrived staff was self screening for COVID-19, and she did not know how long that process had been going on. She stated Staff B was not doing her job as the ICP in the facility, thus changes were made. She stated she immediately revised the screening process to include a designated staff member to perform the screenings. 8) Staff I, RN. During an interview on 10/14/2020 at 2:00 PM Staff I stated, that there was a lack of comunication between nursing and administration regarding COVID-19. Direction came from Staff B and there was a couple of weeks staff was screening themselves. She stated Staff C had asked the question, what are we doing at the door, referring to the screening process for COVID-19. She stated Staff B would state, as long as they (referring to staff) weren't running a fever they needed to come to work. 9) Staff J. Nursing Assistant Registered. Review of Staff J's COVID-19 screening form, dated 07/14/2020, showed Staff J resided in a community where spread was occurring, worked in a setting in which there was confirmed COVID-19 and had close proximity to positive or suspected cases, had known contact with someone with or being tested for COVID-19 in the last 14 days, body temperature was 99.1 degrees, had shortness of breath, and a cough. During a telephone interview on 10/23/2020 at 11:29 AM Staff J stated, on 07/14/2020 she had a new onset of cough and shortness of breath. She stated she went to Staff B who informed her that because her temperature was not significant she needed to continue to work, which she did for the entire eight hour shift, despite feeling ill. Staff J stated the day she got her postivie COVID-19 results (07/16/2020) by phone from the health department she had already started her shift. She went to her immediate supervisor to notify her of the positive COVID-19 results and was told by the supervisor to notify Staff B. Staff B gave Staff J the option of continuing to work at the facility or to go home. Staff J then went home as many of the residents at that time were positive for COVID-19. Review of Staff J's time card showed she worked on 07/14/2020 from 2:00 PM to 10:23 PM, 07/15/2020 from 2:27 PM to 10:44 PM, and on 07/16/2020 from 2:01 PM to 6:38 PM. The facility implemented the following interventions by 07/26/2020, which corrected the past noncompliance of the Immediate Jeopardy: 1) Ensured the new screening process met Centers for Disease Control and Prevention (CDC) recommendations and Federal regulations 2) Trained staff on the new screening process 3) Assigned staff member to perform COVID-19 screenings on staff 4) Poster Board set up on an easle which instructed staff not to screen themselves, guidance to notify supervisors if they had COVID-19 symptoms, and educational materials 5) Bonus pay for staff that performed screening duties 6) Requests were made by the Regional Licensed Nurse to call her for assistance if staff arrived to work and were ill 7) Monitored the new screening process to ensure sustained compliance Reference (WAC) 388-97-1320(1)(a)(b)(2)(a) This is a repeat deficiency from Statement of Deficiencies dated 12/17/19.

Based on record review, and interviews, the facility failed to ensure 1 of 3 residents (#3) reviewed for pain, recieved timely management of that pain. This failed practice resulted in actual harm to Resident #3, who displayed signs/symptoms, and complaints of pain regarding her right arm, and never received any treatment to alleviate her pain prior to her transfer to the emergency room . Findings included: Resident #3. Review of the resident's Medical Record/Progress Notes (PNs), dated 01/12/18 at 3:08 PM, showed she was readmitted to the facility from the hospital on [DATE] following a stroke with right sided weakness. The resident was alert to self only and did not know the time or place. The resident required assistance with eating due to her poor vision. Two staff members assisted with transfers utilizing a gait belt and walker. She was at high risk for falls due to poor safety awareness. At 10:45 PM on 01/12/18 the resident was found sitting on the floor next to her bed. She had difficulty explaining what had happened due to her [MEDICAL CONDITION] (partial loss of the ability to produce language) secondary to the stroke. There were no injuries noted on initial assessment. The following documentation by Staff G, Registered Nurse, was noted in the PNs dated 01/13/18: 11:06 AM - Resident very tearful this morning - crying to roommate. Complaints of right arm pain - keeps rubbing it saying she needs to see a doctor. 1:10 PM - Resident's family member at facility. Resident still complains of right arm pain. 2:43 PM - On-call physician notified. Resident complaining of increased pain with decreased range of motion of the right arm. Orders were received to transport the resident to the emergency room . Review of hospital records, dated 01/13/18, showed the resident sustained [REDACTED]. In addition, laboratory studies revealed a urinary tract infection. A telephone interview on 01/30/18 at 1:22 PM with Staff G, Registered Nurse, revealed at approximately 9:00 AM on 01/13/18 the resident was very frantic stating she needed a doctor. She was very uncomfortable, crying and crying. Staff G asked the resident why she was crying, however the resident was unable to tell her why. The resident then settled down and took a nap, but started the same behaviors in the afternoon. An interview conducted later at 6:25 PM on 01/30/18 with Staff G, revealed the resident also kept stating, don't touch me - don't touch me. She was wringing her hands, and asking for a doctor. Staff H, Nursing Assistant, stated on 01/31/18 at 11:00 AM she had assisted the resident with eating on 01/13/18. The resident was upset, agitated, and confused. She was insisting she really wanted to see a doctor. The resident would not allow staff to do anything, which was not normal behavior for her. The resident's family member stated on 01/31/18 at 10:45 AM, she arrived at the facility at approximately 1:00 PM on 01/13/18. She stated the facility had called her as the resident was hysterical and crying. The resident had been refusing to get dressed that morning so when the family member picked up her right arm to dress her, she immediately cried out in pain. Two additional attempts were made to lift the resident's right arm with the same reaction obtained from the resident. Review of the resident's Medication Administration Record [REDACTED]. Despite the above documentation in the PNs by Staff G, and the above interviews, relative to the significant changes in the resident's condition, the physician was not consulted regarding the resident's pain, which was not normal for the resident. Reference (WAC) 388-97-1060(1)

Based on observation, interviews, and record review, the facility failed to provide treatment and services to 1 of 1 sampled resident (#1), who displayed symptoms of mental and psychosocial difficulty. Failure to provide appropriate treatment and services resulted in psychosocial harm to Resident #1, as her behaviors were escalating without effective interventions and affecting other residents and their environment. Findings include: Resident #1. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment dated [DATE] revealed she put others at risk for physical injury, intruded on the privacy or activities of others, and significantly disrupted care or living environment. She displayed physical behaviors at others such as hitting, kicking, pushing, scratching, or grabbing, which occurred four to six days in a seven day period of time. Verbal behaviors to others such as threatening, screaming, and cursing occurred daily. The above comprehensive assessment relative to the resident's behaviors differed signficantly from the assessment completed on 8/18/15 (seven days following the resident's admission to the facility). The assessment revealed there were no physical or verbal behavioral symptoms present. There were noted behaviors symptoms that were not directed towards others that occurred on a daily basis such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms such as screaming, disruptive sounds. The identified behaviors did not impact Resident #1 or other residents. Review of an assessment on the resident on 4/22/16 by Staff A, Social Services (SS), revealed severe cognitive impairment, and memory issues. The resident continued to have sun downing (syndrome in which residents with Alzheimers experience confusion and agitation when the sun goes down), and escalated behaviors due to pain and situation circumstances with other residents in facility. The resident continued to scream and curse obscenities at other residents and got into arguments with people. Resident's family was pursuing discharge to a lower care facility if behaviors could be managed accordingly. Review of the annual assessment by SS, dated 7/12/16, noted her behaviors had escalated since the last assessment. Her behaviors significantly intruded on the privacy and disrupted the environment for staff and other residents. Staff and residents were at risk for physical harm when her behaviors acted up. The resident was started on an antipsychotic medication on 6/28/16 to manage her behaviors, but there was no evidence the medication was effective. The resident's family was looking into alternative placement which could take care of her needs. Review of the following Progress Notes (PNs) between 6/17-7/10/16 revealed Resident #1's behaviors towards staff and other residents: 6/17 - verbally/physically aggressive towards other residents and staff. Resident #3 reported Resident #1 slapped her on the shoulder following a verbal altercation. 6/24 at 12:26 a.m.- wandered about facility making comments to and about residents' and staff all shift. Name calliing, arguing, threatening comments and gestures to several residents during the evening meal in the dining room. The Licensed Nurse (LN) was unable to diffuse her behaviors. Resident #2 (roommate of Resident #1) ws very upset and felt Resident #1 should be in another room as she was too aggressive for the residents living on her unit. 6/24 at 9:54 p.m. - Resident #1 very agitated over half of the shift with name calling and wanting to call the police. Resident #2 thought she had a rash due to the stress caused by Resident #'s behavior. Every resident on the east hall heard her yell four letter words, very verbally abusive. Distraction caused her to be worse, she refused when care offered, refused to watch TV, nothing worked. 6/26 - Resident confused/delusional - believed she was going to be in an arranged marriage that she wanted no part of. This escalated to attempting physical abuse to staff to include that the staff were thieves. She then threw books on the floor and attempted to knock over two computers. The verbal abuse was so loud with colorful metaphors that other residents called 911. Resident #1 was then standing over Resident #2 yelling and screaming while taking an aggressive swing at her. She missed but knocked over a water pitcher. Resident #1 entered other resident rooms and loudly used profanity at staff. 6/27 - (late charting for day shift on 6/26) - After lunch the resident shouted at other residents in the hall. She threatened to smash other resident over head with wheelchair. 6/27 - Resident had been anxious off and on during the evening with several outbursts at other residents. 6/29 - On 6/28 the resident was screaming at the staff and residents, who were in the west dining hall, that there was a bomb, and they were all going to blow up. 7/1 - Resident continues to have episodes of delusions and verbally abusive behavior. 7/2 - Resident continues to have verbal outbursts and cursing as well as physical aggression towards staff, and verbal altercations with peers. The resident was not redirectable. Approximately one hour later she was cursing and hitting, kicking staff, throwing computer monitor, water vase on telephones, and attempting to break glass doors with stool and wheelchair. The police were called after the resident entered a male resident's room, and became physically aggressive by shaking his bed when he was asleep. 7/3 - Resident very irritable this evening - shouting out on occasion at staff and residents. 7/4 - Resident ambulated to an assisted living facility, located next door to the facility, and grabbed one of their residents and shook the resident's arm. Later that day she was yelling, swearing, threatening residents, staff, and visitors. Each attempt to calm her down made her more agitated. 7/5 - Resident agitated most of the evening shift - hollering, swearing, on and off with agitation. 7/10 - Starting at 1:45 p.m. resident had become out of control - screaming at other residents, name calling, threatening to hit them. 7/11 - Resident very verbal, angry, swearing, and stomping about on the evening shift. 7/12 - Resident was convinced on the evening shift there were bombs in the facility. She was extremely upset that staff was doing nothing. Review of physician orders [REDACTED]. There were no other [MEDICAL CONDITION] medications ordered to be administered to the resident. Review of PNs on 12/16/15 noted a psychiatric Nurse Practitioner (NP) evaluated the resident due to changes in her behavior. Her recommendation at that time was to redirect the resident to a more quiet place when she seemed distressed. Despite increased behavioral issues there was no evidence the NP was consulted again for further services. Review of documentation on 7/1, 2/16 noted the Crisis Line was called in an attempt to get a Mental Health Professional (MHP) to evaluate the resident during a crisis incident. The MHP stated they were unable to do so due to the resident's [DIAGNOSES REDACTED]. Progress Notes, dated 7/1/16 by SS, noted a care conference was to be scheduled with the resident's legal representative to discuss potential solutions and management of behaviors. Interviews with Staff A (SS), on 7/13/16 at 10:55 a.m. and 3:20 p.m., revealed Resident #1's behaviors occurred almost daily. Most of the residents stayed away from her. That had become a routine here - a disruptive environment. Recently Resident #1 had been harder to redirect. Staff could not engage/confront her as she became more combative. She had exhibited behaviors since being admitted to the facility, but they were far more manageable then. He stated he heard a couple of days ago a family member was looking into alternative placement, but he had not encouraged family members to do so. In addition, he had not made any recent telephone calls relative to seeking alternative placement for the resident. Despite the above PN on 7/1/16 stating a care conference was to be arranged with famly, he stated he had not yet done that (13 days later). Per telephone interview on 3/20/16 at 1:00 p.m. with the resident's legal representative revealed the resident was quite a different person when she was initially admitted to the facility in August 2015. Her behavioral outbursts have escalated and they were not an issue when she first was admitted to the facility. She stated she seldom has been called by the facility to come and sit with the resident due to her behaviors. She did come in the night of 7/2/16, but that was the first time she had ever been called by the facility during the night due to her behaviors. She stated she had pursued alternate placement with a current facility, without staff assistance. Per interview on 7/13/16 at 3:05 p.m. with Staff B (LN on the evening shift), revealed the resident had been having behaviors off and on since being admitted , but they had gotten worse in the past two - three weeks. Her behaviors started at approximately 3:00 p.m. as she became increasingly anxious. She screamed and hollered at residents and had gone after other residents. Approximately one month ago she informed a family member, following the resident's death, that the resident was murdered. Staff did not know what would set her off. The antipsychotic medication was not working on the evening shift. On 7/13/16 at 10:05 a.m. an interview with Staff C (Resident Care Manager) revealed the resident would target certain residents (resident names given). Anyone who would talk back to the resident would be an automatic explosion. She stated Resident #'s 2, 4 and 5 were fearful of her. There used to be things we could do for her such as a pop or pain medication, but that no longer worked. She stated Resident #1 was affecting many residents with her yelling, screaming, and cursing. There was going to be an opening at the end of the month at a memory care assisted living facility, but she stated the bed had not been designated for the resident at that time. Staff D, Nursing Assistant, stated on 7/13/16 at 11:00 a.m. that Resident #1 gets violent at times .try to remove residents from her .needs to be somewhere where they can handle her .redirecting her is impossible. She stated Resident #'s 2, 4, and 5 were afraid of Resident #1. Staff E, LN during the above incident on 7/2/16, revealed during an interview on 7/13/16 at 1:50 p.m., the resident had thrown a stool the night of 7/2/16 in an attempt to break the window. She was going into other resident rooms and shaking their beds while they were sleeping. She called the police and when they arrived she informed them the resident was a danger to other residents. She stated Resident #'s 2 and 4 had told her they were scared of Resident #1. Per interview on 7/13/16 at 11:45 a.m. with Resident #2 (roommate of Resident #1) revealed Resident #1 makes me a nervous wreck. I'm afraid she is going to hit me on the head one night. She has one heck of a temper. The resident yelled and screamed at her almost daily, and yelled at other residents. I don't sleep good at night worring about her hitting me. She stated she had made complaints regarding Resident #1 to SS and Staff B, but nothing had been done. On 7/13/16 at 3:30 p.m. staff informed the state investigator the resident was displaying escalating behaviors. The resident was observed ambulating independently down the hall from the nursing station without difficulty. She entered her room and went directly over to Resident #2 and started screaming and yelling at her. When Resident #2 responded by stating she had not spoken to her in awhile Resident #1 raised her voice even louder and yelled at her. Despite staff being aware of the resident's having increased behaviors at that time they did not supervise the actions of the resident as she left the nursing station. Review of Resident #2's PNs revealed documentation on 6/26/16 stating she was verbally assaulted by Resident #1, and Resident #1 took a swing at her, knocking her water pitcher to the floor. She stated she was afraid of Resident #1. Social Services was notified of the incident, however there was no evidence of follow-up documentation by SS until 7/13/16 (17 days later). On 6/27/16 the resident stated she was afraid of suffering harm from Resident #1 while she was sleeping. The resident continued to complain about Resident #1 and her outbursts on 7/3, 4, 5/16. Per interview with Resident #4 on 7/13/16 at 12:25 p.m., revealed she had an incident the day before in which Resident #1 flipped over a folding chair. I thought she was going to hit me. She stated the resident used profanity and that was so offensive. Earlier this month the resident had woke her and her roommate up during the night screaming and banging on resident room doors. The resident stated, she scared me, and she has gotten terribly worse. She stated she had informed several staff members of her concerns, and on 7/2/16 had filed a written grievance. Review of the above written grievance, dated 7/2/16 by Resident #4, noted Resident #1 had woke both her and her roommate up during the night of 7/2/16 as she was banging on residents' doors with her chair. The resident wrote it was not the first time that had happened. Please address this issue immediately!!!. She actually scares me. Per interview with SS on 7/13/16 at 3:20 p.m. revealed he had not received the above grievance and had no knowledge of it. He stated a LN had put the written grievance under the door of the Director of Nursing, thus it could still be in her office. Review of Resident #4's plan of care, dated 12/19/15, revealed she was alert and oriented. Review of PNs noted that despite her written concerns/fears relative to Resident #1 (as noted in the grievance) there was no assessment for psychological harm until 7/13/16 (11 days following the incident). At that time documentation stated she had stress and anxiety due to Resident #1, and was afraid at times when she exhibited behaviors. She also expressed concern for other residents in the facility. Per interview with Resident #5 (former roommate of Resident #1) on 7/13/16 at 2:15 p.m., revealed Resident #1 was unbearable, and no one could stop her. She stated there were times when she was scared of her - when she got into those moods. One time Resident #1 came to her bed and stated she wanted to kill someone. She stated she reported the incident to SS and requested to be moved to a different room. She stated she reported her concerns to SS months ago and there had been no changes. Review of PNs dated 3/14/16 revealed Resident #5 requested to be moved to a different room due to her fear of Resident #1, which was done. An interview conducted with Resident #6 on 7/13/16 at 12:30 p.m., revealed Resident #1 continually screamed and yelled at other residents. She stated Resident #1 would go into the lobby and yell profanity at everyone. I don't think that it is fair to berate everyone. She stated she pounds on her door with her wheelchair, very scary and I don't know what she's going to do as she's very strong. She stated she had reported her concerns to SS. Review of the medical record for Resident #6 revealed documentation on 7/11/16 noting she was cognitively intact. There was no evidence of documentation between 6/25-7/13/16 relative to her concerns about Resident #1. Please refer to F225 for additonal information relative to the behaviors of Resident #1.

