Every finding on record at North Auburn Care

Based on interview and record review, the facility failed to conduct performance reviews for 5 of 5 Certified Nursing Assistants (CNA's) (Staff M, N, O, P, & Q) at least every 12 months, as required. This failure placed residents at risk of receiving care from staff whose performance did not meet expectations and required additional training.Findings included.Review of the facility's Staff List provided on 07/21/2026 showed the following:Staff M (CNA) was hired on 09/16/2024, 22 months prior to survey.Staff N (CNA) was hired on 03/14/2024, 16 months prior to survey.Staff O (CNA) was hired on 04/20/2021, 63 months prior to survey.Staff P (CNA) was hired on 07/29/2024, 23 months prior to survey.Staff Q (CNA) was hired on 08/14/2024, 23 months prior to survey.The facility did not provide any documentation to show that performance reviews for Staff M, Staff N, Staff O, or Staff P were conducted.Review of Staff Q's Employee Performance Review, dated 11/27/2025, showed Staff Q's performance was reviewed 15 months after their date of hire. The facility did not provide any other performance review documentation for Staff Q.In an interview on 07/28/2026 at 8:28 AM, Staff R (Human Resources) stated that the facility was waiting to do annual performance reviews because the employee union was still working on new wage rates. Staff R stated they understood performance reviews were required to be done every 12 months, but they were not because employees wanted to know how their performance reviews would affect their wages. Staff R stated they could not locate any previous performance reviews for the above staff.In an interview on 07/28/2026 at 9:18 AM, Staff B (Director of Nursing) stated that they expected performance reviews to be done annually, and many were overdue.REFERENCE: WAC 388-97-1680 (2)(b)

Based on observation, interview, and record review the facility failed to ensure the residents and their environment were kept safe for 2 of 4 units (Birch Hall and Cedar Hall) observed with accident hazards and for 5 of 13 residents (Residents 63, 67, 17, 94, & 28) reviewed for accidents. The facility failed to ensure their sharps containers were not overfilled (rooms & treatment carts), resident safety assessments regarding device use (Resident 6) and smoking (Resident 28) were completed, Care Plan (CP) interventions were developed and implemented to prevent falls (Resident 67), smoking materials were safekept properly (Resident 17), and residents assessed with elopement risk were provided adequate supervision (Residents 94 & 28). These failures placed residents at risk for bloodborne pathogen exposure, avoidable injury, and other negative health outcomes. Findings included.<Facility Policy>According to the undated facility policy titled, Sharps Handling and Disposal, the facility would provide for the safe handling and disposal of sharps to reduce the risk of healthcare associated infections. The policy showed staff were to replace sharps containers before the contents go above the fill line.According to the facility policy titled, Accidents and Incidents: Report, Investigate, Review, and Analysis, dated 02/03/2023, the facility would provide an environment that was free from hazards where the facility had control over with and would provide supervision and assistive devices to each resident to prevent avoidable accidents. The policy showed the facility would provide for resident safety through: Risk Reduction: Falls and Injuries Elopement Prevention Safety Devices Wheelchair Safety, and Occupational Safety and Health Administration (OSHA) Safety According to the facility policy titled, Fall and Injury: Prevention and Management Care Plan, dated 01/30/2023, the facility would revise the residents CP and/or facility practices to prevent the likelihood of another fall. The policy showed the facility would determine causal factors that led to a resident fall and provide consistent intervention to help prevent future occurrences. <Sharps Containers> <Cedar Hall> In an observation on 07/21/2026 at 8:37 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/21/2026 at 8:40 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/21/2026 at 8:51 AM, the sharps container in room [ROOM NUMBER] was seen observed filled over the fill line. <Birch Hall> In an observation on 07/21/2026 at 9:40 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/21/2026 at 10:32 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/21/2026 at 12:05 PM, the sharps container on a treatment cart opposite room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/22/2026 at 7:44 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/22/2026 at 7:48 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/22/2026 at 11:53 AM, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/22/2026 at 11:54, the sharps container in room [ROOM NUMBER] was observed filled over the fill line. In an observation on 07/22/2026 at 2:54 PM, the sharps contained on the treatment cart labelled A/B was observed filled over the fill line. In an observation and interview on 07/22/2026 at 3:04 PM, Staff C (Assistant Director of Nursing) confirmed the sharps containers in each of the observed rooms and both treatment carts were overfilled. Staff C stated it was important to replace the sharps containers before they were full to prevent infections and to provide a safe space for staff when disposing sharps after use. <Safety Device Use> <Resident 63> According to the 04/16/2026 admission Minimum Data Set – (an assessment tool), Resident 63 had severely impaired cognition and used a wheelchair. The MDS showed Resident 63's ability to move from room to room with their wheelchair was not assessed during the lookback period due to illness or injury. The MDS showed Resident 63 had a seizure disorder. Review of Resident 63's physician orders showed a 06/24/2026 order for a self-releasing seat belt to be used when the resident was up in their tilt-in-space wheelchair (a specialized wheelchair allowing the angle of the seat and back of the chair to be adjusted backwards). Record review showed a 06/24/2026 safety device assessment for Resident 63's self-releasing belt. The assessment showed the belt was needed due to tremors and was to be used when Resident 63 was in their tilt-in-space wheelchair. There was no corresponding safety device assessment of Resident 63's tilt-in-space wheelchair. Observation on 07/27/2026 at 1:13 PM showed Resident 63 ambulating in their wheelchair. The self-releasing belt was across Resident 63's lap. Resident 63 ambulated in a slow, determined way. In an interview on 07/28/2026 at 8:28 AM, Staff E (Resident Care Manager) stated a tilt-in-space wheelchair could limit a resident's independent movement and required assessment to make sure the wheelchair was appropriate and safe. Staff E reviewed Resident 63's chart and confirmed no assessment was completed. <Fall Prevention> <Resident 67> According to the 06/01/2026 Annual MDS, Resident 67 admitted to the facility on [DATE] with medical diagnoses of dementia (a progressive disorder affecting memory, cognition, and the ability to do daily tasks), restlessness and agitation, and age-related physical weakness. The MDS showed that Resident 67 required supervision with all activities of daily living. The MDS showed Resident 67 had two falls during the assessment period. Review of Resident 67's fall CP showed the resident was at risk for falls related to poor safety awareness. Resident 67's fall CP included but was not limited to the following interventions: 03/11/2023 Frequent safety check related to falls 03/15/2023 Resident 67 not to be left alone in room in wheelchair 06/15/2023 Provide toileting during safety checks 01/14/2026 anti-slip matt added to wheelchair cushion 04/17/2026 therapy referral related to falls 06/03/2026 Encourage Resident 67 to wear non-skid socks Review of Resident 67's CP showed it was not updated after 06/03/2026. Review of Resident 67's 05/28/2026 fall incident investigation summary showed they had a fall in the hallway down the hall from their room. Resident 67's fall incident summary showed they were impulsive and wandered frequently, and that staff were very aware and supervised the resident when the resident was walking. The summary showed, during this fall incident, the resident was able to ambulate out of their room and down the hall before being seen by staff. In an observation on 07/22/2026 at 1:33 PM, a staff member was heard yelling into the hallway from Resident 67's room for assistance due to a fall. In an observation on 7/22/2026 at 2:23 PM, Resident 67 was observed sitting on the floor in their room, scooting on their bottom toward the door. The surveyor alerted staff that Resident 67 was on the floor. In an observation on 07/27/2026 at 8:06 AM, Resident 67 got up from a chair in the hallway and walk back to their room and got into bed without staff assistance or supervision. In an interview on 7/27/2026 at 8:09 AM, Staff II (Licensed Practical Nurse) stated for the successive falls on 07/22/2026, they had Resident 67 put on non-skid socks and encouraged them to use their wheelchair instead of their walker. Staff II stated there were no other interventions put in place that they were aware of regarding Resident 67's fall. In an interview on 07/27/2026 at 8:12 AM, Staff JJ (Certified Nursing Assistant) stated they were the assigned aide for Resident 67, and they were not aware of any recent care plan changes related to fall prevention. Staff JJ stated that if there was a CP change for Resident 67, someone would tell them what the change was, but there were no updates given to staff recently. In an interview on 07/27/2026 at 12:11 PM, Staff B (Director of Nursing) stated there were no care planned interventions to prevent Resident 67 from falling following the falls they had on 7/22/2026, but there should have been. Staff B stated it was important to put in an intervention after a fall to prevent reoccurrence. <Smoking Materials> <Resident 17> According to the 05/19/2026 admission MDS, Resident 17 was admitted to the facility on [DATE] with medically complex conditions, was able to understand and be understood, and currently used tobacco. Review of the facility's 07/21/2026 Active Smokers list showed four residents, including Resident 17, who currently smoked. In an interview on 07/21/2026 at 12:06 PM, Resident 17 stated they kept their smoking materials in their closet which was not locked. Resident 17 stated that confused residents wandered into their room occasionally. In an observation and interview in Resident 17's room on 07/23/2026 at 1:49 PM, Resident 17 stated they had their smoking materials in their pocket. Resident 17 stated they did not have a lock box to store them. Observation showed Resident 17 opened their closet drawer and no lock box or smoking materials were observed. Resident 17 stated they usually kept their smoking materials on their overbed table and kept them hidden. Review of Resident 17's medical records showed they signed a copy of the facility's Smoking policy on 05/18/2026 and agreed to abide by the policy. The policy showed residents who retained their own smoking materials were required to keep them in a locked cabinet when not in use. In an interview on 07/24/2026 at 12:50 PM, Staff A (Administrator) stated they were new to the facility and did not know if locked storage was provided for Resident 17's smoking materials but would find out. Staff A did not provide further information. In an interview on 07/27/2026 at 1:39 PM, Staff B stated they expected smoking materials to be stored in a personal locked drawer or in the nurse's medication cart, depending on the resident's assessed ability to store them safely. Staff B stated they were not aware that Resident 17 did not have locked storage available and stated they would provide locked storage for them. <Facility Document - Elopement> Observation and record review on 07/28/2026 at 11:17 AM showed an Elopement Binder at the nurse's station