Based on record review and interviews the facility failed to consistently provide medically related social services for 1 of 1 sampled resident (#1) reviewed with increased behavioral outbursts. This failed practice resulted in harm to Resident #1 as her condition deteriorated from her usual baseline with no effective interventions in place to assist her to attain her highest level of psychosocial well-being. Additionally, the failure of staff to effectively manage and assist Resident #1 in de-escalating her behaviors resulted in other residents being afraid of Resident #1. Findings include, but are not limited to: Resident #1. admitted to the facility in August 2015 with [DIAGNOSES REDACTED]. There were noted behaviors that were not directed towards others that occurred on a daily basis such as hitting or scratching self, pacing, rummaging, verbal/vocal symptoms such as screaming, disruptive sounds. The identified behaviors did not impact Resident #1 or other residents. Review of the resident's plan of care, dated 7/12/16, revealed she exhibited signs/symptoms of increased manic depressive behaviors associated with her dementia. Those behaviors were displayed in the following ways: violent delusions, harmful statements directed at residents/staff, throwing objects, attempting to hit others, and wandering out of the facility. Interviews conducted on 7/13/16 with Resident #2 (roommate of Resident #1) at 11:45 a.m., Resident #5 at 12:15 p.m., Resident #4 at 12:20 p.m., and Resident #6 at 12:30 p.m. revealed fear due to the frequent, on-going behaviors exhibited by Resident #1. They stated the resident yelled and screamed, used profanity at times, to residents and staff. Despite the reporting of their concerns to Social Services (SS) nothing was being done. Interviews conducted on 7/13/16 with Staff B (Licensed Nurse on the evening shift) at 3:05 p.m., Staff C (Resident Care Manager) at 10:05 a.m., and Staff D (Nursing Assistant) noted Resident #1's behaviors had worsened over recent weeks. Interventions that had worked to minimize her behaviors no longer worked as effectively. Due to her yelling, screaming, and threatening behaviors, the above staff identified residents in the facility who were fearful of her. During interviews conducted on 7/13/16 at 10:55 a.m. and 3:20 p.m. with Staff A, SS, revealed Resident #1's behaviors occurred almost daily. Most of the residents stayed away from her. That had become a routine here, a disruptive environment. She had exhibited behaviors since her admission to the facility, but they were more manageable then. She had been harder to redirect. Interventions that had worked previously such as giving her a Coke, or having the family visit were not as effective. The resident received a routine antipsychotic medication since 6/28/16, but still had behaviors daily. He denied seeking alternate placement recently as he had heard the resident's family had consulted with a memory care assisted living facility. In addition, he had not yet arranged for a care conference to discuss the resident's behaviors with family members. Review of Progress Notes in the resident's medical record between 6/17-7/10/16 revealed the resident displayed frequent behaviors of name calling, arguing, yelling/screaming, and threatening comments to residents. Assessments conducted by Staff A, dated 4/22/16 and 7/12/16 (almost three months later), revealed the resident's family was looking into alternative placement with other facilities, but there was no documented evidence as to what facilities had been contacted, and their response to the inquiries. There was no evidence mental health/psychiatric services had been contacted (other than the Mental Health Professional during a crisis and the Nurse Practitioner on 12/15/16). In addition, the physician had not been informed relative to the resident's continued behaviors, since the initiation of the antipsychotic medication on 6/28/16, for possible changes in medication orders. The above residents who had voiced fears regarding the behaviors of Resident #1 were not assessed for psychological harm, nor provided social services in a timely manner. Despite the resident's behaviors of throwing objects, harmful statements, attempting to hit others, and violent delusions, there was no plan in place (other than contacting the police) that would be effective, to ensure the safety of Resident #1 and other residents. Refer to F319 for further information on Resident #1's behaviors.

Based on interview and record review, the facility failed to ensure that a significant medication error did not occur for 1 of 11 residents reviewed for medications(#16) in a sample of 31. Resident #16 received a dose of intermediate-acting insulin that was not ordered for her. This failed practice resulted in harm to the resident who required increased blood glucose monitoring. Per record review, Resident #16 had [DIAGNOSES REDACTED]. The resident had memory problems, difficulty understanding, making herself understood, making daily decisions, and required extensive assistance with most activities of daily living. The resident had physician orders [REDACTED]. The resident preferred to take her medications with sugar-free hot chocolate. Review of the July 2012 Medication Administration Record (MAR) revealed the resident required short-acting insulin for 5 of 31 days in the AM and 20 of 31 days in the PM for elevated blood glucose readings. Per record review, on 7/25/12 at 7:00 A.M., Staff D, a Registered Nurse, was orienting to medication administration under supervision of Staff L, another licensed nurse. Staff D prepared 14 units of intermediate-acting insulin ordered for Resident #1 and administered the insulin to Resident #16, the wrong resident. Per record review, Staff D realized the significant medication error as soon as she administered the insulin. She notified Staff L, the resident's physician, and family member. Per record review, the physician issued new orders to monitor the resident's blood glucose level at 1 hour, 2 hours, and 4 hours post insulin administration, and to offer regular hot chocolate rather than sugar-free chocolate with medication pass for the day. Per record review, the resident's 7/25/12 subsequent blood glucose readings were elevated as follows: 8 A.M.- 248. 9 A.M.- 316 11:00 A.M.-287. The P.M. blood glucose reading was 306, for which the resident received 6 units short-acting insulin as ordered. Review of Staff L's Medication Pass Competency checklist dated 7/24,25,26/12 revealed she was not checking residents' identiyy prior to giving medications. A second checklist dated 7/26/12 after the medication error noted Staff L was checking residents' identity prior to giving medications. Per review of the facility investigation dated 7/27/12, Staff L stated she felt Staff D was prepared to give insulin so she did not follow her into the resident room to watch her administer the insulin. In an interview on 8/1/12 at 3:15 P.M., Staff L stated she oriented Staff D on 7/24/12, 7/25/12, and 7/26/12. On 7/24/12, Staff D observed the medication pass. On 7/25/12, she asked Staff D to perform blood glucose testing and insulin administration. She stated she did not have the facility Medication Pass Competency checklist available so she reviewed the information verbally with Staff D. Staff L stated that the facility procedure for identification of the right resident included checking the resident's picture in the MAR and the resident's name band. She stated the resident was wearing a name band on 7/25/12. In an interview on 8/1/12 at 8:10 P.M., Staff L stated she was taught to review resident arm bands and did not do so when she gave insulin to the wrong resident on 7/25/12. She stated she was discussing Resident #16 while preparing insulin for Resident #1 and does not think looking at the arm band would have cued her as to her confusion about the 2 residents. She didn't realize her confusion until after she administered the insulin. The facility's failure to ensure that licensed nurses checked residents' identity prior to giving medications, as trained, which resulted in Resident #16 receiving insulin that was ordered for Resident #1. After the medication error, Resident #16 was given hot chocolate with sugar and required blood glucose testing 3 times before lunch to prevent and evaluate for low blood glucose readings.

Based on observation, record review, and interview, the facility failed to provide care and services to facility residents in a manner that allowed them to attain/maintain their highest well-being. Many facility Licensed Nurses (LNs) who knew the residents were dismissed and Agency LNs attempted to provide care for the residents. LNs were overwhelmed by the volume of the workload and their lack of familiarity with the residents. The LNs failed to: provide consistent, timely medication administration; provide necessary medical assessments to prevent physical harm, and prevent mental anguish for the residents. The neglect was systemic involving the LNs on the floor, the facility Administrative staff, and Corporate Representatives attempts to audit to prevent recurrence but implemented measures that proved ineffective and allowed for ongoing neglect/sub-standard care that affected all 22 residents in the sample and potentially impacted the entire facility. This was determined to be an Immediate Jeopardy. Findings include but were not limited to: Immediate Jeopardy at F224, Neglect, was based on the pervasive findings in the following F-tags: Residents #1, #4, #5, #11, #13, #14, & #16 experienced actual harm. Resident #6 experienced ongoing psychosocial distress. Residents #7, #8, #9, #15, #17, & #18 experienced potential harm related to not receiving necessary care and services. Immediate Jeopardy findings at F309, Care and Services: Residents #1, #4, #5, #11, #13, #14, & #16 experienced actual harm. Resident #6 experienced ongoing psychosocial distress. Residents #7, #8, #9, #15, #17, & #18 experienced potential harm related to not receiving necessary care and services. Sub-Standard Findings at F314, Pressure Sores, evidenced a pattern of harm related to development of pressure sores. Residents #10, #13, and #19 experienced harm as the result of the development of pressure sores. Immediate Jeopardy findings at F333, Significant Medication Errors: Refer to F333 for details related to significant medication errors. Residents #5, #13, & #16 experienced actual harm as a result of the significant medication errors. Additionally, Resident #14 (under F309) experienced pain and distress due to multiple medication omissions (referenced under F309). Residents #1, #4, #5, #6, #9, #11, #13, #15, #18, & #22 experienced potential harm. The actual impact was not readily discernable for many of the errors. There was a continued likelihood of significant medication errors. Immediate Jeopardy at F353, Nursing Services occurred as a result of the facility's failure to ensure sufficient, qualified staff were present to meet the needs of the residents. All 22 residents in the sample were impacted and the entire facility resident population of 55 was potentially impacted. Immediate Jeopardy was identified at 490, Administration, due to the failure to ensure a safe operation of the facility which affected 22 sampled residents and potentially affected the remaining 33 residents. Immediate Jeopardy was identified at F493, Governing Body, for the facility's failure to provide necessary oversight of the total facility operations to prevent harm to residents and maintain compliance with State and federal nursing home regulations which affected all 55 facility residents. These multiple system failures beginning on or about February 10, 2012 and affected all 22 residents in the sample and potentially impacted impacted the entire facility.

Based on observation, record review, and interview, the facility failed to provide sufficient, qualified nursing staff to ensure the 55 facility residents attained or maintained their highest practicable levels of physical, mental, and psychosocial well-being. Multiple sampled residents experienced actual harm in the areas of physical compromise, unrelieved pain, and psychosocial harm or distress related to the unreliability of the nursing care (#1, #4, #5, #10, #11, #13, #14, #16, & #19). Resident #6 experienced ongoing psychosocial distress. Resident #7, #8, #9, #15, #17, #18, & #22 experienced potential harm. Known facility staff were dismissed and Agency Licensed Nurses (LNs) with little or no knowledge of the building, facility systems, and most importantly, the residents, provided much of the nursing care in the facility. This was determined to be an Immediate Jeopardy. Findings include but were not limited to: Interviewed via telephone on 3/05/12 at approximately 8:34 a.m., Anonymous Facility Licensed Nurse (LN) #1 reported that many of the regular LNs had been fired or suspended. Reportedly, the Director of Nursing Services (DNS) had mandated the LNs do 12 hour shifts instead of 8. Agency LNs were brought in to provide care for the residents. LNs were expected to provide primary care for the residents including: medications, treatments, (supervising the Nursing Assistants, NAs), physicians' orders, and care planning, all without help from the Administrative LNs. Agency LNs were overwhelmed and some morning medications were administered at 2:00 p.m. The reporting Facility LN stated she questioned whether anyone was directing the NAs and called the facility care, "sub-standard". During a 3/12/12 investigative interview, Anonymous Facility LN #2 discussed the medication errors involving Resident #1 and stated she was fearful about working at the facility due to all the nursing care and medication delivery problems. On 3/13/12 at approximately 4:50 p.m. the Director of Nursing (DNS) reported that Agency LN E had returned to the facility to work on 3/12/12 despite the ongoing Police Department and Coroner investigations into the death of Resident #1 and the identified clinical practice concerns involving Agency LN E. The facility allowed the LN to work at the facility that day. The DNS stated she would not allow Agency LN A or Agency LN E to return in the future. On 3/09/12 Staff LN N received reports of multiple residents not receiving medications and/or care, naming Staff LN F as the LN involved. The facility allowed Staff LN F to continue to work despite the investigation underway. Additionally, the facility did not recognize that Staff LN F did not have a current license. See F225 and F499 for further data. When interviewed on 3/13/12 at approximately 4:45 p.m. Staff Member O, a Nursing Assistant, stated Agency LN B didn't report a resident fall and she had to assist the Agency LN to make out a fall report. The Staff Member stated she tried to assist the Agency LNs because she was aware the medications were late. One Agency LN had reportedly told Staff Member O s/he was not coming back because it wasn't worth their license. Resident Council Meeting Minutes, dated 3/15/12, identified "Agency Nurse Issues". Three of the six resident attendees had mentioned Agency Nurses had been passing medications "very late". One resident stated, "It is stressful for the residents". The two other residents stated they had major issues with their medications being late yesterday. On 3/16/12 at approximately 8:45 a.m. the DNS stated they had another "bad" Agency LN. At least five residents had complained about late medications, including pain medications. The Agency LN wouldn't leave the building despite their attempt to remove her. (On 3/19/12 at approximately 1:30 p.m.) Staff LN E was interviewed and stated Agency LN C worked on the day shift on 3/15/12. The Agency LN had reported to Staff LN E that the resident had a [MEDICAL CONDITION] during breakfast in the dining room. There was no nursing documentation about the [MEDICAL CONDITION] activity or duration. Staff LN E stated she had to assist Agency LN C beginning at approximately 2:00 p.m. and ultimately had to remove the keys from the Agency LN at 5:00 p.m. The Agency LN was so frustrated and she did "not even know where she was struggling". There had also been a call-in that morning by another Agency LN and so there was a heavier workload that day. On 3/16/12 at approximately 4:45 p.m. the DNS was asked about the orientation program for the Agency LNs before working at the facility. The DNS stated the Agency LNs come in early and reviewed policies contained in a binder and then they are to sign that they reviewed them. Review of the binder revealed only three Agency LN's names. On 3/16/12 at approximately 3:45 p.m. Agency LN H stated she had come in about one hour early to organize before starting her shift but she was not shown the whereabouts of the emergency equipment. On 3/17/12 at approximately 1:53 p.m. Staff Member M stated that during the night shift starting on 3/15/12 Resident #12 developed "breathing distress". There were two Agency LNs working that shift. The LNs had not been shown the location of the emergency cart (containing emergency supplies). Investigative interviews on 3/19/12 and 3/20/12 with the Agency LN B and Agency LN G revealed that neither had received an orientation about the whereabouts of the emergency cart but had discovered it themselves. Both LNs stated the tubing for the suction machine was missing the morning of 3/16/12. However, the LNs stated they didn't end up needing to suction Resident #12. During a 3/19/12 interview with the Staffing Coordinator at approximately 11:30 a.m., she discussed the normal LN staffing patterns for each shift. A list of 14 Agency LNs was provided. The list represented the Agency LNs who had recently worked at the facility. There was also a new Agency LN working on day shift that day who was not included on the list, Agency LN D. The Staffing Coordinator stated the facility had utilized an occasional Agency LN in the past but their use of Agency LNs had increased since 2/10/12. They used two agencies. The facility had a new DNS who started on 12/12/11. Since that time six facility LNs had left through termination or they chose to leave. Typically, Agency LNs were to report 1/2 hour early for work to go through the policy/procedure book and they are to receive a mini-orientation of the medication room, the bathroom, the break room, and the clean linen room. Agency LNs then took a typical staff assignment for their shift. Despite ongoing medication audits following administration, the delivery system continued to evidence ongoing medication errors due to lateness and a lack availability of the medications. Agency LNs were given a typical workload with full responsibility for primary nursing with medications, treatments, assessing residents, taking orders, interacting with family members, getting residents out for appointments, and updating care plans as well as supervising NAs all with negligible ancillary support. As one Agency LN stated, "When you don't know anyone, alot can go wrong." For additional resident related care outcomes refer to F309.

Based on observation, record review, and interview, it was determined the facility was not administered in a manner that A.) prevented immediate jeopardy situations, B.) ensured thorough and appropriate investigations of neglect allegations with protective actions, C.) ensured appropriate monitoring of residents' conditions, D.) provided sufficient and qualified staff for the safe and competent delivery and supervision of care, and E.) maintained a system to ensure timely physician visits for residents F.) maintained a system to ensure Nursing Assistants' performance evaluations and inservice records were completed and available, G.) utilized the Medical Director to help ensure quality of care, and H.) maintained an effective quality assurance program at the facility. Review of the facility policy and procedures for abuse prohibition and changes of condition revealed there were policies in place but they were not sufficiently implemented to protect all 55 facility residents. Harm was identified for Residents #1, #4, #5, #10, #11, #13, #14, #16, & #19. Resident #6 experienced ongoing psychosocial distress. Residents #7, #8, #9, #15, #17, #18, & #22. This was determined to be an Immediate Jeopardy. Findings include but were not limited to: Administrative responsibility for provision of qualified staff was deficient. Without qualified staff, residents did not receive the necessary timely care and services to function at their highest level of physical, mental, and psychosocial well-being. Residents did not receive provision of care consistent with professional standards and federal and state regulations. The survey determined that administrative deficiencies resulted in harm to residents and interfered with their attaining for maintaining their highest practicable well-being. In the past 12 months F309, Care and Services, was previously cited four times with three of the four instances involving resident harm and one involving multiple residents who sustained harm. Additionally, there was resident harm identified at F323, involving a fall with a substantial injury. During this abbreviated survey, the facility was found to have multiple deficits in medication administration resulting in numerous significant medication errors and resident neglect. Despite facility and corporate medication audits performed after medication administration, the actions proved ineffective in preventing ongoing errors and breaches in infection control practices and professional standards of practice. Observations on 3/19/12 during the medication pass by Agency Licensed Nurse (LN) D (her first time in the building) revealed that some of Resident #18's medications were administered at the wrong time and one medication was not in the building (medication errors). See F309. When the Agency LN was asked whether she had completed any treatments that morning, she stated she had not checked the treatment book yet. The LN further stated the night shift LN was late so that made her late in getting started. On 03/26/12 during the noon medication pass a Licensed Nurse, Staff LN T was observed passing medications to 7 residents. Staff LN T did not use hand gel or wash his hands before or after coming in contact with any of residents, most significantly he did not hand wash before or after administering an eye drop to Resident # 8. Additionally, he dropped a pill on the ground in the hallway and picked it up, threw it away and did not wash his hands. On 03/27/12 during the midday medication pass Resident #11 did not receive her prescribed twice dailly iron tablet. It was also noted she had not recieved it for 23 days since her admission. Laboratory results, dated 03/20/12 and 3/27/12, indicated the resident had poorly treated [MEDICAL CONDITION]. Additionally, Staff LN T misinterpreted the resident's orders and checked her blood sugar instead of checking her blood count (one test the LN could draw and the other test had to be done by a laboratory, two very different lab tests). Resident #22, received a "do not crush" long acting medicaiton crushed. The Administrator failed to ensure there was a system in place to ensure that physician visits occurred timely. When interviewed on 3/27/12 at approximately 12:42 p.m., the Medical Records Coordinator stated that about five months earlier she had identified there was no system in place to monitor the frequency of physician visits. When she reported her concerns she was told she had plenty to do and not to worry about it. See F387 for additional data. There was no system in place to ensure the Nursing Assistant Competency was evaluated. On 3/27/12 at approximately 3:40 p.m. and on 3/28/12 at approximately 11:35 a.m., the Staffing Coordinator stated there were no Nursing Assistant (NA) performance evaluations located after 2009 (required at least every 12 months and to be utilized to identify NA training needs). The Staffing Coordinator stated she was unsure who was currently responsible for completing the NA evaluations. The task had been repeatedly re-assigned between facility and Corporate individuals. Refer to F497. The Administrator failed to ensure the adequate utilization of the Medical Director to ensure quality of care at the facility. See F501 for additional data. Additionally, the facility failed to include the Medical Director consistently in the Quality Assurance program as required. See F520. It was deemed that further harm was likely to occur. Agency Nurses were utilized by the facility, often without sufficient orientation to the building including emergency equipment. See F353. Agency LN's were given a usual workload and asked to perform primary nursing functions, often independently, to residents they did not know. Their duties included medication administration, treatments, taking orders, amending care plans, and supervising Nursing Assistants. The failure to prevent resident neglect through consistent qualified nursing services constituted Immediate Jeopardy at F224, Neglect; F309; Care/Services; F333, Significant Medication Errors; and F353, Nursing Services. Additional findings of Immediate Jeopardy were identified at F490, Administration. When interviewed on 3/27/12 an anonymous facility LN stated,"Residents who we knew and who knew us, their worlds were turned upside down."

Based on record review and interview, the facility's governing body failed to ensure systems and qualified staff were in place to provide consistent resident care and services for the 55 of 55 facility residents allowing them to attain and maintain their highest practicable level of physical, mental, and psychosocial well-being and to remain in compliance with state and federal regulations. In the past 12 months the facility has had three different Administrators and four different Directors of Nursing. This resulted in facility instability with findings of 6 Immediate Jeopardy level citations. The governing body failed to demonstrate the ability to stabilize the facility and ensure the delivery of quality care and services. This was determined to be an Immediate Jeopardy. Findings include but were not limited to: The facility operates under the mandate of an off-site governing body who is responsible for the varied operations. There are multiple nursing homes under its jurisdiction. Although Corporate representatives had been on-site intermittently since the hire of the current Director of Nursing and before, the facilty continued to experience difficulties in maintaining a stable nursing staff and providing timely, quality care. There were instances of resident neglect and failure to recognize and prevent recurrence. During this abbreviated survey, the facility was found to have multiple deficits in medication administration resulting in numerous significant medication errors and resident neglect. Despite facility and corporate medication audits performed after medication administration, the actions proved ineffective in preventing ongoing errors. It was deemed that further harm was likely to occur. Agency Nurses were utilized by the facility, often without sufficient orientation to the building including emergency equipment. They were given a usual workload and asked to perform primary nursing functions, often independently, to residents they did not know. Their duties included medication administration, treatments, taking orders, amending care plans, and supervising Nursing Assistants. The failure to prevent resident neglect through consistent qualified nursing services and care constituted Immediate Jeopardy at F224, Neglect; F309, Care/Services, F333, Signficant Medication Errors, and F353, Nursing Services. See the referenced F-tags for interview data. Additional findings of Immediate Jeopardy were identified at F490, Administration and at F493, Governing Body. A review of the facility's compliance history over a 12 month period showed that the facility, prior to this investigation had been cited at F309 four times under the category of CFR 483.25 Care and Services, for failing to ensure that residents received care to attain their highest level of physical, mental, and psychosocial well-being. On [DATE] the facility was cited at a harm level for failing to respond to the emergency needs of a resident as his condition became critical. On [DATE] the facility was cited for a resident burn that deteriorated significantly before any treatment was sought. On [DATE] there were multiple examples of resident harm and on [DATE] a terminally ill resident did not receive sufficient care at night and was found to have deceased by his spouse when she visited the next morning. In the past 12 month period the facility has had three different Administrators and four different Directors of Nursing. When administration experienced this much change in personnel, it created an environment where expectations and processes were frequently changing. There was also an apparent lack of Licensed Nurses (LNs) in the facility nursing team to attend to the vital supervision and delivery of care and services. Additionally, the dismissal of multiple staff LNs and the influx of at least 15 Agency LNs created a culture of uncertainly and distress for the residents. Residents experienced neglect, deterioration in their medical conditions without appropriate, timely interventions, the onset of pressure sores, significant medications errors, and psychosocial distress as they lost familiar LN staff and received late and inappropriate medications from LNs they did not know and who did not know them. Residents were aware and spoke of some of the serious health outcomes that had befallen other residents and also expressed concern for the residents who could not monitor their own medications or speak for themselves. In the course of less than one month there were 15 complaint investigations completed related to the allegations and events occurring at the facility. The care delivery system remained broken despite the intermittent presence of corporate representatives. In the past 12 months F309, Care and Services, was previously cited four times with three of the four instances involving resident harm and the other time a potential for resident harm. One involved multiple residents receiving harm. Additionally, there was resident harm identified at F323, involving a fall with a substantial injury. Immediate Jeopary findings were brought to the attention of the facility and corporate representatives on [DATE] at approximately 3:40 p.m. and on [DATE] at approximatley 3:30 p.m.