on a shelf available to staff. Inside the binder was a policy titled, Elopement Prevention and Management Program, revised January 2017, showed the facility would provide adequate supervision through individual assessment of a resident's needs and potential hazards. The policy showed the facility would implement an elopement care plan with interventions to mitigate the risk of resident elopement. Observed in the binder were elopement photograph sheets for seven residents of the facility who were identified as an elopement risk. <Resident 94> Review of Resident 94's 06/29/2026 Hospital Discharge Summary showed the resident was hospitalized after a ground-level fall resulting in a left hip fracture that required surgical intervention. Resident 94 had medical diagnoses including delirium (a change in mental ability with symptoms including confusion and disorientation) and advanced dementia. The discharge summary showed Resident 94 exhibited agitation, restlessness, impulsivity, removing medical devices, and was an elopement risk while in the hospital. Review of the 06/29/2026 Nursing admission Assessment showed Resident 94 was admitted for dementia on 06/29/2026. Resident 94 was assessed to require extensive assistance from staff for care and mobility needs. The assessment showed Resident 94 was not at risk for falls and was not at risk for elopement. Review of the 07/01/2026 facility investigation showed on 07/01/2026 at 7:30 AM, Resident 94 was outside the facility on the ground after an unsupervised fall. Resident 94 had exited the facility through the therapy door, without staff knowledge or supervision, stood from their wheelchair to walk outside and fell to the ground. The progress notes of the investigation showed Resident 94 was restless, agitated, physically aggressive with staff, wandering inside, and trying to leave the facility since admission on [DATE]. The investigation notes showed staff had initiated one-to-one supervision for Resident 94 on the night shift on 06/30/2026. The investigation showed Resident 94 was last seen by staff on 07/01/2026 at 7:20 AM next to the nurse's medication cart, then was outside 10 minutes later lying on the ground. In an interview on 07/28/2026 at 11:20 AM, Staff B reviewed Resident 94's electronic medical records and stated the resident discharged from the facility on 07/01/2026. Staff B reviewed the 06/29/2026 hospital discharge summary and stated Resident 94 had advanced dementia, had a prior fall at home which required hip surgery, and demonstrated restless, agitated, impulsive behaviors in the hospital, and was an elopement risk. Staff B stated the Nursing admission Assessment showed the nurse assessed Resident 94 with no risk of fall or elopement which was not accurate, and Resident 94 should have been identified as both a fall risk and elopement risk with an individualized care plan in place. Staff B stated the exit door in the therapy gym was an exit only door and had an active wander guard system (detection system to prevent resident elopement) in place. Staff B stated Resident 94 should have been identified as an elopement risk and should have a wander guard device to prevent them from leaving the facility unsupervised, but the resident did not. <Resident 28> Review of the 06/04/2026 admission MDS showed Resident 28 was admitted to the facility on [DATE] for encephalopathy (brain dysfunction), stimulant dependance, chronic respiratory disease, failure to thrive, paranoia, and anxiety. The MDS showed Resident 28 had wandering behaviors which placed them at a significant risk of getting to a dangerous place such as outside the facility. The MDS showed Resident 28 could use a manual wheelchair for mobility of 150 feet with staff supervision and assistance. Review of the 06/05/2026 CP showed Resident 28 was at risk for elopement, demonstrated exit seeking behavior, wanted to be outside and had a history of smoking. The CP showed Resident 28 used a wander guard device on their ankle, but the resident cut the device off on 06/05/2026, and it was then secured to Resident 28's wheelchair. Review of a 06/26/2026 elopement assessment showed Resident 28 was confused, expressed desire to leave the facility, was independent with mobility, and was exit seeking without supervision. Review of the 07/17/2026 incident investigation showed a witness statement that Resident 28 was seen on 07/16/2026 at 2:00 PM, on the sidewalk, two buildings away from the facility while smoking a cigarette. The facility investigation summary showed Resident 28 had a wander guard device on their wheelchair, but the device did not alert staff to Resident 28's exit outside, therefore Resident 28 was smoking outside unsupervised two buildings away. Observation and interview on 07/28/2026 at 11:10 AM showed Resident 28 was in the hallway self-propelling their wheelchair. Resident 28 stated they were going down there while pointing down the hall. Resident 28 had no recollection of leaving the facility by themself or going outside to smoke cigarettes. Resident 28 stated they used to smoke and would like to smoke again. An observation on 07/28/2026 at 11:17 AM showed Resident 28 had an Elopement Photograph Sheet inside the elopement binder at the nurse's station. The sheet had information about Resident 28's wander guard device location and expiration date, emergency contact, physical description, and photograph. In an interview on 07/28/2026 at 11:20 AM, Staff B stated, after the facility investigation was completed, it was reasonably concluded that Resident 28 was assisted outside the main door by an unknown person during a congested time of the day. Staff B stated the investigation could not conclude who assisted Resident 28 outside, why the wander guard system did not alarm, or how Resident 28 obtained a cigarette. Staff B stated Resident 28 was not safe to be outside the facility unsupervised and was not assessed to smoke safely without supervision. Refer to F744 – Treatment/Services for Dementia. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure appropriate treatment and services were provided to attain or maintain the highest practicable physical, mental and psychological well-being for 1 of 4 residents (Resident 94) reviewed for dementia care. The failure to assess and implement a person-centered dementia care plan based on the resident's behavioral needs placed residents at risk for injury, accidents, behavioral distress, and unmet care needs. Findings included. <Facility Policy>Review of the 06/09/2023 facility policy titled Dementia Care showed the facility would take an individualized approach to meeting the health, psychosocial, and behavioral needs of all residents, especially those with dementia. The policy showed residents with dementia may exhibit behaviors to communicate underlying and unresolved medical, physical, emotional, psychiatric, or environmental issues. The facility would assess the cause of a resident's behavior and implement an individualized care plan. The policy showed the facility used a person-centered approach to reduce potentially distressing or harmful behaviors and promote quality of life for residents with dementia. <Resident 94> Review of the 06/29/2026 hospital discharge summary showed Resident 94 discharged to the facility on [DATE] after a fall at home and hospitalization for surgical repair of their hip. The discharge summary showed Resident 94's hospital stay was complicated related to their advanced dementia, persistent confusion, episodes of agitation, restlessness, impulsivity, attempts to remove medical devices, and elopement risk. The hospital summary showed Resident 94 required three different medications to manage their behavior while hospitalized . Review of the 06/29/2026 nursing admission assessment showed Resident 94's admitting diagnosis was dementia. The assessment showed Resident 94 was alert and only oriented to their name, and not oriented to the date or time, where they were, or the situation of what was going on around them. The assessment showed Resident 94 required extensive assistance from staff for all bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident 94 was assessed to require a wheelchair for mobility. The assessment showed Resident 94 was not prescribed any medications for mood or behavior. The assessment showed Resident 94 had difficulty with sleep. Resident 94's assessment showed they were not at risk for falls or elopement (leaving a safe area). A review of the 06/30/2026 admission care plan for Resident 94 showed no resident specific interventions to direct staff how to respond to Resident 94's behaviors related to the diagnosis of advanced dementia. Review of the progress notes from 06/29/2026 to 07/01/2026 showed Resident 94 resided at the facility for under 48 hours. The progress notes showed on 06/30/2026 during the early morning, Resident 94 was confused, refusing care, taking off their clothes and hitting staff, was wandering in their wheelchair and was not re-directable, the on-call provider was called and staff waited for a call back. An order for medication for anxiety was received and the staff obtained Resident 94's consent to administer. On 06/30/2026 at 8:44 AM, the staff gave Resident 94 a copy of their baseline care plan. On 06/30/2026 at 6:56 PM, Resident 94 had aggressive behaviors toward therapy staff and punched staff in the face. On 06/30/2026 at 8:59 PM, Resident 94 was alert, confused, was wandering and attempting to get up from the wheelchair multiple times; staff tried to redirect, reorient and assist back to the wheelchair for safety. The progress note showed Resident 94 had a history of Alzheimer's dementia and was not taking medication for the condition, the nurse notified the provider of behaviors and confusion and monitored Resident 94. On 06/30/2026 at 9:44 PM, Resident 94 continued to wander in the hallway in the wheelchair going into other resident rooms, did not follow staff re-direction and staff noted Resident 94 needed one person to monitor Resident 94's behaviors. On 07/01/2026 at 12:43 AM, Staff documented Resident 94 needed, and the nurse and nurse aide provided one-to-one care. On 07/01/2026 at 5:28 AM, Resident 94's roommate complained about Resident 94's behaviors and a room change was initiated for Resident 94. Review of the 07/01/2026 incident investigation showed on 07/01/2026 at 7:30 AM Resident 94 was outside the facility on the ground after an unsupervised fall. Resident 94 had exited the facility through the therapy door, without staff knowledge or supervision, stood from their wheelchair to walk outside and fell to the ground. The progress notes of the investigation showed Resident 94 was restless, agitated, physically aggressive with staff, wandering inside, and trying to leave the facility since admission on [DATE]. The investigation notes showed staff had initiated one-to-one supervision for Resident 94 on the night shift on 06/30/2026. The investigation showed Resident 94 was last seen by staff on 07/01/2026 at 7:20 AM next to the nurse's medication cart, then was found outside 10 minutes later lying on the ground. Review of the 07/01/2026 2:15 PM progress notes showed Resident 94's representative arrived at the facility and requested to take Resident 94 home and Resident 94 was discharged on 07/01/2026 against medical advice. In an interview on 07/28/2026 at 11:20 AM, Staff B (Director of Nursing) reviewed Resident 94's hospital and facility medical records and stated the admission nursing assessment was not accurate according to the behaviors recorded in the hospital records. Staff B stated the admission nurse should have reviewed the hospital records, identified the dementia behaviors, implemented interventions to prevent falls and elopement, and created a resident specific dementia care plan for Resident 94. Staff B stated Resident 94 was not oriented to a level of being able to make decisions regarding their own safety and care. Refer to F689 Free of Accident Hazards/Supervision/Devices REFERENCE: WAC 388-97-1040(1)(a-c)(2)(b)(c)(iv).

Based on observation, interview, and record review, the facility failed to implement preventive measures to protect residents' feet from injury, monitor the feet of high-risk residents, identify changes in skin integrity, report changes in wounds, seek treatment from the physician, ensure foot care treatments were completed consistently and according to physician orders, and arrange timely appointments with a podiatrist or wound care specialist for 2 of 3 Residents (Resident 1 and 2) reviewed for foot care. These failures placed residents at risk for impaired skin integrity, wound infection, hospitalization, and diminished quality of life.Resident 1, who was at an increased risk of skin impairment due to underlying diabetes, impaired circulation and sensation in their lower extremities, experienced harm when the facility staff did not identify changes in, or take timely action for, a diabetic foot ulcer (an open wound with skin loss, caused by trauma, poor circulation and/or nerve damage) between the right toes that became infected, required hospitalization for treatment of a systemic infection, and two separate surgeries for amputation of their right toes then amputation of their partial right foot.Findings included.The facility policy for Wound Prevention and Treatment revised on 02/03/2023 showed all residents were considered at risk for skin impairment, intensive efforts would be directed at managing risk factors, preventative interventions and provision of treatment for wounds including diabetic ulcers. The policy showed wounds would be monitored weekly and documented for size, color, odor, healing progression, notification and other pertinent information in the medical record.<Resident 1>Review of the 12/22/2025 quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was admitted for rehabilitation following an amputation below the knee of their left leg. The MDS showed Resident 1 had diagnoses of diabetes, impaired circulation, and decreased sensation in their lower legs.Review of the 03/11/2026 closed Care Plan (CP) showed Resident 1 had a left below the knee amputation with a surgical wound from a prior bone infection in the ankle. The CP showed Resident 1 had diabetic neuropathy (decreased sensation in the foot with decreased ability to feel pain). The 09/10/2025 diabetic CP interventions directed nursing staff to ensure socks were clean and absorbent and not too tight daily, ensure the use of non-skid footwear at all times to protect toes, nurses to inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness and report any of the above to the physician, and refer to podiatrist/foot care provider to provide foot care needs and to cut toenails. The 10/01/2025 CP intervention for Activities of Daily Living (ADL) showed Resident 1 required staff assistance with a shower twice a week and staff should check Resident 1's skin while providing ADL care daily.Review of the February 2026 and March 2026 Treatment Administration Records (TAR) showed nurses were directed to assess Resident 1's feet weekly (not daily as stated in the CP), cut the toenails related to the diagnosis of diabetes, and notify the physician of skin issues noted. The TARs showed nurses signed on 02/06/2026, 02/13/2026, 02/20/2026, 02/27/2026, 03/06/2026, that Resident 1's right foot was assessed, and toenail care was provided.A 02/11/2026 Physician progress note showed Resident 1 self-reported a new blister between their toes, with no pain, no sensation at baseline, with occasional drainage, and was unsure how long the blister had been there. The note showed Resident 1 received physical therapy and used their left leg prosthesis (artificial limb) for ambulation. The skin assessment noted by the physician described a soft blister on the side of the second toe, the top of the blister shed off exposing a deeper layer of skin. The note showed the physician's plan was to make a referral to podiatry for management of Resident 1's diabetic foot disease.Review of a weekly skin assessment completed on 02/12/2026 showed no new skin issues for Resident 1.Review of a weekly skin assessment completed on 02/19/2026 showed Resident 1 had redness and tenderness of the right toes. A blister was not noted on the assessment.Review of a weekly skin assessment completed on 02/23/2026 showed Resident 1 had no skin issues on the right toes.A 02/24/2026 a Nurse Practitioner (NP) 30-day follow-up visit note showed a copied note from the prior 02/11/2026 Physician note. The visit note showed there was an active order for podiatry for a diabetic ulcer. The skin assessment noted by the NP showed a copied assessment from the 02/11/2026 Physician note, a new assessment on the diabetic ulcer was not noted.Review of the weekly skin assessments completed on 02/26/2026 showed Resident 1 had a popped blister, dry scabs on the right toes and there was treatment in place. Review of the February 2026 TAR showed no treatment orders were provided to Resident 1's right toes. The TAR only showed monitoring the toes for infection three times a day, signed as completed by the nurses on the day, evening, and night shifts.A 03/05/2026 NP note showed Resident 1 saw the NP for a follow up visit regarding their diabetic foot ulcer because Resident 1 told the nurses they wanted to talk to the NP about another podiatry referral. The NP documented that Resident 1 felt they were getting weaker, and not able to walk around due to not being able to put weight on the right foot with the diabetic ulcer. The note showed Resident 1 asked for the dressing on the foot to be changed. The skin assessment by the NP showed multiple necrotic (severe skin tissue death) diabetic ulcers on Resident 1's right toes. The NP noted Resident 1 did not see the podiatrist and had an active order for podiatry for the diabetic ulcer, and the NP would follow up with the facility's scheduling team.Review of the weekly skin assessment completed on 03/05/2026 showed Resident 1 had dry eschar (a patch of dead tissue that covers a wound or ulcer) and scabs on the right toes and there was a treatment in place.Review of the March 2026 TAR showed no treatment orders were provided to Resident 1's right toes. The TAR only showed monitoring the toes for infection three times a day, signed as completed by the nurses on the day, evening, and night shifts.Review of the February 2026 to March 2026 physician order summary showed no treatment orders were implemented by the Physician or the NP. The only orders were for a 02/11/2026 podiatry referral and a 02/20/2026 order to monitor the popped blister to second toe each shift, initiated nine days after the diabetic ulcer was identified.Review of the 02/11/2026 through 03/08/2026 progress notes for Resident 1 showed no progress notes written by a nurse. The review of progress notes only showed the physician, the NP and Social Services (SS) notes entered.Review of the 03/09/2026 5:01 PM nurse progress note showed the infection control nurse spoke to Resident 1 about a respiratory illness. Resident 1 reported they were weak, coughing, sleepier than usual, slept the whole day, and had a loss of appetite. The note showed the nurse would report the worsening signs and symptoms of respiratory illness.Review of the 03/10/2026 10:18 AM, nurse progress note showed Resident 1 was lethargic, did not eat breakfast, voice was weak, had very low blood pressure, a high pulse, and low oxygen saturation which required oxygen supplementation. The note showed staff called 911, and Resident 1 was transferred to the Emergency Department (ED).Review of the 03/10/2026 hospital transfer record showed Resident 1 had dry and flaky scabs on right toes.Review of the 03/10/2026 2:22 PM hospital ED admission record showed Resident 1 was admitted for hypoxia (a medical condition where body tissues and organs do not receive adequate oxygen to function), low blood pressure, and altered mental status. The record showed Resident 1 had a worsening mental condition and a cough for the past four days. The report showed Resident 1's right foot had two toes that had both wet and dry gangrene (dead skin due to loss of blood supply, severe bacterial infection, or traumatic injury that is a life-threatening emergency requiring immediate medical attention. Dry gangrene is caused by poor circulation from diabetes or artery disease, and wet gangrene involves an active severe bacterial infection in the tissue that is swollen, blistered and filled with pus which can spread rapidly).Review of a 03/13/2026 SS progress note showed a call was made to Resident 1's Representative (RR) who stated Resident 1 required surgery for a foot infection and their toes were amputated. The RR stated Resident 1's foot's condition was known by facility staff the day before the ambulance was called. The SS note showed a facility investigation was started.Review of the 03/13/2026 facility investigation showed a timeline of events: the blister was identified on 02/11/2026 by the physician; on 02/12/2026 there was a discussion with the interdisciplinary team to schedule Resident 1 to see the podiatrist; 02/20/2026 an order was entered for the nurses to monitor the blister every shift; 02/23/2026 the weekly skin assessment did not document ongoing concern to the right toes; on 02/24/2026 the NP documented the blister sloughed (top layer opened); a 03/05/2026 skin assessment documented dry eschar and scabbing, indicating worsening of the wound; on 03/10/2026 Resident 1 was sent to the hospital for abnormal vital signs, lethargy and decline in status. The conclusion of the investigation showed the identification of gaps in documentation accuracy, gaps in coordination of wound interventions, and gaps in staff follow-up. The facility immediately implemented a plan of correction including education for nurse staff on identified wound care issues, issued disciplinary action to identified staff, and terminated one staff with a trend of documentation discrepancies.Review of the 03/13/2026 investigation packet showed the facility reported neglect to the state agency hotline, 12 nurses required education on completing skin evaluations on assigned days, new skin conditions required an incident report and care plan update, new wounds should have a referral sent to the wound provider, all wounds should be measured on every assessment, any wound changes must be reported to the provider and progress note written with any new treatment orders. The investigation packet identified eight nurses who received disciplinary action for signing for care and monitoring of a wound that was either not assessed, not documented, not placed on alert charting, not notifying provider of wound worsening, not initiating wound treatment orders and/or not providing treatment or monitoring of wounds when signing the medical record as completed.In a phone interview on 07/01/2026 at 12:56 PM, the RR stated they talked on the phone with Resident 1 often during the time they had the ulcer on their foot. The RR stated Resident 1 was alert, oriented, and managed their healthcare without help from their power-of-attorney. The RR stated Resident 1 said they frequently asked to see the physician and the podiatrist, and for the nursing staff to look at and treat the ulcer on their right foot. The RR stated the nurses did not change the bandage on Resident 1's foot when asked. The RR stated when they arrived at the ED to see Resident 1, the RR could smell the infection in the cubicle before they even saw the foot. The RR stated they saw the right foot and the big toe and surrounding tissues were black, blue, green, and yellow and obviously infected. The RR stated the odor of the foot was so strong in the ED they did not know how the nurses at the