Based on observation, record review, and interview, the facility failed to provide necessary, timely care to prevent further health deterioration in 5 of 6 sampled residents (#1, #4, #5,#13, & #16) with changes of condition. Resident #5 experienced respiratory distress/harm (and had medication errors) and Agency Licensed Nurse (LN) A failed to respond timely despite multiple reports by Staff Member A, a Nursing Assistant (NA), stating the resident required nursing intervention. Resident #13 was not given her prescribed anti-[MEDICAL CONDITION] medications for a day and had [MEDICAL CONDITION] activity. Resident #4 was not adequately monitored for excessive fluid retention, developed excessive overload and an abnormal heart rhythm, and required hospitalization /harm. Resident #1 had several acute medical issues and was not provided necessary monitoring and nursing care/harm and the resident died unexpectedly. Resident #16 had eye surgery and did not receive necessary pain medication/harm post-ioperatively. Resident #11 and Resident #14 experienced harm as a result of unrelieved pain and emotional distress. Residents #6, #7, #8, #9, #15, #16, #17, & #18 also experienced emotional distress related to missing medications, late, erratic, and/or erroneous medication administration. This was determined to be an Immediate Jeopardy. Findings include but were not limited to: Resident #5: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to the physician's orders [REDACTED]. Further review of the [DATE] physician's orders [REDACTED]. In addition, the physician had discontinued the prescribed cough syrup (The date of discontinuance in February 2012 was not very legible.) that was administered every six hours while she was awake. However, February and [DATE] Medication Administration Records (MARs) revealed documentation that facility nurses continued to administer the discontinued medications. (On [DATE] at approximately 2:05 p.m.), Staff LN B reviewed the physician's orders [REDACTED]. The resident had current orders for [MEDICATION NAME] nebulized respiratory treatments to be given four times a day routinely and every two hours as needed for wheezing and shortness of breath. The [DATE] nursing entry documented a Staff Member A, a Nursing Assistant (NA) had called Agency LN A to the resident's room. The resident was ashen in color and was lying flat on her back in bed and was unresponsive. The resident had labored breathing and her oxygen saturation level was 14% (extremely low). The resident was given 4 liters of oxygen and she was repositioned with her head elevated. The resident's color improved and she began talking but her respirations remained rapid and labored. The resident was sent to the ER. She was found to have an exacerbation of her respiratory condition and medications were ordered. Review of the February 2012 MAR revealed the resident had not received her scheduled bedtime [MEDICATION NAME] respiratory treatment on [DATE] and no additional as needed treatments were documented on the MAR. On [DATE] at approximately 3:10 p.m., Staff Member A was interviewed (the NA on-duty on [DATE]) and stated she and Staff Member C had assisted the resident into bed at about 9:30 p.m. The resident needed her breathing treatment so Staff Member A notified Agency LN A, the LN on the unit. Next, Staff Member A recalled hearing the resident go from moaning to very loud calling out. When she re-entered the room the resident was sitting on the edge of her bed, leaning forward "clenching" an over-bed table, and was more short of breath. Once again, Staff Member A told Agency LN A the resident needed a respiratory treatment. When Staff Member A returned to the resident's room again the resident was purple in color and she was still yelling out. Staff Member A approached the LN the third time and asked for assistance for the resident but the Agency LN reportedly stated, "I can't help" and returned to her other medication duties. When Staff Member A returned to check on the resident she had flopped back on the bed and was only breathing about once every 30 seconds. This time, Staff Member A ran out to the nurses' station and found two LNs who were charting, Staff LN D and Agency LN B. Approximately twenty minutes had lapsed since Staff Member A had started requesting help from Agency LN A. The two other LNs hurried to the resident's room and sat her up. Agency LN A came in behind the other LNs. The resident was not talking and was very limp. The resident was given a breathing treatment and began to respond. On [DATE] at approximately 2:05 p.m., Agency LN A was interviewed about the resident's care and condition on [DATE]. The Agency LN recalled she was late with the medications that night and hadn't gotten to Resident #5's room yet. The facility residents were upset because their medications had been late even on the day shift. Agency LN A recalled the caregiver had come to her at about 9:30 p.m. requesting a breathing treatment for [REDACTED]. At about 9:40 p.m. the caregiver had reappoached her and there were three residents at her medication cart. She responded by telling the caregiver, "I'll be there as soon as I can." She stated she didn't see the urgency. At about 9:45 p.m. the caregiver came to her again requesting a breathing treatment for [REDACTED]. The Agency LN stated the caregiver never conveyed the urgency to her. When she went into the room the caregiver and another LN were in the room assisting the resident and the resident was laying flat across the bed with her feet over the edge of her bed. She was ashen, not talking, and her oxygen saturation was 14 %. After repositioning and the breathing treatment, the resident's condition improved. The physician and family member were notified and there was a decision to send the resident to the hospital ER. New medications were prescribed to address her respiratory condition. Staff LN D was interviewed on [DATE] at approximately 10:02 a.m. and recalled that on [DATE] she had worked the day shift, had clocked out, but was still finishing her charting at the nurses' station. Staff Member A came up to the nurses' station stating the resident had difficulty breathing and was turning blue so the LN responded to the room. Staff LN D recalled the resident had fallen back on her bed, was breathing but was bluish and not responding or conscious. They repositioned the resident. Staff LN D then took the keys from Agency LN A and got a [MEDICATION NAME] respiratory treatment for [REDACTED]. Staff LN D stated she gave the last respiratory treatment on the day shift sometime between 2:00 p.m. and 4:00 p.m. "If ,[DATE] hours past breathing treatment she gets short of breath." When interviewed on [DATE] at approximately 12:05 p.m., Staff Member C, a NA, recalled she had helped put the resident to bed on [DATE]. When the two caregivers exited the room, Staff Member C overheard Staff LN A asking Agency LN A for a breathing treatment for [REDACTED].'s name) can't breathe; (resident's name) can't breathe!" She further stated Staff LN A was clear that the resident's condition was serious. On [DATE] at approximately 7:00 p.m., Agency LN B was interviewed and stated she was charting at the nurses' station and the caregiver came up in a panic stating, "I need help with (the resident's name); she can't breathe". Agency LN B advised the caregiver to let her nurse know but she stated she had been trying. The caregiver and the two nurses at the desk entered the room and the resident was blue and "in respiratory distress". The LN described the other actions taken and then stated, "(Agency LN A, named) could have responded in a more timely manner to the CNA's (Nursing Assistant's) report of shortness of breath". The LN on the wing, Agency LN A, was late with her medication administration pass and was focused on her routine tasks instead of recognizing and responding to the urgent needs of the resident as conveyed by Staff Member A and by the resident's audible verbalizations of distress/calling out. Additionally, the lateness of the resident's breathing treatment and her resulting distress/reaction were likely contributing factors to her respiratory distress. The resident's condition was seriously compromised as a result of the delay in her treatment. Resident #5 was observed on [DATE] at approximately 4:30 p.m. She was seated in the foyer by the nurses' station. She was receiving oxygen via a portable tank. She stated she was feeling, "okay". She was pleasant but answered with short, vague responses. Resident #13: Review of the medical record revealed multiple [DIAGNOSES REDACTED]. Physician orders, dated [DATE], contained an order for [REDACTED]. Review of the nursing entries for approximately three months did not reveal [MEDICAL CONDITION] activity. The [DATE] MAR documented the resident did not receive either of her [MEDICATION NAME] doses on [DATE] (due to running out of medication). The narcotic record did not contain documentation that the medication was signed out during that interval and it was not administered until 12:00 noon on [DATE] according to the narcotic record. The nursing entry documented that a [MEDICATION NAME] level was drawn. It was found to be low at 8 (desired was ,[DATE]). Although not documented in the nursing notes, a [DATE] physician's orders [REDACTED]. On [DATE] at approximately 4:46 p.m. the cognitively impaired resident was observed to be interacting with Staff Member E as she awaited her medication administration. The resident was in her wheelchair at the medication cart. There was no observation of any abnormal movements or [MEDICAL CONDITION] activity at that time. On [DATE] at approximately 1:30 p.m. Staff LN E was interviewed and stated Agency LN C was working on the day shift on [DATE]. The Agency LN had reported to Staff LN E that the resident had a [MEDICAL CONDITION] during breakfast in the dining room on [DATE]. There was no nursing documentation about the type of [MEDICAL CONDITION] activity or duration. Staff LN E stated she had to assist Agency LN C beginning at approximately 2:00 p.m. and ultimately had to remove the keys from the Agency LN at 5:00 p.m. The Agency LN was so frustrated and she did "not even know where she was struggling". There had also been a call-in that morning by another Agency LN and so there was a heavier workload that day. During a medication pass audit on [DATE], it was noted that the resident had not received her 6:00 a.m. dose of [MEDICATION NAME] that morning. The [DATE] 5:40 p.m. nursing entry documented family notification related to a missed [MEDICATION NAME] dose that morning. The error was discovered later and the physician was notified. The dose was given later, adjusting the administration times for the day. During a [DATE] 12:30 p.m. interview with the resident's Power of Attorney (POA), the POA stated she was notified two days earlier (on [DATE]) about another omission of the resident's Phenbarbital. The POA reported the resident had not had a [MEDICAL CONDITION] for years, not as long as she remained on her medication. Also refer to F314 related to missed antibiotic doses during a wound infection. Resident #4: Review of the medical record revealed the cognitively alert resident had multiple medical [DIAGNOSES REDACTED]. There was a [DATE] order to assess the resident's left lower leg for changes in [MEDICAL CONDITION]. There were baseline measurements provided and both legs were measured for five days, ending on [DATE]. The [DATE] nursing entry documented the resident continued to have [MEDICAL CONDITION] in her thighs. The physician ordered HCTZ 25 milligrams (mg) for 4 days (a water pill) on [DATE]. There was a [DATE] order for [MEDICATION NAME] 40 mg (another type of diuretic, a water pill) to be given twice daily. On [DATE] the Nurse Practitioner ordered the [MEDICATION NAME] to be increased to 60 mg in the morning and 40 mg in the afternoon for 5 days only. The [DATE] nursing entry documented the HCTZ had been restarted (use short term) to address "fluid on her thighs". The February 2012 MAR documented [MEDICATION NAME] 60 mg daily continued thereafter. The resident's Cardiovascular/Circulatory Plan of Care noted staff were to "monitor for sign/symptoms of [MEDICAL CONDITION]". The February 2012 Treatment Administration Record (TAR) documented LNs were initialing they were monitoring daily for leg swelling but there was no measurement or scale used to evaluate potential changes. There was only one nursing entry during February 2012, on [DATE], that documented some additional lower extremity [MEDICAL CONDITION] (+1, a slight amount). According to the February 2012 MAR, the resident was to be weighed twice weekly. Despite the presence of [MEDICAL CONDITION] and changes in her diuretic doses, only three of eight scheduled weights were recorded during the month of February 2012. There were two noted refusals but there was no dcoumented attempts to reschedule or to discuss the importance with the resident. When interviewed on [DATE] at approximately 12:05 p.m., Corporate LN A stated there was no monitoring scale on the February 2012 TAR to evaluate changes in the resident's [MEDICAL CONDITION], therefore, documentation should be in the nursing progress notes. (It was only addressed as noted above on [DATE] and on [DATE].) The [DATE] MAR documented an omission of the [DATE] daily dose of [MEDICATION NAME] 60 mg. The [DATE] nursing entry documented the resident was complaining of left sided chest pressure and felt an irregular heart beat. Her heart rate was 120. The provider was notified and the resident was transferred to the hospital. A [DATE] Physician's Discharge Summary from the hospital recorded that the resident was given intravenous [MEDICATION NAME] and other medications. During three days at the hospital the resident had lost 33.2 pounds. Resident #4 was interviewed on [DATE] at approximately 12:35 p.m. The cognitively alert resident stated she was told she had received the wrong medication prior to going to the hospital. A LN at the facility had provided her with the State Hotline number but she had opted not to call. On [DATE] the resident had experienced neck and jaw pain prior to going to the hospital. Resident #4 stated that while she was in the hospital 40 pounds of fluid were removed and she was told she had [MEDICAL CONDITION]. After returning from the hospital she stated her heart rate remained elevated. The resident pointed to her lower abdomen and stated she felt she had more fluid accumulating. The resident spoke of a recent interaction with an unnamed Agency LN. The Agency LN had reportedly told her she wasn't returning because she didn't want to lose her license and she had expressed concern about the safety of the resident while staying in the facility. The resident recalled that on [DATE] she had not received her 6:00 a.m. -7:00 a.m. medications until 12:00 p.m. to 1:00 p.m. According to the resident, the Director of Nursing (DNS) had "gotten rid of" the LNs who knew the residents and now there were Agency LNs caring for them; some of them welcomed input and some didn't (regarding the medications). Despite the administration of multiple diuretics over the course of the previous month and the plan to weigh the resident twice weekly, the facility failed to implement their monitoring plan and failed to recognize the excessive fluid accumulation in order to notify the physician or nurse practitioner in order to alter treatment and avoid further deterioration and/or hospitalization . Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. During an investigative interview with a Registered Dietitian (RD)/Diabetic Educator, she reported the young resident had experienced a lot of medical complications [REDACTED]. The RD's written recommendations on [DATE] and [DATE] included obtaining an order for [REDACTED]. The facility obtained the insulin pen and allowed the resident to inject his insulin without a physician's orders [REDACTED]. Nursing entries on the night shift of [DATE] into [DATE] by Staff LN Q, a Licensed Nurse (LN) and on the night shift of [DATE] going into [DATE] by Staff LN P (a LN), and an entry on [DATE] by Staff LN Q documented the resident was self-injecting his insulin with the insulin pen. On [DATE] at approximately 11:35 a.m. the Director of Nursing (DNS) stated Resident #1 was not on a self-medication program (no current order was located). According to the [DATE] hospital physician admission note, the resident had a bone infection in his right thumb. The resident returned to the facility on [DATE] with continued IV antibiotic treatment, [MEDICATION NAME] 600 mg every 8 hours until [DATE]. Then [MEDICATION NAME] 450 mg was to be administered orally every 6 hours. The resident was also to receive daily [MEDICATION NAME], a blood thinning medication. According to a [DATE] facility Medication Error Report, when the resident transitioned to the oral dose he was given only 150 mg, instead of the ordered 450 mg, of the [MEDICATION NAME]. The error involved 18 doses between [DATE] and [DATE]. One of the doses in the interval was not documented as given, the midnight dose on [DATE]. The Vital Signs Record documented the resident had a temperature of 101.2 degrees Fahrenheit the morning of [DATE]. The [DATE] day/evening shift nursing entry documented the medication error was found by the night shift nurse. The physician ordered the resident be sent to the ER for evaluation but the resident refused to go. Nursing entries on [DATE] documented the resident's temperature was within normal range and he was feeling better. On ,[DATE] the resident was complaining of stomach pain and nausea and received a one time dose of [MEDICATION NAME] (medication to relieve excess acid in his stomach) and an anti-nausea medication. The resident also received anti-nausea medication and a liquid antacid on [DATE]. An evening shift nursing entry for [DATE] documented the Nurse Practitioner had been in to see the resident. He was experiencing pain in his left upper arm. The resident had declined an ER visit at the time stating he was going to the hospital on Friday ([DATE]). Additionally, a lab finding on [DATE], documented that the resident's INR (a measure of his blood clotting) revealed a value of 6.7 (high, normal range approximately 2.5) and there was an order to hold his [MEDICATION NAME] dose until [DATE] (due to his increased risk of bleeding). A [DATE] 6:20 p.m. nursing entry noted a new order for cough syrup and change in his anti-nausea medication. The computer report documented the resident ate half or more of his lunch and dinner. According to the ,[DATE] MAR, the resident's bedtime blood sugar was 125 and he received only his nightly long acting insulin at bedtime and two [MEDICATION NAME] 10 mg (narcotic pain pills) at 9:00 p.m. for leg pain. At 10:00 p.m. he was noted to be sleeping per the [DATE] MAR entry. There were no further nursing narratives related to the resident's condition despite him being on alert charting for his infection, his upset stomach, and his elevated lab value. Entries in the [DATE] MAR documented the resident's [DATE] midnight antibiotic dose was not administered but the 6:00 a.m. dose was documented as given (Interviews later revealed it was not given). On [DATE] the resident's 8:00 a.m. blood sugar was documented as 129. Morning "AM" Humalog (shorter acting insulin) was to be administered "right after meal" and if the resident didn't eat breakfast he was to receive Medpass 100 cubic centimeters (a nutritional supplement). Documentation on the MAR revealed the resident's insulin was administered by Agency LN E and the site was recorded. However, no Medpass supplement was documented as given for a meal replacement. (The resident had not eaten breakfast according to interviews with nursing and kitchen staff). Fire Department EMS records for [DATE] documented they received an alarm at 11:25 a.m. and arrived at 11:28 a.m. at the facility. The resident was found without pulse and respirations. He was "cold, waxy, and cyanotic (bluish)". He was pronounced deceased at 11:35 a.m. The resident's condition on arrival did "not coincide with time frame that staff had given". The documentation noted the presence of rigor mortis in multiple body sites. Multiple investigative interviews revealed: When interviewed on [DATE] (at approximately 11:10 p.m.), Agency LN A recalled on [DATE] at bedtime the resident had requested the Medpass supplement because of his blood sugar level. She offered Resident #1 his antibiotic at midnight but he was hard to awaken and said, "Not now". The LN re-approached the resident at about 1:00 a.m.-1:30 a.m. and told the resident he needed to take his medication. He pulled his arm away and didn't answer her but made a sound like, "Errrr". At 6:00 a.m. It was time for the next antibiotic dose. He didn't speak to her but made a noise. His eyes fluttered and he made a "smirk". The LN recalled she had listened to his lungs and pulse. She failed to document that she had not actually given the 6:00 a.m. dose and she did not complete her alert charting entry stating she did not have time. On [DATE] (at approximately 10:00 p.m.), Staff Member H, the NA on the night shift, stated Resident #1 went to bed late at about midnight and he got up at about 3:30 a.m.-4:30 a.m. and went outside to smoke. The resident returned to bed and when Staff Member H returned to the room later the resident appeared to be sleeping. It seemed to be a usual night. On [DATE] (at approximately 2:30 p.m.), Staff Member I, the NA on [DATE] day shift stated she checked on the resident at about 7:00 a.m.-7:30 a.m. and he was under his covers as he usually slept. She did not attempt to awaken him. She did not ask the resident if he wanted breakfast or touch him because he would typically become upset if disturbed. She let him rest. The resident did not have breakfast that morning. Staff Member J was also interviewed on [DATE] (at approximately 1:50 p.m.), the other NA on the wing, and he stated he had not seen the resident that morning. The Dietary Manager was interviewed (on [DATE] at approximately 10:45 a.m.) and she also stated the resident did not eat breakfast on [DATE] When interviewed on [DATE] (at approximately 12:30 p.m.) Agency LN E, the day shift LN, stated it was her first day at the facility. She was told in report by Agency LN A that the resident refused his medications (antibiotics) and she discarded them. Agency LN E stated she was late with her medication pass. "It was a three ringed [MEDICATION NAME] this morning." The night shift LN was not out until 9:00 a.m. Agency LN E reportedly checked the resident's blood sugar at approximately 8:15 a.m. The resident was underneath his covers and even his head was covered. She did not check him or assess him at that time. His left hand was hanging down and she obtained a blood sample from his left middle finger. She noted he had a cold hand. "I should have uncovered him." Agency LN E denied giving any medication including insulin to the resident. The LN recalled a staff member had called her to the resident's room later that morning and the resident was uncovered. When she touched him she knew he was dead. He was blue and without a pulse and there was froth coming from his mouth. He even had the gauze pad in place on his finger from the finger prick for the blood sugar check. On [DATE] (at approximately 3:08 p.m.), Staff Member K stated she had entered the resident's room at approximately 9:45 a.m. and he did not have the covers on, his shorts and t-shirt were showing. He was on his back with his arms to the side. She "hollered at him" a couple times but got no response; he resident appeared to be sleeping. When interviewed on [DATE] (at approximately 2:45 p.m.), Staff Member L,, the Activity Director, stated she entered Resident #1's room at about 11:10 a.m. and called the resident's name a couple times. He looked really white and "not normal". The resident did not have his covers on. She notified the LN on the wing (Agency LN E). A follow-up interview was conducted with Agency LN E on [DATE] at approximately 12:15 p.m. The Agency LN was asked about documentation on the [DATE] MAR. She was notified that the MAR documented she had given insulin. Agency LN E stated she did not administer insulin to Resident #1, it must have been a documentation error as she gave insulin to his roommate. (The roommate's record also documented he had received insulin). The site abbreviation "RA" meant right abdomen to the LN she stated. The LN further stated she had not received a report about the resident's breakfast. She had not given the resident the Medpass supplement. She stated she had not returned to provide care for the resident following the 8:15 a.m. blood sugar check. She was late with her medications all morning. Resident #11: A [DATE] interview was conducted at approximately 1:53 p.m. with Staff Member M. Staff Member M recalled when she came on-duty on [DATE] Resident #11 had tears "running down her face because she was hurting so badly. The resident stated she had waited for her pain medication for a couple hours. Staff Member stated she repositioned the resident and wrote the request down for the LN. Resident #14: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident had several types of routine medications and as needed medications to manage her pain. The cognitively alert resident was interviewed on [DATE] at approximately 2:20 p.m. and stated, "It's really been horrible. Last week was worse than any other." The resident recalled on [DATE] she waited for her morning medications until 12:00 p.m. and "I was really starting to feel it (the pain)." She did not receive her p.m. pills until 9:00 p.m. after multiple requests to the NAs. There were an inappropriate number of pills. She was in pain between 12:00 p.m. and 9:00 p.m. and asked for her pain medication five times. The resident stated she was crying with the pain. She stated she heard one of the residents had a [MEDICAL CONDITION] on [DATE]. Resident #14 also recalled that the day Resident #1 died (on [DATE]) she didn't receive her morning medications until 2:20 p.m. Additionally, the resident stated on [DATE] she did not receive any pills until 1:40 pm. That night she had alot of pain and "felt sick mentally". The Agency LN came in at about 9:00 p.m. and stated, 'I can't find all your pills', there were about only half of her pills. At 10:00 p.m. the resident asked the NA to tell the LN she was in pain and at 1:00 a.m. the LN came in with some medication for her pain and also tried to give her medication for blood sugar control. The resident informed the LN that she was not diabetic and asked the LN to look for her other pills. The resident stated because of the missing pills and late medication delivery, she felt "physically sick for two days and mentally sick." Resident #14 stated the DNS had fired some of the best facility nurses who really cared about the residents. She stated she decided to speak out because of all the residents who could not speak out for themselves. Review of the [DATE] MAR revealed multiple omissions for [DATE] for medications throughout the day and evening that could assist in pain management. A [DATE] interview was conducted at approximately 1:53 p.m. with Staff Member M, a NA. Staff Member M recalled that when she came on-duty on [DATE] Resident #14 was crying due to waiting for her pain medication for hours. Resident #16. The resident had chronic pain in her joints from [MEDICAL CONDITION] joint disease and was prescribed pain medication three times daily for the pain. She had a scheduled eye surgery (cataract removal) on [DATE]. Her doctor had not prescribed an increase or an addition of the pain medication following eye surgery. On [DATE] at 9:15 a.m. the resident had a scheduled appointment to have the eye surgery site assessed by her doctor. However, when interviewed on [DATE] at approximately 1:40 p.m., the resident stated that on [DATE] facility staff had brought her breakfast tray and set it by her bed without waking her up. She woke up independently close to the time of the appointment. She had not been given her morning medications which included the pain medication. She bathed herself on her commode and an off-duty NA assisted her to get dressed. She reportedly arrived at her appointment at approximately 10:45 a.m. As a result of not receiving her pain medications she stated, "I was crying in pain. I cried the first half hour I was there because I was in so much pain. I almost had a panic attack I was so anxiety filled." The resident had been prescribed hourly [MEDICATION NAME] eye drops (while awake) after her surgery to keep eye inflammation down and decrease pain. However, on [DATE], the resident stated she had not been receiving the hourly drops as prescribed. On [DATE], the Medication Administration Record (MAR) documented the resident was ordered to receive the eye drops hourly while awake, however, the area provided for the nurses to document on the hourly instillation of the eye drops did not provide an area for documenting each drop given. Instead the MAR had an area for three times a day dosing. On [DATE] at approximately 2:30 p.m. the Agency Licensed Nurse (LN) D stated she was aware the resident should get the eye drops hourly but had not been able to give them as ordered. She further stated she did not know how many times she had given the eye drops during her shift. She had documented the drops as given on the MARs in the area provided for her shift. The progress notes, dated [DATE] and timed 4:20 a.m., documented the resident was not to eat or drink before her eye surgery. There were no other notes documenting the nursing staff had monitored the resident's health status baseline previous to surgery or upon her return from surgery later that same day. Without the baseline and monitoring immediately following her return to the facility, the nurses would not be able to make a valid comparison in the event of a decline in the resident's condition. Additionally, the progress notes did not document the resident's pain and/or the incident of not receiving her pain medications on the morning of [DATE]. On [DATE] at approximately 1:40 p.m., the resident stated, " I was out of it the day of the surgery, I can hardly remember a thing and the day after surgery was horrible because of my pain." "I was in a vulnerable state while my anesthesia was wearing off and when my pain was under better control and I was able to take control