facility did not see or smell how bad the infection was on Resident 1's foot. The RR stated Resident 1 required two separate surgeries, first to amputate the toes, then to amputate part of Resident 1's foot. The RR stated Resident 1 was in the hospital for a long time, then went to another nursing facility where they did not heal from surgery and ended up dying on 04/24/2026.In an interview on 07/15/2026 at 11:37 AM, Staff CC (Regional Director of Operations) stated the facility's prior Administrator and the prior Director of Nursing (both no longer employed at the facility) completed the investigation after Resident 1 was hospitalized and identified that the facility staff did not arrange podiatry services for Resident 1 when the diabetic ulcer was identified.In an interview on 07/16/2026 at 3:59 PM, Staff DD (Medical Records Coordinator) stated the podiatrist visited the facility every couple of months and was at the facility on 02/18/2026 (seven days after the blister was identified and the physician ordered a podiatry referral). Staff DD stated Resident 1 was not on the podiatrist list for 02/18/2026 and did not see the podiatrist. Staff DD reviewed Resident 1's electronic medical record and stated there were no podiatry visits or wound care specialist documents in Resident 1's records. Staff DD stated if Resident 1 saw the podiatrist or wound care specialist there would be documents in their medical record.In a phone interview on 07/16/2026 at 4:20 PM, Staff EE (Regional Director of Clinical Operations) stated they were involved in the investigation of Resident 1's diabetic ulcer. Staff EE stated the biggest issue was the nurses lack of assessment, lack of documentation, and lack of follow up on Resident 1's diabetic ulcer. Staff EE stated the facility recognized during the investigation that the ulcer worsened and the nurse staff did not recognize, report, or seek treatment as expected. <Resident 2>Review of the June 2026 facility incident report log showed on 06/23/2026 Resident 2 had a blister with an identified origin related to their condition.Review of the 06/26/2026 incident investigation packet showed Resident 2 had diagnoses of diabetes, poor circulation and poor sensation to their lower legs and feet with multiple other medical conditions. The investigation showed a two-centimeter round blister was found on the side of Resident 2's right heel, notifications were made to the provider and the RR, and a topical treatment was ordered and implemented. Interventions for care included directions to staff to float Resident 2's heels to offload pressure.In an observation and interview on 07/01/2026 at 4:22 PM, Resident 2 was in their bed with the head of the bed slightly elevated, both feet had non-skid socks on, both heels were resting on the mattress and there were no pillows under the resident's feet or legs. Resident 2 had an extra wide bed and showed they could move their own feet in bed. Resident 2 stated they had pain in the right heel, and someone took a lidocaine patch off the heel that morning and pulled the blister off their heel. Resident 2 stated the nurses had been applying a lidocaine patch for about a week because the blister hurt, but the patch did not do a whole lot to make it better. Staff FF (Assistant Director of Nursing) removed the sock on the right foot and stated the blister was open, was the size of a nickel, the wound surface was wet and there was some slough (dead tissue that is yellow, sticky, and stringy) in the middle of the wound. Staff FF stated the wound care provider visited that morning and removed the lidocaine patch, and the blister cover came off. Staff FF stated Resident 2's heels should be up on pillows to keep the pressure off the heels.In an interview and record review on 07/01/2026 at 4:50 PM, Staff FF stated the blister was found on 06/23/2026. Staff FF stated the wound care provider came weekly on Wednesdays and evaluated Resident 2's other wounds on 06/24/2026. Staff FF looked at the wound care provider notes and stated the blister on the right heel was not evaluated by the wound care provider on 06/24/2023. Staff FF stated the wound care provider first evaluated the blister on 07/01/2026 and the lidocaine patch was removed and opened the blister.In an interview on 07/01/2026 at 5:06 PM, Staff BB (Director of Nursing) stated Resident 2 had a blister on their heel because they preferred to lay on their back when in bed and there was friction on the heel that created the blister. Staff BB stated floating residents' heels while in bed is a standard of practice for all residents and staff were expected to float Resident 2's heels. Staff BB stated the blister was found on 06/23/2026 and should have been evaluated, but was not, by the wound care provider on 06/24/2026. Staff BB reviewed Resident 2's electronic medical record and stated the provider ordered a topical skin treatment when notified of the blister on 06/23/2026. Staff BB stated on 06/25/2026 another provider ordered a lidocaine patch for heel pain. Staff BB stated a lidocaine patch would not be indicated for a heel blister.In an interview on 07/16/2026 at 5:10 PM, Staff BB stated documentation from the nurses or the prescriber regarding heel pain and implementation of the lidocaine patch could not be found. Staff BB stated the lidocaine patch should have been discontinued on 07/01/2026 and was not discontinued until 7/06/2026. Staff BB stated the lidocaine patch was not indicated for a blister on Resident 2's heel and should not have been applied over a blister. Staff BB stated a nurse did place it over the blister and was how the blister opened on 07/01/2026 when the wound care provider removed the patch and opened the blister.REFERENCE WAC: 388-97-1060(1)(3)(j)(viii).

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 3 of 3 residents (Residents 4, 5, & 6) reviewed for resident-to-resident altercations. This failure placed the residents at risk of physical injury, fear, intimidation, mental anguish, and emotional distress.Findings included.Review of the facility policy titled Abuse Prevention and Reporting revised on 08/2025 showed residents have the right to be free from abuse. The facility prohibited abuse of a resident by anyone including staff, residents, resident representatives, family, and friends. The policy defined types of abuse as verbal, sexual, physical or mental and was a willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy defined willful as the individual must have acted deliberately, with the knowledge and understanding that their actions would result in injury or harm.Review of the May 2026 and June 2026 facility incident report logs showed Resident 3 had three separate incidents of resident-to-resident altercations on 05/16/2026, 06/23/2026 and on 06/25/2026.Review of the 05/16/2026 facility investigation showed Resident 3 was in the dining room at dinnertime and was throwing things at Resident 4 while sharing the same table. The staff escorted Resident 3 to the hallway where they were able to self-propel in their wheelchair to their room. The investigation showed a witness saw Resident 3 in the doorway of Resident 5, moving their hands up and down in a motion to hit Resident 5; when the witness arrived at the doorway, they saw Resident 5 had fallen backwards onto the floor. The investigation showed staff intervened, Resident 3 was removed from the area, Resident 5 was assessed and not injured. The investigation concluded that Resident 3 deliberately caused Resident 5 to fall to the floor.Review of the 06/23/2026 facility investigation showed Resident 3 was leaving the dining room in their wheelchair upset at another resident for wearing Resident 3's pants. When Resident 3 exited the dining room, Resident 4 entered the dining room, they tried to get past each other in the doorway when Resident 3 grabbed Resident 4's left index finger and twisted it, then Resident 4 yelled at Resident 3. The staff intervened and the residents were separated. When the nurse arrived, Resident 4 was crying and holding their left index finger. The investigation showed witnesses saw both residents verbally arguing and had their fists up. Resident 4 was evaluated by the physician onsite, after an x-ray, severe injury to the fingers was ruled out. The investigation found Resident 3 was the aggressor but could not substantiate Resident 3 intended to hurt Resident 4 as they were upset about something else and often reached for objects to help self-propel the wheelchair. The investigation showed Resident 3's actions caused Resident 4 to cry related to inflicted pain to their finger.Review of the 06/25/2026 facility investigation showed Resident 3 was banging on the dining table demanding food at 4:15 PM. The investigation showed when Resident 6 told Resident 3 the staff were serving food, a verbal altercation occurred between Resident 3 and Resident 6, then Resident 3 threw a cup at Resident 6. As staff intervened and moved Resident 3 to another table, Resident 3 grabbed a second cup to throw at Resident 6 but accidentally hit Resident 7. The investigation showed neither Resident 6 nor Resident 7 were injured. The facility investigation included witness statements which determined Resident 3 was the aggressor who intended to harm Resident 6 by throwing two cups at them. The facility investigation substantiated abuse from Resident 3 to Resident 6 and implemented one-to-one staff supervision for Resident 3 to ensure other residents' safety. In an interview, on 07/01/2026 at 2:08 pm, Staff BB (Director of Nursing) stated Resident 3 was easily irritated, and one-to-one staff supervision was initiated to ensure residents' safety. Staff BB stated Resident 3 had a private room and had ongoing evaluations by various medical practitioners to assist the facility in managing Resident 3's behaviors. Staff BB stated Resident 3's representatives were aware of interventions and on-to-one staff supervision.In an observation and interview, on 07/01/2026 at 2:40 PM, Resident 4 stated a few days ago someone grabbed their finger and hurt it. Resident 4 stated the finger was ok, not broken, and could not provide any further information. Resident 4 was observed to not be distressed by the incident.In an interview, on 07/01/2026 at 2:47 PM, Resident 6 stated they had an argument with another resident in the dining room a few days ago and the other resident threw a cup at them. Resident 6 stated they were not harmed and the staff intervened. Resident 6 stated [Resident 3] now always had staff with them.On 07/01/2026 Resident 7 was not available for interview and Resident 4 was not able to be interviewed.In an observation and interview, on 07/01/2026 at 2:31 PM, Resident 3 was in their room, lying in bed looking at their cell phone. Resident 3 did not have a roommate and Staff GG (Certified Nursing Assistant) provided one-to-one supervision. Resident 3 stated they were mad at their prior roommate because they wore Resident 3's pants to the dining room. When asked, Resident 3 did not recall the incidents of Resident 5, Resident 4 or Resident 6. Staff GG stated Resident 3 required one-to-one supervision because of the prior behaviors toward other residents. Staff GG stated they were instructed to stay with Resident 3 so Resident 3 did not go on their own around other residents.In an interview, on 07/16/2026 at 4:48 PM, Staff BB reviewed the incidents of Resident 3 towards Residents 4, 5, and 6. Staff BB stated residents had the right to be safe and free from abuse. Staff BB stated interventions were in place to protect residents from the behaviors of Resident 3 because the facility had the responsibility to protect all residents from abuse.REFERENCE: WAC 388-97-0640(1)(a).