Based on observation, record review and interview, the facility failed to ensure significant medication errors did not occur for 13 of 16 residents reviewed (#1,4,5,6,8,9,11,13,15,16, 17,18,& 22) in the sample. Medications were administered without appropriate physician's orders [REDACTED]. Resident #5 experienced harm/respiratory distress due to a delay in her breathing treatment. Resident #13 had a [MEDICAL CONDITION]/harm due to a missed dose of her anti-[MEDICAL CONDITION] medications. Resident #16 experienced pain/harm following her eye surgery. The actual impact of many of the significant errors was difficult to ascertain but the ongoing occurrences created a likelihood of harm. Additionally, many of the residents (#4, #6, #9, #15, & #17) experienced emotional distress related to the ongoing medication administration problems. This was determined to be an Immediate Jeopardy. Findings include: Also refer to findings under F309 for Residents #7 and #14 who did not name specific medications but who experienced distress related to medication related problems. Not administered as prescribed: Resident #13: Multiple [DIAGNOSES REDACTED]. Review of the nursing entries for approximately three months did not reveal [MEDICAL CONDITION] activity. The March 2012 MAR (Medication Administration Record) documented the resident did not receive either of her [MEDICATION NAME] doses on 03/11/12 (due to running out of medication). The narcotic record did not contain documentation that the medication was signed out during that interval and it was not administered until 12:00 noon on 03/12/12 according to the narcotic record. The nursing entry documented that a [MEDICATION NAME] level was drawn and found to be low at 8 (desired was 15-40). Review of a 03/15/12 physician's orders [REDACTED]. On 03/19/12 at approximately 1:30 p.m. Staff LN E was interviewed and stated Agency Licensed Nurse (LN) C, was working on the day shift on 03/15/12. The Agency LN had reported to Staff LN E that the resident had a [MEDICAL CONDITION] during breakfast in the dining room on 03/15/12. On 03/19/12 it was noted that the resident had not received her 6:00 a.m. dose of [MEDICATION NAME]. The investigator identified the ommision and reported it to the facility. On 3/24/12 the resident failed to received her dose of [MEDICATION NAME] as it was scheduled. On 03/26/12 at 12:30 p.m., the resident's Power of Attorney (POA) stated she was notified two days earlier (on 03/24/12) about another omission of the resident's medication. The POA reported the resident had not had a [MEDICAL CONDITION] for years, not as long as she remained on her medication. Resident #13 also had a pressure sore on her right heel. The 3/06/12 nursing enty documented there was brownish drainage present and it was odorous. On 3/07/12 an antibiotic, [MEDICATION NAME] 500 milligrams, was ordered to be administered four times daily for 10 days. According to the March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was also a new wound treatment ordered on [DATE]. A 3/2012 Skin Grid entry documented the resident's wound continued to have an odor. Resident #5: The resident had current orders for respiratory treatment to be given four times daily and every two hours as needed for wheezing and shortness of breath. Review of the February 2012 MAR indicated [REDACTED]. On 02/29/12 at approximately 9:30 p.m. the resident had labored breathing and her oxygen saturation was 14% (extremely low). The resident was sent to the Emergency Department. She was found to have an exacerbation of her respiratory condition. Resident #4: [DIAGNOSES REDACTED]. On 01/29/12 the physician ordered HCTZ 25 mg for 4 days (a water pill). On 01/31/12 an order for [REDACTED]. A nursing entry on 02/03/12 noted the HCTZ was restarted to address "fluid on her thighs." The February 2012 MAR indicated [REDACTED]. The following day nursing notes documented the resident complained of left sided chest pressure and irregular heart beat. Her heart rate was 120. She was transferred to the hospital and received treatment for [REDACTED]. On 03/13/12 at approximately 12:35 p.m. the cognitively alert resident stated she was told she had received the wrong medication prior to going to the hospital. She recalled that she had not received her 6:00-7:00 a.m. medications until 12-1:00 p.m. On 03/14/12 at approximately 12:30 p.m. Nurse Practitioner #1 stated the [MEDICATION NAME] error was "an unfortunate error." It was difficult to determine the degree of impact the medication omission had on the resident's condition. Resident #1: Multiple [DIAGNOSES REDACTED]. He was to be treated with IV antibiotics ([MEDICATION NAME]) between 02/08-19/12. After completion of the IV [MEDICATION NAME], it was to be administered orally every six hours. Review of a 02/25/12 facility medication Error Report, when the resident transitioned to the oral dose, noted he was given only 150 mg, instead of the ordered 450 mg of the [MEDICATION NAME]. The error involved 18 doses between 02/19-24/12 and one of the doses, the midnight dose on 02/20/12, was not documented as given. Entries in the March 2012 MAR indicated [REDACTED]. However, interview on 03/01/12 at approximately 11:10 p.m. with the Agency LN A revealed she had failed to document that she had not given the 6:00 a.m. dose. On 03/01/12 the resident's 8:00 a.m. blood sugar was documented as 129. Short-acting insulin was to be administered right after the meal, however he did not eat. Documentation on the MAR indicated [REDACTED]. Resident #8: The resident had eye surgery on 03/15/12 for cataract removal and had been pescribed [MEDICATION NAME] eye drops to be given four times daily. After the surgery on 03/16/12 the MARs documented the correct dose of the eye drops to be instilled. However, the area provided for the nurses to document had only three areas for documentation, not the four times it was to be given, thus the resident did not receive the four prescribed doses. Resident #16: The resident had chronic pain in her joints from [MEDICAL CONDITION] joint disease and was prescribed pain medication three times daily for the pain and hourly [MEDICATION NAME] eye drops (while awake) to keep inflammation down and decrease eye pain. She had a scheduled eye surgery (cataract removal) on 03/15/12. On 03/16/12 at 9:15 a.m. the resident had a follow-up appointment after her eye surgery. However, when interviewed on 03/19/12 at approximately 1:40 p.m., the resident stated she not receive her hourly [MEDICATION NAME] eye drops or her pain medication prior to her appointment. "I was crying in pain. I cried the first half hour I was there because I was in so much pain. I almost had a panic attack I was so anxiety filled." On 03/19/12 the MAR indicated [REDACTED]. Rather space only for documenting three doses. On 03/19/12 at approximately 2:30 p.m. Agency LN D stated she was aware the resident should get the eye drops hourly, but had not been able to give them as ordered. Resident #15: The March 2012 MAR indicated unable to locate" and there was no documentation it was given later); 03/15/12 daily Aspirin 81 mg dose, midday [MEDICATION NAME] caplet and midday Acidophilus caplet, and a midday [MEDICATION NAME] tablet (also omissions for multiple days involving approximately 9 doses, a 03/16/12 note that the LN was unable to find in the building). On 03/19/12 at approximately 5:20 p.m., Resident #15 stated his medications had been very slow lately. Many of his morning medications were not administered until 10:30 to 11:00 a.m. and were "jogged throughout the day, medications were way off time." Without physician's orders [REDACTED]. Resident #5: Multiple [DIAGNOSES REDACTED]. The 02/01/12 physician's orders [REDACTED]. However, the February and March 2012 Medication Administration Records (MARs) revealed documentation that facility nurses continued to administer those discontinued medications. The resident had current orders for a respiratory treatment to be given four times daily and every two hours as needed for wheezing and shortness of breath. Review of the February 2012 MAR indicated [REDACTED]. Wrong dosage: Resident #6: On 03/13/12 at approximately 11:20 a.m. and on 03/19/12 at approximately 1:50 p.m., the resident stated she was having a hard time trying to control herself with all the frustrations with the medication administration and changes. She stated one day they could not find her blood pressure medication and she got it late at 9:00 p.m. Her blood pressure was high. Additionally, her oral diabetic medication was to be given with her meals. Her oral medication and insulin for lunch were not given until 2:40 p.m. Another time, they were unable to locate her diabetic oral medication at dinner and she didn't receive it. They pulled the diabetic medication from the emergency kit the next morning and gave it to her but it was a lower dose. Review of the February and March 2012 MARs revealed the facility had run out of her narcotic pain medication on 02/28/12 for two doses. On 03/15/12 there were omissions of the resident's afternoon blood sugar check and her daily allergy medication and blood pressure medication. Documentation revealed on 03/16/12 the morning diabetic oral medication was not administered at the usual dose, but a lower dose. Outside of the scheduled time frame: Resident #17: On 03/20/12 at approximately 8:50 a.m. the resident who was interviewed via telephone stated that one night during the last week he had to stay up until 1:00 a.m. to receive his evening pills (evening med pass time was 8-10:00 p.m.) from (Agency LN F). On 03/19/12 he received his evening pills at 11:00 p.m. When he asked Agency LN F why the medications were so late he said, "I've got to go slow and take my time." Resident #9: Multiple [DIAGNOSES REDACTED]. Routine and "as needed" narcotic pain medication was ordered and the "as needed" pain medication could be administered up to four times a day. Review of the March 2012 MAR indicated [REDACTED]. On 03/19/12 at approximately 12:00 noon, the resident was in the hallway raising his voice at Agency LN D (first day in the building) stating "You know I have an appointment, you are supposed to give me my (pain) medication!" When interviewed on 03/20/12 at approximately 9:03 a.m. via telephone, Resident #9 stated he waited up to 3 ? hours before he received it. His morning medications were often not given until 11:00 a.m. Resident #18: Physician orders [REDACTED]. On 03/19/12 during the medication pass by Agency LN D (her first time at the facility) revealed the resident's Papaya Enzyme tablets, after breakfast dose, were given at 12:25 p.m. directly before she began eating her lunch (not after breakfast as ordered). The [MEDICATION NAME] was given at the same time immediately before she ate lunch (to be given 30 minutes before the meal and scheduled for morning on the MAR). Additionally, there were no Cranberry tablets available in the right dosage so the medication was not administered at that time. Observed medication errors: Resident #22: On 03/27/12 at approximately 11:45 a.m. (Midday pass) Staff LN T prepared medications for the resident. Included was [MEDICATION NAME] CR 50-200 milligrams, a sustained release medication used to control tremors. The medication was crushed along with 7 other medications. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. (Sustained, or extended release medications, are meant to release in the blood stream over time, not immediately.) Resident #11: Multiple [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the March 2012 MAR indicated [REDACTED]. Review of laboratory results, dated 3/20/12 and 3/27/12, indicated the resident's hemoglobin and hematocrit levels were lower than normal. On 03/27/12 at approximately 4:00 p.m. the acting Director of Nursing Services (DNS) stated there was not an order on the March 2012 MAR (it had not been transcribed onto the MAR) for the medication and it had not been given since the resident's admission on 03/04/12. Despite identification of multiple significant medication errors and ongoing facility and corporate medication audits, LNs at the facility continued to make ongoing medication errors. When interviewed, on 3/27/12 at approximately 12:00 p.m., about the audits over the previous weekend, Staff LN N stated she had been involved in facility audits of the medication and treatment administration records. The floor LNs audited each other's books for completeness and she would also audit the records for completeness. They were reviewing to ensure documentation was complete. Refer to F490 for observed medication errors continuing despite corporate/facility audits. Documentation audits/reviews failed to adequately identify medication timing errors and technique problems as they were occuring. Despite the facility submitting a safety plan for medications, medication errors continued. Refer to F490 for observed medication errors continuing despite the safety plan, and corporate facility audits.