Based on interview and record review, the facility failed to ensure 4 of 4 licensed nurse staff (Staff D -Registered Nurse, Staff E - LPN, Licensed Practical Nurse, & Staff F- LPN) and 3 of 6 nurse aide staff (Staff H, I & J) had the specified competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This failure placed residents at risk infection, injury, inadequate care, and rehospitalization.Findings included.In an interview on 06/10/2026 at 6:35 PM, Staff B (Director of Nursing) and Staff C (Administrator in Training) was asked to provide documentation which showed the facility had verified the competency and skill sets of licensed nurses Staff D, Staff, E, Staff, F and Staff G assigned to provide care to Resident 1's wound vacuum (specialized equipment for wound care that applies negative pressure to the wound to manage drainage and promote healing). Documentation for nurse aides Staff H, Staff I, and Staff J to show they were evaluated and able to demonstrate competency in assisting residents with mobility was requested. None of the documentation requested was provided for Staff D, E, F, G, H, I, or J.In a phone interview on 06/11/2026 at 12:05 PM, Staff A (Interim Administrator) stated it was important for licensed nurses and nurse aides to be trained, and verification of competent skill sets upon hire prior to providing care to residents and annually.Reference: WAC 388-97-1080(1), -1090(1), -1680(1)(2)(a)(b)(i)(ii)(c).

Based on interview and record review, the facility failed to protect the residents right to be free from neglect when it failed to provide goods and services that were necessary to avoid physical harm, pain, mental anguish, and emotional distress for 1 of 5 residents (Resident 1) reviewed for admission and rehospitalization. The failure to identify Resident 1 required a wound vacuum (WV - specialized equipment for wound care that applies negative pressure to the wound to manage drainage and promote healing) to treat a surgical wound on admission, ensure nursing staff had the skill set and supplies to manage the WV, and implement monitoring of the operation of the WV, placed Resident 1 at risk for impaired wound healing, infection, and rehospitalization. Findings included.Review of the 03/10/2026 Facility Assessment (FA - a tool used to conduct a facility-wide assessment of the resident profile, services and care offered, and resources needed to provide competent care to residents) showed the facility would review the medical records for all referred residents for admission, prior to acceptance to the facility. The FA showed a resident requiring surgical wound care could be admitted to the facility. The FA did not show if the facility could manage a resident with a WV. The FA showed if a new diagnosis determined additional staff training, in-service training would be provided for staff. The FA showed staff would be trained and assessed for competency to provide specialized care, including wound care and wound dressings.Review of the 06/03/2026 hospital discharge summary showed Resident 1 had surgery on their right hip with complications. The summary showed after surgery Resident 1 had increased drainage from the surgical wound requiring a WV and medications to prevent infection. The discharge summary showed Resident 1 was stable and planned to discharge to a skilled nursing facility for therapy and nursing management. The discharge summary did not provide any instructions for monitoring or maintaining the WV.Review of a 06/03/2026 Nursing admission Assessment showed Resident 1 was admitted to the facility on evening shift on 06/03/2026 from the hospital after hip surgery, the assessing nurse documented Resident 1 had a surgical wound on their right hip with a wound bag.Review of the physician orders for 06/03/2026 through 06/04/2026 showed no indication that Resident 1 had a WV for their surgical incision drainage. The physician orders did not provide any directions to staff to monitor Resident 1's surgical site for drainage into the WV canister or to monitor the WV to ensure it was functioning.A 06/03/2026 nurse progress note showed Resident 1 was entered into the medical record to one room and needed to be changed to another room. This was the only nurse note entered on 06/03/2026 to describe the admission of Resident 1 to the facility; there was no documentation of the WV. A 06/04/2026 5:41 AM nurse progress note showed Resident 1 was alert and oriented, two-person assist for care, had pain in right leg, and wound bag was intact. There was no further assessment or monitoring of Resident 1.A 06/04/2026 4:33 PM nurse progress note showed the nurse manager documented Resident 1's WV was beeping, when checked it was full, canister was changed, line patent, and suctioning well. There was no documentation regarding the assessment of the wound, drainage, pain, notification of the doctor, or Resident 1's condition.A 06/04/2026 doctor visit note showed Resident 1 required skilled therapy after surgery for functional limitations, limited weight bearing, mobility precautions, skilled nursing care to manage the WV with active drainage, wound monitoring, and medication administration to prevent infection and control pain. The doctor's note directed staff to monitor the WV output, drainage character, dressing seal, tubing patency, and suction function, monitor surgical site for redness, warmth, swelling, increased pain, purulent drainage, odor, fever or wound opening and notify provider and surgeon for increased drainage, loss of suction, bleeding or infection. The doctor's note showed Resident 1 was at risk for complications of blood clots, infection, dislocation, and hardware failure of the hip prosthesis.A 06/05/2026 3:45 AM nurse progress note showed a one-line statement, wound bag is beeping.A 06/05/2026 6:00 PM nurse progress note showed Resident 1 was discharged to the hospital for wound evaluation per the doctors order.In a phone interview on 06/10/2026 at 1:35 PM, Collateral Contact (CC) stated they arrived at the facility on 06/04/2026 at about 1:00 PM to find Resident 1 being interviewed by facility staff. The CC stated Resident 1 was upset, stated she was in pain, had not received pain medication since last night, was worried that the surgical wound was draining so much the canister was full, then Resident 1 started crying. The CC stated they asked to see someone in charge, then at about 2:00 PM Staff B (Director of Nursing) and Staff C (Administrator in Training) arrived in the room, and the WV alarm was sounding, they checked it and saw the canister was full of wound drainage. The CC stated two other nurses came in at separate times to look at the WV and did not know what to do to make it stop beeping. The CC stated, finally, at 4:30 PM, two and a half hours later, another nurse came and changed the canister, and the WV was operating again. The CC stated the hospital sent an extra canister with Resident 1 because the wound was draining so much at the hospital. The CC stated they visited again on 06/05/2026 at 11:00 AM, and the WV again started alarming. The CC stated Staff B and Staff C came into the room, said the canister was full again and said the facility did not have any more WV supplies, discussed WV supplies needed to be ordered, and would not arrive for a few hours. The CC stated at 2:30 PM the supplies still were not delivered so the CC and Resident 1 discussed the situation with the facility doctor who was onsite. The CC stated the doctor told Resident 1 the facility staff did not have the skill set to manage the WV and did not have the supplies needed for that type of WV. The CC stated since it was a Friday afternoon, the CC did not want to leave Resident 1 at the facility, so they asked the doctor how to get Resident 1 sent to the hospital. The CC stated they would have the nurse on duty make necessary arrangements to send Resident 1 to the hospital. The CC stated Resident 1 left the facility at about 4:00 PM and was still admitted in the hospital on [DATE].In an interview on 06/10/2026 at 4:25 PM, Staff B stated the facility uses a central admissions team located offsite of the facility to review records of potential residents for admission. The central admissions staff notified Staff B and Staff C of Resident 1's admission for 06/03/2026 through email, then uploaded the hospital documents and admission orders into the electronic medical record. Staff B looked at the email notification from the central admissions and stated it did not have any information about Resident 1 having a WV. Staff B stated the nurse managers review the hospital documentation prior to admission and the admission nurse entered in the physician orders for medications and treatments and started the care plan. Staff B stated the facility staff was not made aware Resident 1 had a WV prior to admission on [DATE]. Staff B stated on 06/04/2026 when they walked into Resident 1's room and the WV alarm was sounding, and the drainage canister was full. Staff B stated the hospital sent an extra canister and it was changed on 06/04/2026. Staff B stated on 06/05/2026 the WV canister was full again and was alarming. Staff B stated Resident 1 had to go to the hospital so the WV canister could be changed because the facility did not have the supplies. Staff B stated no training was provided for staff prior to Resident 1's admission on how to operate Resident 1's specific WV, and Staff B expected nurses to know how to operate a WV.In a phone interview on 06/11/2026 at 12:05 PM Staff A, Staff B and Staff C stated they were not informed by the central admissions team that Resident 1 was being admitted with a WV. Staff B stated they became aware of Resident 1's WV the day after admission which did not allow time to ensure nursing staff were provided with training for Resident 1's specific WV or ensure the facility had the supplies needed to manage the WV at the time of admission. Staff B stated nurses should have entered monitoring orders into the medical record to ensure nurses were assessing and monitoring Resident 1's surgical site, drainage into the canister, and ensure the WV was operating as expected.Staff A stated there was no communication from the central admissions team that Resident 1 had a WV and that it was important to know the needs of residents on admission to ensure staff were trained, competent to provide specialized care, and had the supplies needed to manage resident care. Staff A stated there was no excuse to miss the WV for Resident 1 on admission screening.REFERENCE: WAC 388-97-0640, -1660(1)(a-b), -1680(2)(b)(i-ii)

Based on interview and record review the facility failed to implement a policy and procedure to obtain verification from the Washington State Nurse Aide Registry and/or Multi-State Nurse Aide Registry to ensure nurse aide staff met competency evaluation requirements for 12 of 12 nurse aide staff (Staff E, F, I, K, L, M, Q, R, S, T, U, & V). The failure to verify nurse aide competency and maintain registry verification records prior to allowing nurse aide staff to care for residents, placed residents at risk for incompetent care, unmet needs, and possible injury during care.Findings included.In an interview on 05/06/2026 at 2:05 PM, Staff A (Administrator) was asked to provide state nurse aide competency verification records for 12 sampled nurse aide staff currently working in the facility on 05/06/2026 evening shift and for staff scheduled to work 05/06/2026 on the night shift. Staff A stated staff files were not organized, and registry verification records were not readily available.In an interview and record review on 05/06/2026 at 5:46 PM, Staff A stated they discussed with the corporate human resources representative who completed an audit a few months ago and ensured all nurse aide registry competency verifications were completed and the corporate staff had completed all new hire verifications since the audit. Staff A stated the registry verification records were usually kept in a binder in the human resources office but could not be located.In an interview and record review on 05/06/2026 at 2:30 PM, Staff A provided registry verification for Staff E, I, K, L, M, Q, R, S, T, U, & V. Staff A was asked for Staff F's registry verification and it was not provided. Staff A stated the nurse aide registry competency verification records should be, but were not, available for the state agency to review as required.REFERENCE: WAC 388-97-1660(1)(a)(2)(b)(3)(c), -1820(1)(b)(i).