Based on observation, interview and record review the facility failed to provide sufficient supervision to ensure residents' treatment orders were followed. Multiple observations revealed the facility failed to reposition residents appropriately including keeping pressure off the residents' heels. The facility systemic failure resulted in harm for 3 of 3 residents (#'s 10, #13, & #19) in the sample who developed pressure ulcers. Findings included: Resident #19: The resident had advanced dementia and was dependent on staff for all cares including turning in bed to relieve pressure. She had a history of [REDACTED]. She had a recent (current) pressure ulcer on her right heel. On 03/21/2012 the facility "skin grid" documented the right heel wound had worsened with a new onset of odor, yellow drainage, yellow color of the wound bed and an increase in size. The left heel had not been monitored on the "skin grid". On 03/21/2012 the resident had been seen by a Provider who had written orders to culture the right heel wound. Additionally, an order for [REDACTED]. On 03/23/2012 a physicians telephone order documented the resident was to have "Podus boots" (boots made of hard plastic outer heels and soft inner lining used to lift the heel away from any type of pressure such as the bed mattress) on at all times. Orders had also been written for an antibiotic injection to be given to the resident daily for 7 days. (The right heel wound culture had been positive for the growth of 2 types of bacteria and required antibacterial treatment.) No other orders regarding the care or discontinuation of care of the heels had followed the above orders. On 03/26/2012 at approximately 4:15 p.m. the resident was lying in bed on her right side. She had on a pair of soft heel protectors (not the prescribed podus boots) over bare skin on her left heel and over a sock on her right heel. There had not been a dressing on either of her heels. While the Licensed Nurse (LN), Staff V, attempted to pull the resident's sock on over her left heel the resident jerked her left foot away and loudly stated, "ow, ow." During the removal and subsequent replacement of the right sock the resident again loudly expressed discomfort and pulled her foot away from the Staff V. Both of the residents socks were replaced over her heels and the soft heel protectors were replaced. No dressing or any type of wound cover was placed on either heel. During the observation of the resident, the heels were noted to be moderately pink to red in color with an area of yellow discoloration in the middle of red. The right heel had an open area with scant drainage in the middle of the yellow discoloration. On 03/27/2012 at approximately 3:40 p.m. the resident was lying in bed on her right side with one Podus boot on her left foot/heel and a large boot on her right foot/heel, not the prescribed Podus boots on both heels. On 03/27/2012 at approximately 4:00 p.m. Staff LN S stated the physical therapy department had stated on 03/27/2012 that only one boot was available for the resident to use and another would be ordered. The March 2012 Treatment Administration Record (TAR) documented the nursing staff had performed a scheduled weekly skin assessment on 03/24/2012 and marked a minus for the absence of current skin problems. Additionally, orders to free float her heels (keeping the heels up away from pressure to prevent a worsening or the start of a pressure ulcer) and the orders for left and right heel cleansing and wound cover were discontinued on 03/24/2012. On 03/25/2012 the order to have the resident use Podus boots was also discontinued on the TAR. Despite the absence of an order to discontinue treatment of [REDACTED]. The resident experienced pain as evidenced by her response when her socks were touched on her heels and had not been provided with the prescribed treatments to decrease her heel ulcers and increase her comfort. Resident #13: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. On 8/18/11 the resident was assessed to be at moderate risk for skin breakdown. The resident's skin care plan noted the resident's heels were to be protected. The Care Delivery Guide documented she required cueing and assistance from a caregiver to reposition in bed every two hours. The resident's heels were to be floated (suspended and not in contact with the bed or other surfaces). Additionally, the resident was to have a pillow between her feet at all times. Further review of the medical record revealed a 10/17/11 Physician Notification form documenting the resident was complaining of right hip pain and was calling out with any exertion. An 11/09/11 facility Accident/Incident documented a 4 centimeter (cm) by 4 cm (more than 1 1/2 inches) blister on the resident's right heel. A 11/10/11 Physician Notification form documented the resident had a "big blister" on her right heel. "Could you look at it please...It looks bad." Although the resident was seen by Nurse Practitioners at the facility, there was no documentation that the physician visited after 9/22/11. See F387 for additional data. Notes on 11/10/11 from the Interdisciplinary Team Meeting documented a "dark puple area to (R) Heel 4 by 4 cm. Suspect DTI (deep tissue injury)...Root cause noted resident just recently w/in (within) week staying in bed more often than usual which causing resident (sic) heel to lay on bed, causing skin issue." The care plan was updated and staff educated to keep heels floated at all times while the resident was in bed. An October 2011(appears to be 10/23/11) comprehensive assessment noted the use of an air mattress on the resident's bed. The same 11/10/11 treatments for the wound site continued as the area turned dark purple and then later dry/dark and scab-like over four months. The wound size narrowed slowly over time to 3.4 cm by 3.0 on 3/06/12. There was a 3/06/12 order to talk with the family regarding a wound clinic referal for the ulcer and a directive to monitor for signs of infection. The 3/06/12 nursing enty documented there was brownish drainage present and it was odorous. On 3/07/12 an antibiotic, [MEDICATION NAME] 500 milligrams, was ordered to be administered four times daily for 10 days. According to the March 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was also a new wound treatment ordered on [DATE]. A 3/2012 Skin Grid entry documented the resident's wound continued to have an odor. Wound clinic notes on 3/21/12 noted a new treatment order and directives to keep the pressure off the resident's right heel. During a 3/26/12 12:30 p.m. interview with the resident's Power of Attorney (POA), the POA stated she was not notified at the time of the onset of the ulcer and was only notified in conjunction with the wound clinic discussion. Observations on 3/26/12 at approximately 12:55 p.m., revealed Resident #13 was seated in her wheelchair and her right foot had fallen between her foot pedals as no pillow was present. Her foot was purplish in color as it hung down unsupported. Another observation was conducted on 3/26/12 at approxmately 1:55 p.m. during a dressing change and treatment. The resident had a soiled dressing with light brown/yellowish drainage showing through at the heel. The resident continued to have a right heel ulcer that was approximately 1 1/4 inches in diameter and appeared to be a crater with pink, yellow, and white tissue present. Directly following the dressing change, Staff Member U, a Nursing Assistant, stated in the past the facility was using a heel floating device that was not high enough so that the residents' heels still rested on the bed (causing heel pressure). The new heel elevating device still required a pillow on top to float the residents' heels off the bed. Staff LN N, the Resident Care Manager, was interviewed on 3/27/12 at approximately 12:00 noon, and she reviewed the medical record and stated it sounded like the resident's pressure ulcer was caused by her heel resting on the bed. She had no further recall except to state they had changed heel elevating devices. Further observations on 3/27/12 at approximately 11:15 a.m., 2:20 p.m., and 4:32 p.m. revealed the resident's left heel was resting on the bed at the first observation time and both heels were resting on the bed at the times of the other two observations. Resident #10: Review of the medical record revealed the cognitively alert resident had multiple [DIAGNOSES REDACTED]. The resident's Care Delivery Guide noted the resident was on bedrest, had an air bed, and required two caregivers to reposition her every two hours. The head of her bed was to be elevated 30 degrees. The skin plan of care documented the resident was at high risk for skin breakdown. She was to have an increased frequency of turning and was to be positioned off her back as much as possible. The resident had a rash on her groin and excoriation on her buttocks at the time of re-admission to the facility. Review of the Skin Grids noted a small Stage II (partial loss of dermis presenting as a shallow open ulcer with a red, pink wound bed) pressure area at the top of the gluteal cleft noted on 3/17/12 and resolved on 3/26/12. In addition, the resident had a small Stage II pressure sore on her right buttock. The pressure sore was first identified on 2/14/12 and was healed on 3/13/12. Observations on 3/27/12 at approximately 11:30 a.m., 1:00 p.m., 2:15 p.m., and 3:00 p.m. revealed the resident was positioned on her back with a pillow under her left arm. At the first observation timeframe the resident stated she was repositioned, but not as often as every two hours. She had just been repositioned but was on her back. On 3/27/12 at approximately 3:00 p.m. the resident's buttocks were observed. There were larger areas of redness on each buttock but on the right buttock there were two smaller areas that were open and red. When interviewed on 3/27/12 at approximately 4:00 p.m., Staff LN N stated that although the areas on the right buttock had healed on 3/13/12, they had re-opened on 3/27/12 and she had measured the areas.

Based on observation, record review, and interview, the facility failed to perform necessary assessments and facilitate timely medical treatment for 1 of 3 sampled residents (#1) reviewed. Resident #1 experienced shortness of breath and significant abdominal pain. Despite multiple reports/requests from the assigned Nursing Assistants (NAs), the Licensed Nurse (LN) failed to assess the resident's condition. Resident #1's spouse called 911 to seek emergency assistance for the resident when his condition deteriorated. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. admission orders [REDACTED]. The resident's oxygen saturation levels were to be checked every shift and as needed. Additionally, the resident had documented he wanted CPR and full treatment including transfer to the hospital and intensive care as needed. A [DATE] physician's orders [REDACTED]. The comprehensive assessment, dated [DATE], documented the resident had scored 15 out of 15 on his cognitive assessment, revealing his was cognitively alert. The ,[DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident received pain medication and at 5:30 a.m. he appeared to be sleeping. The MAR indicated [REDACTED]. There was no recorded oxygen saturation check for the day shift on [DATE]. The resident's routine morning medications were signed as administered the morning of [DATE]. Also documented as administered was a dose of Milk of Magnesia (for constipation) and an anti-nausea medication. Review of the resident's bowel record revealed it had been 10 shifts (3+ days) since he had a bowel movement. Day shift vital signs on [DATE] documented a pulse rate of 86, respirations of 16, and a blood pressure of ,[DATE]. The [DATE] morning vital signs included a pulse rate of 65, respirations of 20, and a blood pressure of ,[DATE]. On [DATE] at approximately 12:05 p.m., Staff Member B, a NA, was interviewed regarding events occurring the morning of [DATE]. The caregiver recalled she had gone to Resident #1's room at approximately 6:00 a.m. The resident was complaining of pain across his abdomen. He thought he needed to go to the bathroom to have a bowel movement but decided to get up after breakfast. When Staff Member B returned it was approximately 8:00 a.m. and his wife was there. Staff Member B had reported the resident's symptoms to the LN. The resident appeared to be in a "cold sweat, gray, and dripping". The caregiver assisted the resident into the bathroom. Typically, the resident was easy to transfer but she had to lift him during the transfer onto the toilet. Staff Member C was also in and out reporting to the LN on the resident's declining condition. He was having "dry heaves, complaining he couldn't breath, and nearly passing out, not there". "After about ,[DATE] minutes, Staff Member A (the LN) came in and turned up his oxygen to 6 liters per minute and exited quickly. She did not assess the resident or provide additional assistance or directives. When interviewed on [DATE] at approximately 3:30 p.m., Resident #1 recalled on [DATE] at about 4:00 a.m. he had some pain. He spoke with the night shift LN about the pain. At about 6:00 a.m. he called his wife on the telephone and asked her to come to the facility because he was not feeling well. The resident recalled he had shortness of breath and abdominal pain. He did not recall that Staff A, the LN on the wing, had performed an assessment or checked his saturation level. The Physical Therapy Staff Member entered the room and the resident informed him that he was not feeling well enough to participate in therapy. Resident #1 recalled Staff Members B and C, NAs, had assisted him that morning. He was very weak during the transfer. While in the bathroom, he had increasing difficulty breathing, "blurred vision", and felt as if he was "passing out on the toilet". A NA suggested an oxygen saturation check and performed it. He also recalled the EMTs (Emergency Medical Technicians) assisting him. During the interview, the resident was resting in bed with 6 liters of oxygen flowing. He moved very little but was pleasant and spoke without obvious shortness of breath. The resident's spouse was present and the resident requested she remain and participate in an interview. The spouse stated she recalled receiving a telephone call from her husband early on [DATE]. He stated he was not feeling well and wanted her to come to the facility. When she arrived she put her head against his and noted his skin was "cold and clammy". "He was white. No color in his face". His oxygen was set at 3 liters per minute. She was not certain of the exact time of her arrival but thought it was 7:30 a.m. -8:30 a.m. The NA(s) assisted the resident into the bathroom. The resident developed increasing problems while in the bathroom. The NAs attempted multiple times to get the LN to provide care for the resident but she did not provide necessary care. It was reported to her that the LN had stated if the resident did not have a bowel movement she would give him an enema later. The resident began throwing up with dry heaves. He was sweating and the NA had to hold him on the toilet to ensure he did not fall. "I knew he was in distress. I was scared to death." The wife stated she called 911 from her cell phone. They were unable to find the LN. The [DATE] day shift nursing entry by Staff member A documented the resident complained of nausea and medication was provided. The resident requested to be placed on the toilet where he had a super large bowel movement. The spouse indicated the resident was sweaty and pale and called 911. No resident assessment was located. Staff Member C (the second NA) was interviewed on [DATE] at approximately 12:30 p.m. The Staff Member recalled on [DATE] she first saw the resident at 6:45 a.m. and he was complaining of stomach pain. He didn't look good. She reported to the LN on the unit twice about the resident's nausea and the LN stated the resident already had his nausea medication. Staff Member C observed the transfer and noted he was weak. Staff Member B reported the resident was sweating and complaining of bad stomach pain. Staff Member C reported to the LN again about the resident's condition stating he was "gray, pale, and didn't look good." Reportedly, the LN stated she was passing medications and it would be a while. Staff Member C obtained a machine to check the resident's oxygen saturation (not her typical duty or one she was trained on). The machine read "88%" (low). She reported the low reading to the LN and the LN came into the bathroom and turned up the oxygen and left. Staff Member C once again approached the LN to report the resident's sweaty appearance and was reportedly told by the LN he was having a bowel movement, that was why he was sweating. As his condition continued to deteriorate Staff Member C attempted to call out for the LN but she couldn't find her or any other LN. The resident requested 911 be called and his wife made the call. Review of the EMS Field Report revealed the copy was not totally legible. On [DATE] at approximately 8:30 a.m., the Deputy Chief reported that the 911 call was received at 10:08 a.m. EMS arrived at the facility at 10:13 a.m. Nursing staff stopped them and spoke to them upon entry. Vital signs at 10:24 a.m. revealed a blood pressure of ,[DATE] (low), a pulse rate of 190 (very high), a respiratory rate of 30 and labored, and oxygen saturation of 84 %. The resident's skin was pale, cool, and diaphoretic (clammy). An IV was started and the resident was transported to the hospital. ER records,dated [DATE], documented [DIAGNOSES REDACTED]. The resident was hospitalized and later returned to the facility on [DATE]. Despite a notable change in the resident's condition reported by the resident and caregivers on multiple occasions, Staff Member A failed to assess the resident's condition to obtain data to evaluate his condition. Staff Member A continued to perform her other duties while presuming his symptoms were related to constipation rather than indicative of a more serious health deterioration. The resident's symptoms were reported for at least four hours. The resident and his spouse recognized the need for medical intervention and called 911 to obtain necessary care.

Based on observation, record review, and interview, the facility failed to provide necessary care and services for 1 of 3 sampled residents (#1) reviewed following changes of condition. Resident #1 experienced harm as result of a failure to obtain timely treatment following deterioration of a burn site. Findings include: Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. A 3/09/11 physician's orders [REDACTED]. The resident's care delivery guide documented she ate in her room and required staff assistance to set-up her meals. The resident was to have a "sports bottle and straws". According to the 12/21/11 nursing entry and facility investigation, the resident spilled "hot cocoa" on her chest. A pink area was present on the resident's chest directly following the burn. There was no documentation of the size of the skin area burned following the incident. The 12/2011 treatment record noted that the burn on the resident's chest was to be monitored daily. Staff Member C, the Licensed Nurse on-duty on 12/21/11 at the time of the burn, was interviewed via telephone (on 1/01/12 at approximately 1:00 p.m.). Staff Member C recalled, that although not documented in the medical record, the resident initially was yelling out after the cocoa spill. The white and pink burn area was initially about the size of a silver dollar and her skin was intact. By the end of her shift two intact blisters were present. Staff Member C stated she had called Nurse Practitioner (ARNP) A to report the blisters. Reportedly, the ARNP offered a medicated treatment but Staff Member C did not feel it was necessary because the skin was intact. Staff Member C recalled the ARNP planned to check the resident the next day. Staff Member C stated she had a couple days off and when she returned the resident's burn site was "much worse". On 12/22/11 there was an interdisciplinary meeting with a "Discussion on the resident's incident of spilling cocoa on her chest". The entry recorded, "skin pink". No documentation was present that recorded that the size of the burn or an ARNP evaluation. When interviewed on 12/28/11 at approximately 10:30 a.m., Staff Member A stated she had observed the burn area on 12/22/11 and recalled the area was approximately 3 centimeters (cm) by 3 cms (a little larger than an inch in diameter) and had a dried open blister present. Staff were monitoring the area. On 12/23/11 a night shift entry from Staff Member D documented the resident had a large reddened area on her chest. One large blister was intact and the upper blister had popped but was dry. No size was recorded. During the 12/23/11 day/evening shift Staff Member B documented the upper blister had "brownish looking eschar (dead tissue), its (sic) tender to touch the surrounding skin (sic) to both wounds is red in color". No size was noted to evaluate changes in the burn size. According to the nursing entry, on 12/24/11 (3 days after the burn incident) Staff Member D measured the red area on the resident's chest and recorded the size as 7 inches by 5.5 inches. The blisters were also measured. Despite the notable increase in the size of the burn size on 12/24/11 there was no evidence of notification of the physician to secure treatment. When interviewed (on 1/01/12 at approximately 10:20 p.m.) Staff Member E, a Nursing Assistant, recalled that several days after the burn, the resident was scratching the skin off her chest stating, "it itches." The staff member stated she reported the occurrence to Staff Member F, the Licensed Nurse on-duty. A 12/25/11 nursing entry by Staff Member B documented that upon return to the facility that afternoon, the resident's family member expressed concern about the chest burn. Nursing documentation recorded, "that the injured tissue is adhered to the wound base and is brown in color and tender to touch.". There were "multiple blisters of different shapes or healing". On 12/26/11 (5 days after the burn occurrence) the On-Call Physician was contacted. There was an order written [REDACTED]. The 12/27/11 9:25 a.m. nursing entry documented the "chest burn still deep red, tender to touch" but no complaints of pain when burn not touched. The 12/28/11 night shift entry by Staff E documented the resident was given Tylenol for complaints of chest pain. "Reminded resident not to scratch". On 12/28/11 at 10:50 a.m. (7 days after the burn incident), the cognitively impaired resident was interviewed. When asked if she had spilled cocoa, the resident said "yes" and pulled down the neckline of her shirt exposing a large dark pink area covering the right side of her upper chest with four large scabbed areas. Later that morning, at approximately 11:00 a.m., observations with Staff Member B revealed the burn area was greater that six by five inches on her right upper chest and extended to an area lower between her breasts. There were four scabbed areas that Staff B referenced as "necrotic" (areas of dead tissue) and there was also a blister below the primary burn site. The resident stated "ou" when her clothing was moved to allow visualization. The Director of Nursing (DNS) was interviewed on 12/28/11 at approximately 1:25 p.m. and stated she had been called on 12/24/11 and on 12/25/11 about the deterioration in the condition of the resident's burn. On both occasions she had advised the reporting nurse(s) to notify the physician to seek a treatment but there was no documentation of follow-up by the nurse(s). Staff Member G, a Nursing Assistant, was interviewed on 12/28/11 at approximately 3:20 p.m. The caregiver reported "it hurts her a lot" when you take her shirt off. ARNP B was interviewed about the condition of the burn on 12/28/11 (at approximately 11:30 a.m. and 4:25 p.m.) The ARNP stated she had not heard about the resident's burn from facility staff or from the other ARNPs. The resident was last seen by the physician on 12/15/11 (prior to the burn). The ARNP's 12/28/11 documentation recorded, "Blisters with [MEDICATION NAME] loss (skin) due to burn (second degree) of breast" and of "chest wall, excluding breast and nipple". A new medicated cream was ordered twice daily with a dressing covering the area. The other documentation noted, "painful burn". Review of the 12/2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Additional Tylenol 650 mg was available as needed for pain. However, the resident only received one as needed Tylenol dose for her burn on 12/28/11 at 4:00 a.m. The facility failed to adequately assess and document the initial status of the burn site and failed to report and seek necessary treatment when the site deteriorated. A protective dressing was not sought to prevent further damage by the cognitively impaired resident. The area was painful especially with manipulation of her clothing or with touching.

Based on record review and interview, the facility failed to provide adequate staff supervision and safety interventions to prevent accidents for 1 of 3 sampled residents (#1) with falls. Resident #1, a resident with a fall history, was admitted to the facility for rehabilitation following a fall and fracture. The resident fell from his bed and experienced a dislocated hip requiring further medical intervention. Findings include: Resident #1: Review of the medical record revealed the resident was admitted on [DATE] following a fall with a resulting right hip fracture and surgical repair. The admission plan of care identified the resident as at risk for falls and injury. He was documented as unsteady, experienced dizziness, and had limited weight bearing. He required two persons to assist him with transfers, experienced incontinence, and was receiving a diuretic and narcotics. The plan of care identified only one environmental intervention, non-skid socks. The care delivery guide also noted the resident was confused at times. A 9/03/11 Accident/Incident Report documented that at 4:10 p.m. the resident was found on the floor in his room with his right "leg at an obtuse angle-knee in + swelling, hip R (right) twisted in." The resident had a urinal in his left hand. The resident was sent to the hospital where he was diagnosed with [REDACTED]. According to the investigation, the resident last received toileting assistance on the day shift, the time was not specified. It was not documented whether the non-skid socks were in place. The conclusion was that the resident had attempted to get out of bed without assistance or using his call light. LN E was interviewed on 9/16/11 at approximately 5:00 p.m. The LN stated she hadn't seen the resident on her shift prior to entering the room and finding him on the floor at bedside at 4:10 p.m. He was in alot of pain. The door to the resident's room was closed and she was checking on him because he received pain medication every six hours. The resident's call light was not on. She had come out onto the floor at about 2:45 p.m. (nearly 1 1/2 hours earlier) but the NAs came out onto the floor at "2-ish"(two plus hours later). LN E stated she believed the resident had fallen out of bed based on his position next to his bed. She recalled NA C had come in at some point and assisted but she couldn't recall who the assigned caregiver was but must have obtained the information that toileting assistance was last provided on day shift. LN E stated, "hope someone had seen him" (on evening shift prior to the fall). Interviewed on 9/15/11 and 9/16/11, NA C stated the resident's door was closed and she entered to check on the resident. The call light was not on. The resident was lying on the floor near his bed. On 9/15/11 the Director of Nursing stated that after the resident fell on [DATE] the facility added additional protective interventions. The facility failed to provide adequate supervision to anticipate the resident's needs and to maintain visibility of a resident with a known fall risk. Negligible safety interventions had been identified/implemented initially to protect the resident.