Based on interview and record review the facility failed to implement a policy and procedure to ensure staff were trained and competent in hands-on Cardiopulmonary Resuscitation (CPR, an intervention to restore a resident's respiratory function and circulation after they stopped breathing and their heart stopped beating) for 8 of 22 staff (Staff F - Certified Nursing Assistant [CNA], I - CNA, J - Licensed Practical Nurse [LPN], K - CNA, L - CNA, M - CNA, N - Registered Nurse, & O - LPN). The failure to ensure staff had hands-on training and competency to provide CPR placed residents requiring CPR, according to their advanced directive, at risk of injury or death.Findings included.Review of the facility policy CPR updated 12/2023, showed the facility would honor the resident's choice related to CPR in the event the resident stopped breathing or their heart stopped beating. The policy showed the facility would ensure staff maintained current CPR certification. The policy showed online-only CPR training and certification was not acceptable.In an interview and record review on [DATE] at 2:05 PM, Staff A (Administrator) and Staff C (Assistant Director of Nursing) were asked to provide CPR certification records for 22 sampled staff currently scheduled and working in the facility on the [DATE] evening shift and for staff scheduled to work the [DATE] night shift. Staff A stated staff files were not organized, and CPR training records were not readily available. Staff B stated they had to gather the CPR records from electronic records and would contact staff for copies of their CPR cards. Staff B stated some staff completed online-only CPR training.In an interview and record review on [DATE] at 5:46 PM, Staff A stated they could not ensure that every staff person currently working with residents on [DATE] was trained in CPR. Staff B collected and showed CPR cards for 15 staff members working the evening and night shift of [DATE] that met the requirement of hands-on training. Staff B stated there were no CPR cards for Staff F, J, L, and M. Staff B stated Staff I, K, N and O only had online-only CPR training. Staff A stated all nursing staff were required to have hands-on CPR training and valid CPR cards or certificates should be in the staff's record.REFERENCE: WAC 388-97-0280(1), -1060(1),

Based on interview and record review, the facility failed to implement policies and procedures to complete criminal background checks upon hire and every two years for 5 of 25 Staff (Staff D- Licensed Practical Nurse, Staff E - Certified Nursing Assistant [CNA], Staff F - CNA, Staff G - CNA, Staff H - CNA). The failure to ensure completion of criminal background checks placed residents at risk of abuse, neglect, exploitation and misappropriation of resident property.Findings included.Review of the facility Abuse Prevention and Reporting policy revised 08/2025 showed a resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation. The facility would not employ or engage individuals who were found guilty, had a substantiated finding, had disciplinary action, or were on a list of excluded individuals related to abuse, neglect, exploitation, misappropriation of property, or mistreatment. The facility would screen all potential employees during the hiring process using criminal background checks and would file the results in the employee's record.In an interview on 05/06/2026 at 2:05 PM, Staff A (Administrator) and Staff C (Assistant Director of Nursing) were asked to provide criminal background check records for sampled staff currently working in the facility on 05/06/2026 evening shift and for staff scheduled to work the night shift. Staff A stated staff files were not organized, and criminal background check records were not readily available. Staff B stated they had to gather the criminal background check records with help from a corporate offsite staff and access online records from the criminal background check website one by one. Staff A stated they could not ensure each staff presently working in the facility had completed the criminal background check according to nursing home regulations due to inaccessible staff records.In an interview and record review on 05/06/2026 at 5:46 PM, Staff A and Staff C could not provide criminal background check records completed on hire for Staff D, Staff E, Staff, F, and Staff G, and could not provide the biannual criminal background check record for Staff H. Staff A stated they were aware of the requirement of having staff criminal background records completed before hire and every two years to ensure resident's safety from abuse and neglect. Staff A stated the facility should, but did not, have the criminal background checks completed or accessible in the individual staff records as required.REFERENCE: WAC 388-97-0640(2)(a)(b).

Based on interview and record review the facility failed to ensure residents received timely care and treatment prescribed by the Medical Provider (Physician, Nurse Practitioner or Physician Assistant) for a change in condition for 1 of 3 residents (Resident 1) reviewed for accidents and injury. This failure placed residents at risk for harm, worsening medical conditions, and diminished quality of life.Findings included.<Resident 1>Review of Resident 1's quarterly Minimum Data Set (MDS - an assessment tool) dated 11/08/2025, showed Resident 1 had diagnoses including kidney failure requiring dialysis, and a chronic neurological-muscle disease with impairment of their arms and legs. Resident 1 was assessed to require a mechanical lift for transfers, a manual wheelchair for mobility, and was dependent on staff for care. According to a 12/11/2025 day shift nurse progress note, Staff F (Licensed Practical Nurse-LPN) received a call from the dialysis clinic stating Resident 1 reported they were in pain because their left leg was hurt during transport to the dialysis clinic. The note showed the Nurse Practitioner (NP) assessed Resident 1 upon return to the facility. The note showed the NP ordered an x-ray and pain medication. The progress note was entered into the record at 5:54 PM. Review of the NP progress notes from 12/11/2025 visit showed an assessment was completed on Resident 1 upon return from their dialysis appointment. The assessment showed Resident 1 had acute left hip and upper thigh pain after returning from dialysis, Resident 1 told the NP their left leg was bent during transport from the facility to their dialysis appointment. The NP note showed Resident 1's pain was more than a strain to the muscle. The note showed the NP discussed the assessment with the facility nurse, directed the nurse to give pain medication, and ordered a left hip x-ray STAT (as soon as possible). Review of the 12/11/2025 11:19 AM order entered into the medical record by the NP showed a STAT left hip x-ray. The order summary showed Staff E (LPN) confirmed the order at 3:55 PM, four and a half hours later. Review of a 12/11/2025 evening shift progress note written by Staff E, showed a new order for x-ray of left hip STAT was received and the order was initiated. The progress note was entered into the record at 11:33 PM. Review of Resident 1's 12/12/2025 x-ray report showed the left hip x-ray was completed at 8:35 PM, 33 hours after the NP ordered the STAT x-ray. The report showed Resident 1 had an acute hip fracture. The report showed a reported date and timestamp of 12/12/2025 at 9:11 PM. Review of a 12/12/2025 evening shift nurse progress note, entered late on 12/13/2025 at 2:43 PM, showed Staff C (LPN) received a phone call from the x-ray company reporting Resident 1's hip fracture. Staff C wrote information was passed to the night shift for follow up because it was the end of the evening shift. Review of a 12/13/2025 9:29 AM nurse progress note showed the nurse received a report Resident 1 had a hip fracture. The note showed directions to send Resident 1 to the hospital, notify the family, and notify nurse management. In an interview on 12/30/2025 at 9:25 AM, Staff B (Assistant Director of Nursing) stated that when x-ray results were received showing an acute fracture, the Medical Provider should be notified immediately. Staff B stated if results were received after hours there was an on-call provider number staff should call to report. Staff B stated when the on-call provider was called a progress note was automatically generated into the medical record. Staff B stated there was no progress note in Resident 1's record showing the on-call provider was notified of the hip fracture. Staff B stated the NP notified them on 12/13/2025 at about 7:30 AM that Resident 1 had a hip fracture. Staff B stated the NP gave directions to send Resident 1 to the hospital. Staff B stated they called the facility nurse assigned to Resident 1. Staff B stated the nurse was not aware of Resident 1's x-ray results and told Staff B Resident 1 was at their dialysis appointment. Staff B said they directed the nurse to call the dialysis clinic to send Resident 1 to the hospital.In an interview on 12/30/2025 at 9:58 AM, the NP stated they expected the nursing staff to review the x-ray results and report a fracture immediately to the provider, including calling the on-call provider if the report was after hours. The NP stated the facility did not notify the provider of the fracture. The NP stated they looked up the x-ray report in Resident 1's medical record on 12/13/2025 at 7:30 AM and tried calling the facility. The NP stated when they could not reach the facility staff, they called Staff B to instruct the facility to send Resident 1 to the hospital immediately for the hip fracture from the 12/11/2025 incident. The NP stated a hip fracture was a severe injury requiring ambulance transportation to the hospital for immediate intervention. In an interview on 12/30/2025 at 10:16 AM, Staff C stated they were the evening shift nurse on 12/12/2025 and received a phone call and report from the x-ray company about 10:00 PM, which was shift change. Staff C stated they did not report the fracture to the Medical Provider. In an interview on 12/30/2025 at 10:21 AM, Staff D (LPN) stated they were the night shift nurse on 12/12/2025 and they were not informed by the prior shift that Resident 1 had a fracture. Staff D stated when a report of a fracture was received the nurse was expected to notify the Medical Provider immediately. Staff D stated there was an after-hours number to call the on-call provider. Staff D stated Resident 1 should not have gone to dialysis on 12/13/2025 and should have gone to the hospital when the report of a fracture was received by the facility. In an interview on 12/30/2025 at 12:25 PM, Staff B stated they called the x-ray company to verify the report of Resident 1's x-ray results. Staff B stated the x-ray company notified the facility of the fracture on 12/12/2025 at 10:30 PM and spoke with Staff C. Staff B stated the nursing staff did not notify the NP or the on-call provider as required. In an interview on 12/30/2025 at 12:47 PM, Staff A (Director of Nursing) stated the investigation of Resident 1's injury did not identify the delay of nursing staff to process the Medical Provider's x-ray orders and did not identify the error of nursing staff to immediately notify the provider of Resident 1's fracture. Staff A stated the nurse was expected to call the x-ray company right away when the NP provided the STAT x-ray order. Staff A stated STAT x-rays should be completed within four hours of notification of the x-ray company. Staff A stated the nurse was expected to notify the on-call provider immediately upon the report of Resident 1's fracture. Staff A stated if Staff C notified the on-call provider as required, Resident 1 would have gone to the hospital on [DATE] and would not have been transported to dialysis on 12/13/2025.Reference: WAC 388-97-1060.

Based on observation, interview, and record review the facility failed to ensure 3 of 5 residents (Residents 52, 17, & 35) reviewed for unnecessary medications and 2 (Resident 36 & 54) supplemental residents were free from unnecessary psychotropic drugs related to the failure to: ensure clinical justification for dose increases, adequately monitor, and attempt Gradual Dose Reductions (GDR). These failures placed residents at risk to receive unnecessary medications and/or adverse side effects. Findings include: <Policy> According to a facility policy titled, Psychoactive Medication Management, revised 08/2024, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. The policy showed after the first year, a GDR must be attempted annually, unless clinically contraindicated. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 admission Minimum Data Set (MDS - an assessment tool) had multiple diagnoses including anxiety disorder (mental health conditions characterized by persistent and excessive worry or fear that can interfere with daily life and cause significant distress) and depression. This MDS showed staff assessed the resident demonstrated no indicators of psychosis (a term used to describe a set of symptoms, including hallucinations and delusions, that can indicate a significant disconnection from reality) and no behavioral symptoms. Observations on 04/16/2025 at 12:21 showed the resident lying in bed and appeared well groomed. The resident was pleasant and congenial, participating actively in conversation. Record review showed the resident admitted to the facility with orders for an as needed an antihistamine (medication used to relieve allergy symptoms) for anxiety. While the as needed antihistamine was given only four times in April and three times in May 2024, the resident was started on regularly scheduled antianxiety medication twice a day on 05/11/2024. Review of Treatment Administration Records (TARs) showed staff monitored behaviors of anxiety on 5 of 62 shifts in May 2024. Medication Administration Records (MARs) for June 2024 showed the resident's dose was increased on 06/19/2024. Record review showed Resident 52 demonstrated anxiety on 4 of 36 shifts prior to the dose increase and no episodes of anxiety in the week prior to tripling the dose. A physician order note dated 06/18/2024 triggered a drug-to-drug interaction warning but review of progress notes showed no increase in resident behaviors or distress, no clinical justification of the significant increase in the antianxiety medications, and no alert charting related to either behaviors or the increase of anxiety medication. In an interview on 04/18/2025 at 9:50 AM, Staff C (Corporate Nurse) stated, We do not have documentation to support that, referring to clinical justification for tripling Resident 52's antianxiety medication. <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 7/31/2024 admission MDS, had diagnoses which included anxiety disorder and required the use of antianxiety medication. Observations throughout the day on 04/14/2025, 04/15/2025 and 04/16/2025 showed Resident 17 in bed and up in their wheelchair working on art projects or watching TV. In an interview on 04/17/2025 at 1:10 PM, Resident 17 stated that they did occasionally experience anxiety but it was not currently an issue. Record review showed Resident 17 admitted to the facility with Physician orders for antianxiety medication to be administered three times a day. Target behavior records showed no anxiety was demonstrated in July, August, or September of 2024 but review of the MARs showed the antianxiety medication was doubled and was to be administered three times a day on 09/16/2024. A 09/16/2024 progress note showed, Patient received new orders antianxiety medication three times a day for Anxiety. Patient consented to the medication. There was no documented increase in behaviors or distress to justify an increase in dosage. In an interview on 04/18/2025 at 9:41 AM, Staff C stated after reviewing the record there was no clinical justification to increase Resident 17's antianxiety medication. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 admission MDS, had diagnoses including bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of abnormally elevated mood and energy to periods of depression). The MDS showed Resident 36 required the use of antipsychotic medication daily and demonstrated no indicators of psychosis. Review of MARs for April 2025 showed Resident 36 received antipsychotic medication twice a day for Bipolar disorder with psychotic features. Review of April 2025 Target Behaviors showed staff were monitoring for Angry Outbursts and Verbal Aggression but no psychotic behaviors were identified that required treatment. According to a 02/06/2025 Psychiatric Practitioner note, staff were directed to, Continue to monitor for any increase in frequency or severity of auditory hallucinations . In an interview on 04/18/2025 at 9:16 AM Staff C confirmed staff did not, but should, monitor the identified auditory hallucinations.<Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility with diagnoses of cancer and chronic pain. The MDS showed Resident 54 received antipsychotic medication on seven of seven days during the assessment period and was assessed with no behavior or rejection of care during the assessment period. Review of Resident 54's April 2025 order summary showed a 02/06/2025 physician order for an antipsychotic medication to be taken daily for cancer. Review of the 12/13/2024 antipsychotic medication CP included the instructions for staff to discuss with provider regarding ongoing need for use of medication. Review of Resident 54's record showed a 03/31/2025 interdisciplinary team nursing progress note that Resident 54 received antipsychotic medication related to depression from cancer and the provider agreed to discontinue the antipsychotic medication and to start on an antidepressant medication daily. Review of Resident 54's record on 04/17/2025 including physician orders and MARs showed no documentation Resident 54's antipsychotic medication was discontinued, and an antidepressant medication was started. In an interview on 04/17/2025 at 1:09 PM, Staff C stated they reviewed Resident 54's medications in a psych meeting and the provider ordered to discontinue the antipsychotic medication. Staff C reviewed Resident 54's record and stated staff should have followed the provider's recommendations and discontinue the antipsychotic medication, but they did not. <Resident 35> According to a 06/29/2024 admission MDS, Resident 35 admitted to the facility on [DATE]. The MDS showed Resident 35 had a diagnosis of, but not limited to, depression. The MDS showed Resident 35 received antidepressant medications during the assessment period. Review of Resident 35's records showed a 03/27/2025 antidepressant medication use care plan with an intervention to attempt a GDR per pharmacist recommendations. Resident 35's records showed a 06/22/2024 physician order for an antidepressant medication. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) reviewed Resident 35's health records and stated they did not attempt a GDR for Resident 35's antidepressant medication since admission to the facility. Staff E stated it was important to attempt GDRs for psychotropic medications to ensure they were not over medicating the resident or administering and unnecessary medication to the resident. REFERENCE: WAC 388-97-1060(3)(k)(i). .