Based on record review and interview, the facility failed to provide timely care and services for 5 of 9 sampled residents (#1, #9, #13, #14, & #18). Resident #1 received initial treatment for [REDACTED]. Resident #18 developed acute rectal bleeding and the facility failed to recognize the acute change of condition, notify the physician or family, monitor the resident's condition, or facilitate care until the resident's condition became critical. Residents #9, #14, & #18 did not receive timely pain medication despite their requests. Resident #14 experienced ongoing physical pain and psychosocial distress when she was not allowed to contact her family member in the midst of her distress. Resident #18 experienced pain due to the lack of pain medication directly following admission to the facility. Resident #13's cardiac medication was not administered as it was thought to have run out and no monitoring was performed. Findings include: Changes of Condition: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] following hospitalization for hip surgery. In addition, the resident had a history of [REDACTED]. An 8/31/11 nursing entry documented a call was placed to the physician's office to report increased drainage on the dressing, approximately 5-6 inches across having a bloody appearance. The Surgeon ordered lab work and directed the Nurse Practitioner (ARNP) check the wound the following day. On 9/01/11 the ARNP examined the resident and ordered staff to update the Surgeon in the morning about the [DIAGNOSES REDACTED] (redness) on the upper half of the right hip incision. Staff contacted the Surgeon's office staff on 9/02/11 but they were unable to reach the Surgeon. Facility staff contacted the resident's Primary Care Physician who ordered an antibiotic injection for 9/02/11 and an oral antibiotic for three days. There was an additional directive to contact the Surgeon on Tuesday, 9/06/11, written on the 9/2011 medication administration record (MAR). A 9/03/11 nursing entry documented the Surgeon had called the facility during the evening of 9/02/11 and he had concurred with the Primary Care Physician regarding administering the antibiotics. Additionally, the Surgeon ordered that the staples were to be removed on 9/05/11 if no drainage was present. The resident was to keep the follow-up appointment on 9/07/11 with the Surgeon. Review of the 9/2011 MAR revealed the resident finished taking his last antibiotic the evening of 9/05/11. According to the 9/2011 treatment administration record (TAR) the staples were not removed on 9/05/11. Despite the staples not being removed, there was no documentation of an actual assessment of the condition of the right hip incision. Nursing entries the following day, on 9/06/11, did not contain documentation of a wound assessment or of a follow-up contact with the Surgeon as the 9/2011 MAR directed. A 9/06/11 evening temperature reading noted an elevation of the resident's temperature to 99.6 degrees Fahrenheit (F). When interviewed on 9/15/11 at approximately 12:05 p.m., Licensed Nurse (LN) C stated she had cared for Resident #1 on 9/06/11 and recalled his incision showed increased redness spreading over a larger area, around the bottom of the wound and up the other side. LN C said she was not comfortable removing the sutures on 9/06/11 because of the condition of the wound. While on the antibiotics the wound stayed the same but it worsened after completion of the (short course) of the antibiotics on 9/05/11. LN C recalled she reported the deterioration of the resident's wound site to the Director of Nursing for further follow-up. There was no documentation of a report of the change in the resident's condition to the Surgeon or to the resident's Power of Attorney (POA) on 9/06/11. On 9/07/11 at approximately 9:00 a.m. resident's temperature reading was 99.9 degrees F and 101.4 degrees F axillary (under the arm, typically reading one degree lower than an oral reading) at 10:30 a.m. The resident was administered Tylenol but the administration time was not documented. When interviewed on 9/16/11, Nursing Assistants (NAs) A and B stated that on 9/07/11 the resident had a fever, vomited, was more confused, and was shaking. NA A recalled on 9/07/11 the resident's dressing was half off and the incision looked "a lot more red and worse than I'd ever seen it before". The NA stated she had observed the wound before when holding the resident during a prior dressing change. NA A stated she reported the change in the resident's condition to the LN D and to the Director of Nursing (DNS). On 9/16/11 at approximately 2:45 p.m., LN D recalled that on 9/07/11 she gave Resident #1 two Tylenol tablets for his elevated temperature. She was concerned about his condition as she was aware he had thrown up. She had turned up his oxygen based on a respiratory assessment. The LN did not look at the resident's wound/incision that day. LN D spoke to the Nurse Practitioner (ARNP) who was in the building seeing other residents. The ARNP provided an order for [REDACTED]. There was also a decision made not to send the resident to his Surgeon's appointment that day but to proceed with the plan to transfer him to an alterative nursing facility per the family's previous request. A 9/07/11 nursing entry documented the resident's POA was notified of the resident's condition of nausea and malaise (feeling ill). The Surgeon's office was contacted and provided the new facility's contact information for rescheduling the appointment. There was no documentation that the Surgeon was notified of the specifics of the resident's deteriorated condition. Interviews were conducted with the DNS on 9/15/11 and 9/16/11. The DNS stated the physician was not notified of the change in the resident's condition on 9/06/11 or on 9/07/11. The incision was monitored but no actual assessments were located in the medical record that documented the actual changes in the wound status. The resident's POA was interviewed on 9/14/11 at approximately 6:25 p.m. The POA recalled he was planning to meet the resident at the Surgeon's office in another city on 9/07/11. While the POA was waiting at the Surgeon's office, he received a call from the DNS stating they decided not to send him for his appointment as he was not feeling well. The POA was not provided any details of the resident's illness. The POA stated if he had been told the resident had a fever that morning and that he had vomited he would have directed them to send him to the hospital for an evaluation rather than transferring him to another skilled nursing facility. Later that evening the new facility sent him to the hospital because of his confusion and his vital signs. The hospital determined he had bacteria in his blood stream and he remained in the hospital until 9/13/11. Review of the hospital records revealed the resident was admitted with decreased responsiveness from [MEDICAL CONDITION] (an infection that had invaded his blood stream). During a 9/19/11 1:10 p.m. interview with the admitting LN at the alternative facility he stated the hospital nurse reported, from the hospital on [DATE] prior to re-admission, that the hip wound had caused [MEDICAL CONDITION]. Resident #18: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A 9/19/11 2:10 p.m. nursing entry documented the resident had three bowel movements that were reddish in color and tested positive for blood. The Physician and Nurse Practitioner (ARNP) were notified. Orders included testing the next three stools for the presence of blood and if anymore drawing blood for a complete blood count lab test. The physician examined the resident on 9/20/11. When interviewed on 9/27/11 at approximately 10:10 p.m., night shift NA E recalled that on 9/20/11 she took Resident #18's vital signs sometime between 10:30 p.m. and 11:30 p.m. The resident's vital signs record documented her pulse was 70, respirations were 16, and her blood pressure was 111/68, usual values for her. Lab studies on 9/20/11 revealed her red blood cells were within normal range. The 9/21/11 4:30 a.m. nursing entry documented the resident had 375 cc (cubic centimeters, more than 1 1/2 cups) of dark red liquid stool that tested positive for blood and at 5:30 a.m. the resident had 475 cc (nearly two cups) of liquid dark red stool. There was no documentation of any further vital signs, resident assessment, or notification of the physician or family member. The 9/21/11 8:00 a.m. nursing entry documented a LN had reported "increased bleeding, ? rectal". The resident was assessed and found to be pale and lethargic with a "Lg (large) amount of blood (with) clots (between) her legs (approximately) 400+ cc". Her blood pressure was 90/40 and she had an irregular pulse of 102. A follow-up nursing entry documented 911 was called at 8:21 a.m. (nearly 4 hours after the onset of bleeding). Physician and family follow-up were documented as well at that time. LN G, the LN on-duty the night of the rectal bleeding, was interviewed on 9/27/11 at approximately 5:55 p.m. LN G recalled the NA had notified her of the dark stool/possible bleeding and the stool tested positive for blood. The LN recalled the first stool "looked like blood" but she did not observe the second stool (or assess the resident) but directed the NA to measure the amount. The LN did not direct the NA to take vital signs. LN G recalled it was getting close to day shift at about 5:30 a.m.-6:00 a.m. so she decided to "passed it on to the day shift nurse". She had not called the physician or family member to report the change in the resident's condition. When interviewed on 9/26/11 at approximately 4:20 p.m., the DNS stated there were no other vital signs located and reported the blood loss as "a huge amount". The day shift nurses recognized the seriousness of the resident's condition and transferred her to the hospital. Hospital ER records documented the resident arrived at 8:57 a.m. [DIAGNOSES REDACTED]. Physician documentation on 9/21/11 stated the resident "came in shock". She required fluids and blood products. Medication Issues: Resident #14: Review of the medical record revealed the alert resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Additionally, the resident had an order for [REDACTED]. The resident's plan of care noted the resident required assistance for transferring and ambulation. When interviewed on 9/26/11 at approximately 1:40 p.m. and on 9/27/11 at approximately 9:50 a.m., Resident #14 recalled one night at about 3:00 a.m. she was crying and requested pain medication for severe right arm pain, "above a 10" when rated by a 0-10 scale with 10 being the worst possible pain. LN G told her it was too soon to have the pain medication. The resident asked for a telephone to call her family member but staff refused to give it to her. The resident stated she even asked for Tylenol to try to get some pain relief if she was unable to have her narcotic pain pill. Resident #14 stated she might have received Tylenol later that night but did not recall getting her narcotic pain medication. The resident's family member was interviewed on 9/27/11 at approximately 8:30 a.m. The family member recalled receiving a report from Resident #14 that on 9/19/11 she had hit her cast on the bars in therapy when she turned too sharply. Her arm hurt all day. She "wanted pain medication at night (on 9/19/11/9/20/11) and they wouldn't give it to her. She stated she wanted to call her daughter but they refused to give her the phone." Further review of the medical record revealed a late nursing entry, dated 9/20/11 by LN G documenting the resident was complaining of right arm pain two hours after receiving pain medication. Tylenol was given with relief. Despite the nursing entry, the 9/2011 MAR did not document that Tylenol was administered. Additionally, the MAR and narcotic records did not document any [MEDICATION NAME] was administered during that night shift. When interviewed on 9/27/11 at approximately 5:55 p.m. about the absence of medication administration documentation and about the alert resident not being allowed the use of the phone, LN G stated she had "no good explanation". LN G stated she remembered telling the resident her medication was not due yet but she might have looked at someone else's MAR. She was unsure whether Tylenol was administered and not documented. Resident #18: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. The initial 9/17/11 2:15 p.m. nursing entry documented the resident was not having pain at that time. An evening shift entry, without a time, stated, "c/o (complaining of pain q (every) 15 minutes. LN B documented multiple efforts to contact the pharmacy to obtain the medication. The 9/2011 MAR documented the resident had a 6/10 pain level on her right lower ankle and received [MEDICATION NAME] at 6:00 p.m.. At 8:00 p.m. the MAR noted the resident continued to have 5/10 pain and reported, "still hurts". There was no documentation the physician was contacted to report the unrelieved pain. At 10:00 p.m. the resident received another [MEDICATION NAME] tablet for 5/10 pain in her right ankle. At 11:00 p.m. the resident was still awake and reporting 5/10 pain. The 9/18/11 night shift nursing entry noted the resident did not sleep well. The MAR documented the resident received a pain pill at 2:20 a.m. for 6/10 ankle pain. She was noted to be asleep by 3:00 a.m. (poor legibility). On 9/27/11 at approximately 3:50 p.m. LN B recalled that on 9/17/11 the resident had begun complaining of pain at about 3:30 p.m. A family member had reported the resident's pain initially and kept coming back to report the resident's pain. The medications were received at 6:00 p.m. The resident waited approximately 2 1/2 hours for pain medication initially and had ongoing pain for many hours. The pain medication was available at the facility in the emergency kit but there was no authorization obtained to provide the medication from that supply. Resident #9: Review of the medical record revealed the resident was re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. She had longer acting narcotic pain medication, [MEDICATION NAME] (mg) to be administered twice daily, morning and bedtime. In addition, she had an order for [REDACTED]. On 9/15/11 at approximately 2:15 p.m. Resident #9 reported that on 9/13/11 she started experiencing increased pain in her right hip and legs at about 7:00 p.m. but was told the medication was not due until 9:00 pm. The resident stated she did not receive her pain medication until 12:30 a.m. Review of the 9/2011 MAR revealed that on 9/13/11 [MEDICATION NAME] was administered at bedtime (no time was specified) and her "as needed" [MEDICATION NAME] was documented as administered at 2300 (11:00 p.m.) with the resident sleeping at midnight. Resident #13: Review of the medical record revealed the resident had a history of [REDACTED]. According to the 9/2011 MAR, the resident did not receive three consecutive doses of [MEDICATION NAME] between the evening of 9/15/11 and the evening of 9/16/11. The resident received the medication the morning of 9/17/11. Despite the known omission of the resident's heart medication, no vital signs or assessments were documented during that interval to assess the impact of the omissions on the resident. When interviewed on 9/27/11 at approximately 11:15 a.m., the DNS stated she was informed by LN H on 9/19/11 that the resident's [MEDICATION NAME] was not given on 9/15/11 and 9/16/11 and the medication was found in the medication back-up at the facility. The DNS advised LN H to fill out a medication error report but none was located per the DNS or logged in the Medication Error Log. On 9/27/11 at approximately 1:00 p.m. LN I, the LN who omitted the medication, was interviewed. LN I stated she ran out of [MEDICATION NAME] and did not give it as indicated by her circled initials on the MAR. She would typically write the reason for not giving the medication on the back of the MAR but she had not provided documentation related to those omissions. The LN further stated she was unable to locate any vital signs during that interval.

Based on observation, record review, and interview, the facility failed to provide necessary care and services for 1 of 5 sampled residents (#2). Deficient practice was identified for Resident #2, a newly admitted resident with a previous history of chronic wounds, wound infections, and amputation. Although the facility recognized the resident's risk for skin breakdown, they failed to develop a plan and complete timely skin checks under the resident's knee high compression stocking and soft boot. The compromised resident developed skin breakdown and bleeding under the compression stocking. Findings include: Resident #2: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 8/18/10 nursing assessment did not reveal any skin breakdown on his right leg at the time of admission. The August 2010 treatment record noted the resident was scheduled for a weekly skin assessment on 8/20/10 to assess for any skin problems. There was no documentation that the skin check was completed. An 8/25/10 comprehensive assessment documented the resident required assistance from two caregivers to reposition in bed. The facility generated a skin care plan and identified the resident was at moderate skin for skin breakdown. The August 2010 treatment record noted a weekly skin check had been completed on 8/27/10 and there were no findings. When interviewed on 9/15/10 at approximately 4:35 p.m, Licensed Nurse (LN) #4 recalled the resident had a compression stocking on his right leg and a padded boot on his right foot at the time of admission. LN #4 had completed the 8/27/10 weekly skin check. The LN recalled she concentrated on the resident's coccyx (skin over the tailbone) during the skin check, a "more vulnerable area". LN #4 could not recall if she had removed the stocking or boot that the resident wore all the time. Review of the admission physician orders, plan of care, and 8/2010 treatment records did not contain documentation of the compression stocking or boot on the resident's right leg. On 9/09/10 at approximately 11:30 a.m. Resident #2 stated he had used the compression stockings since April 2010 and the right foot/lower leg boot was provided in the hospital after surgery. His previous physician had directed he wear the stocking(s) around the clock. While in the hospital, staff removed the stocking daily (and padded boot) to check the condition of his skin. He had no objection to the staff at the nursing facility removing his boot and stocking for skin checks. He stated he did not have normal feeling in his leg due to his medical condition. Resident #2 stated a female therapist at the facility had identified a skin problem on the back of his right lower leg under his stocking (while his sister, a wound care specialist, was visiting). Review of the facility 9/02/10 investigation revealed there was an "open area on the resident's right calf 2 cm (centimeters) by 5 cm", less than an inch by approximately 2 inches" related to the compression stocking and boot not being removed and assessed on a regular basis. The stockings were "bunched up". The facility investigative statement from the Bath Aide (BA) documented the resident had refused to remove the stockings for his showers so she placed a plastic bag over the area during showers. The facility obtained 9/02/10 treatment orders to treat the area of skin breakdown on the resident's right calf, to manage the compression stocking and boot, and to address the resident's skin hydration needs on his right leg. When interviewed on 9/09/10 at approximately 11:00 a.m., Licensed Nurse (LN) #2 stated she worked on Resident #2's wing (on 9/02/10). A therapy staff member came to her inquiring about the status of the resident's compression stocking. There was no physician's order and it was not on the treatment or medication records. The stocking and boot had been in place for at least a week and there was no follow-up. The typical procedure would be to place the stocking(s) in the morning and remove them at bedtime. If there was a boot it would be checked every shift. The other facility LNs were unaware of the stocking and boot as it had not been documented at the time of admission. LN #2 recalled that on 9/02/10 the resident's compression stocking had become "scrunched" and had caused an abrasion on the back of the resident's lower leg. She had noted the size of the abraded area on the facility investigative document. Interviewed on 9/09/10 at approximately 1:45 p.m., the Physical Therapy Assistant (PTA) stated she was in the room with the resident and his sister. She removed the compression stocking (on the resident's right leg). The resident's lower leg was mis-shaped from the stocking. His right ankle was tiny and his calf was swollen with "red bands"on the skin and there was bleeding on the back of his leg (calf). The skin was very dry as well. The resident's family member was upset and Licensed Nurse (LN) #2 was notified for further follow-up. Observation of resident's right leg treatment on 9/09/10 at approximately 1:05 p.m. revealed the skin on resident's calf had a bright red horizontal linear area about 1 inch long. Although essentially intact, the skin appeared fragile. There was also a bright red linear horizontal area approximately 4 1/2 inches long on the front of the resident's lower leg. The skin did not appear to be broken but remained bright red after removal of the compression stocking and during the treatment. Despite the resident's immobility, diminished sensation, previous wounds, and recent amputation, the facility failed to provide necessary care for Resident #2. A compression stocking and soft boot were utilized without a physician's order or directives. The placement of the compression stocking and boot were not checked regularly by staff. Skin breakdown and bleeding occurred in the area when the stocking bunched and the skin was abraded.