Based on observation, interview, and record review the facility failed to accurately assess 5 (Resident 30, 36, 61, 62, & 69) of 20 residents' Minimum Data Sets (MDS - an assessment tool) reviewed. Failure to ensure accurate assessments regarding cognitive patterns (Resident 36) language (Resident 61), oral status ( Resident 61), vision status (Resident 30), behaviors (Resident 36), dental status (Resident 62), and discharge status (Resident 69) placed residents at risk for unidentified and/or unmet needs. Findings included . <Resident 30> According to the 09/13/2024 Admission, the 12/14/2024 Quarterly, and the 03/05/2025 Significant Change MDSs, staff assessed Resident 30 with adequate vision and no corrective lenses. Observations on 04/14/2025 at 1:20 PM revealed a pair of glasses on Resident 30's overbed table. Resident 30 stated they required eyeglasses, and their current prescription was old. In an interview on 04/17/2025 at 8:29 AM Staff B (Director of Nursing) stated the MDS was coded incorrectly and should reflect the resident's altered vision and use of glasses. According to the 03/05/2025 Significant Change MDS, staff assessed the resident with three pressure ulcers but no vascular ulcers (sores on the skin caused by impaired blood circulation, either in arteries or veins). According to a 03/05/2025 contracted wound company's progress note, Resident 30 was treated for a Chronic Ulcer that was not reflected on the 03/05/2025 MDS. In an interview on 04/21/2025 at 9:05 AM Staff D (Corporate Nurse) confirmed staff should, but did not, correctly code the wound in question. <Resident 36> According to the 03/12/2025 Quarterly MDS staff were able to interview Resident 36 for activity preferences, but did not complete the Cognitive Patterns interview with the resident because the resident was rarely/never understood. Staff coded this MDS to indicate Resident 36 demonstrated delusions (a false belief or judgment about external reality despite evidence to the contrary) during the assessment period. Observations on 04/16/2025 at 7:36 AM showed Resident 36 lying in bed conversing with a family member at the bedside. The resident was able to participate in conversation, answering questions when asked. Observations on 04/14/2025 at 9:02 AM, 10:31 AM, and 12:19 PM, 04/16/2025 at 5:35 AM, 7:36 AM, and 11:20 AM, and on 4/17/2025 at 9:33 AM and 2:48 PM, revealed no indication the resident demonstrated delusional behavior. In an interview on 04/16/2025 at 7:47 AM Staff G (Social Service Director) stated I don't know why the Social Worker coded (the resident) as not interviewable, that's wrong, (the resident) is interviewable. Staff F stated the MDS was coded incorrectly as there was no indication Resident 36 demonstrated delusional behavior during the assessment period. <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 01/02/2025 Admission MDS had diagnoses including a brain injury which caused the loss of muscle function and aphasia (a disorder that affected a person's ability to communicate). According to the dental section of the MDS, staff were unable to examine Resident 61's dental status. Observation on 04/18/2025 at 10:44 AM showed Resident 61 lying in bed. At this time, Staff B did a cursory oral exam and stated, I would say the MDS was wrong, I cannot think of a reason staff would document unable to examine on the MDS. According to Section B of the 01/02/2025 Admission MDS, Resident 61 had no speech and was rarely/never understood. Review of Section F showed staff indicated Resident 61 was able to be interviewed for preferences for activities and Section Q showed the resident, but no family, participated in the assessment. In an interview on 04/21/2025 at 8:42 AM Staff D was unable to answer how staff were able to interview the resident regarding activity preferences, but not mental status. The 01/02/2025 Admission MDS indicated Resident 61's primary language was Samoan but staff documented unable to determine the need or want for an interpreter. In an interview on 04/21/2025 at 8:09 AM Staff G stated they contacted the resident's family and confirmed that while the resident communicated in both Samoan and English, Samoan was the primary and preferred language. Staff E confirmed the resident involved family members and the facility should indicate the resident would benefit from an interpreter. 45941 <Resident 62> Review of a 01/03/2025 Admission MDS showed Resident 62 had no natural teeth and no loose natural teeth. Review of a 01/02/2025 admission evaluation showed Resident 62 had two teeth and no dentures. Review of a 12/31/2024 Oral/dental Care Plan (CP) showed Resident 62 had two natural teeth and instructed staff to report to the dietitian for any chewing issues. Review of a 04/01/2025 Oral/dental health related to broken natural teeth CP instructed staff to coordinate arrangements for dental care. Observation and interview on 04/14/2025 at 10:50 AM showed Resident 62 had only two natural upper teeth and no lower teeth or dentures. Resident 62 stated they had only two teeth left, and they were very loose. Resident 62 stated they had a hard time chewing some of the foods. In an interview on 04/18/2025 at 10:04 AM Staff N (MDS Specialist) confirmed Resident 62's MDS showed they had no natural or broken teeth. Staff N stated the MDS was inaccurate. Staff N stated it was important for the MDS to be accurate to plan residents' care appropriately. 46479 <Resident 69> According to Resident 69's 02/24/2025 Discharge MDS, Resident 69 discharged from the facility on 02/24/2025 to a short-term general hospital. Review of a 02/24/2025 Resident Discharge Summary/Instructions evaluation form showed Resident 69 discharged to their private home. In an interview on 04/16/2025 at 11:39 AM, Staff N reviewed Resident 69's 02/24/2025 MDS and discharge summary. Staff N confirmed the MDS was coded incorrectly. REFERENCE: WAC 388-97-1000 (1)(b).

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5%. Failure to properly administer 5 of 25 medications for 3 of 4 residents (Residents 2, 30, & 19) observed during medication pass resulted in a medication error rate of 20%. This failure placed residents at risk for not receiving the correct dose or receiving less than the intended therapeutic effects of physician ordered medications. Findings included . <Policy> According to the facility policy on ophthalmic (eye) drops, dated 11/15/2024, when administering multiple medications to the same eye, staff would wait 3-5 minutes between drops and staff would apply gentle pressure to the tear duct after administration or instruct the resident to close their eye. Waiting between eye drops was important to maximize their effectiveness and prevent potential side effects. It allows each drop to be absorbed by the eye before the next one is administered, preventing dilution and ensuring the medication stays in contact with the eye longer. Failure to follow Physician Ordered time parameters between eye drops decreases effectiveness of the respective medication and constitutes a medication error. Pressing gently on the tear duct, the small opening in the inner corner of the eye, after applying eye drops helps prevent the medication from draining into the nose and throat and ensures adequate dosage. This technique helps keep the medication in the eye longer, allowing it to be absorbed more effectively and potentially reducing systemic side effects. The facility procedure for oral metered dose inhalers instructed staff to wait 20-30 seconds between administration of doses for the same medication, and 2-5 minutes if medications were different. <Resident 2> Observation on 04/16/2025 at 8:21 AM showed Staff J (Licensed Practical Nurse) bring multiple medications into Resident 2's room, administering them in quick succession. Staff J was observed to administer two drops of an eye drop into each of Resident 2's eyes at 8:26 AM. Staff J then administered a nasal spray according to physician orders at 8:26 AM. Staff J administered one drop of another medicated eye drop to the left eye at 8:26 AM and proceeded to give a tissue to the resident who then wiped their eye. Staff J did not instruct Resident 2 to apply gentle pressure to the tear duct after eye drop administration or instruct the resident to close their eye per facility policy. These medications for Resident 2 were scheduled on the Medication Administration Record (MAR) to be given at 7:00 AM. Staff J administered another medicated inhaler at 8:26 AM to Resident 2. Staff J then administered a different medicated eye drop at 8:27 AM to Resident 2's left eye. The resident blinked and wiped their eye with a tissue. Staff J did not instruct Resident 2 to depress the tear duct or close their eye as directed in the facility policy. According to the manufacturer insert for this eye drop, there should be a 5-minute wait between eye drop administrations but the MAR instructed staff to wait only three to ten minutes between administration from other eye drops. Staff J then administered two puffs of another inhaler at 8:27 AM. In an interview on 04/16/2025 at 8:29 Staff J stated, I know I gotta wait like 5 minutes between eye drops and they want you to wait a couple of minutes between the inhaler. In an interview on 04/16/2025 at 9:23 AM Staff B (Director of Nursing) and Staff C (Nurse Consultant) stated the spacing between the inhalers, should be at least five minutes. In an interview on 04/16/2025 at 1:50 PM, Staff B and Staff C confirmed this was an error and the medicated eye drops should be given before 8:00 AM and not within 3 minutes of other eye drops. <Resident 30> Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J obtain a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered an injectable medication to Resident 30 based on blood sugar parameters in the physician order. According to the April 2025 MAR, the blood sugar check and injectable medication coverage for the blood sugar results was ordered for 11:30 AM but completed at 12:52 PM. In an interview on 04/16/2025 at 9:23 AM, Staff B and Staff C confirmed if the physician's order for blood sugar check and the injectable medication were scheduled at 11:30 AM, they should be done within 30 minutes of that scheduled time. Staff B and Staff C stated if the injectable medication was done late, You need to call the doctor .yes that would be an error. 47836 <Resident 19> Observation of medication pass on 04/16/2025 at 7:00 AM showed Staff W (Licensed Practical Nurse) administer Resident 19 nine medications. Review of Resident 19's physician orders on 04/16/2025 showed one of the nine medications administered to the resident was not ordered for Resident 19. Resident 19's records showed a single stool softener ordered for the residents that Staff W did not administer and instead Staff W administered a medication that had two stool softeners in one tablet. In an interview on 04/16/2025 at 9:38 AM, Staff W stated they administered the wrong stool softener to Resident 19. Staff W stated they should have administered the single stool softener and not the medication with two stool softeners in it. In an interview on 04/18/2025 at 12:05 PM Staff E (Assistant Director of Nursing) stated they expected staff to follow physician orders when administering residents their medications. Staff E stated it was important to follow physician orders to ensure administration of correct medications. REFERENCE: WAC 388-97-1060(3)(k)(ii).

Based on observation, interview, and record review the facility failed to provide risks and benefits of bed rail use prior to installation, ensure proper installation of bed rails, and provide ongoing maintenance of bed rails for 5 of 5 residents (Resident 7, 24, 28, 35, & 17) reviewed for bed rails and 2 supplemental residents (Residents 30 & 22) reviewed. These failures placed residents at risk for injury, entrapment, and other negative health outcomes. Findings included . <Policy> According to a facility policy titled, Safety Device Application, revised 04/07/2023, the facility would review safety devices with the resident and/or representative. The policy showed the facility would ensure proper installation as directed for the bed rails. <Resident 7> According to a 11/08/2024 Annual Minimum Data Set (MDS - an assessment tool) Resident 7 had no memory impairment. Review of Resident 7's health records showed a 06/10/2022 physician order for the bilateral bed rails. Resident 7's records showed an 11/13/2024 safety device assessment form for the bed rails with the resident's guardian name typed in the information provided to box on the form. Observation and interview on 04/15/2025 at 9:56 AM showed bilateral bed rails to Resident 7's bed. Resident 7 stated staff had not discussed the bed rail use with them. <Resident 24> According to a 01/05/2025 Annual MDS Resident 24 had short term and long-term memory impairment. The MDS showed Resident 24's daily decision ability was moderately impaired. The MDS showed Resident 24's primary language was not English. The assessment showed Resident 24's family participated in the assessment. Review of Resident 24's health records showed a 02/28/2023 physician order for the bilateral bed rails. Resident 24's records showed a 01/18/2025 safety device assessment form for the bed rails with son typed in the information provided to box on the form. In an interview on 04/14/2025 at 9:25 AM Staff S (Registered Nurse) stated the maintenance department was responsible for proper safety device maintenance and installation. Observation on 04/15/2025 at 10:52 AM showed bilateral bed rails to Resident 24's bed. Resident 24's right bed rail completely folded inward onto the bed when grabbed and the left bed rail was very loose, making them both unsafe for the resident to use for positioning in bed. <Resident 28> According to a 02/28/2025 Admission MDS Resident 28 had no memory impairment. Review of Resident 28's health records showed a 03/18/2025 physician order for the bilateral bed rails. Observation and interview on 04/14/2025 at 12:25 PM showed bilateral bed rails to Resident 28's bed. Resident 28 stated they did not use the bed rails because they did not want to depend on them. Resident 28 stated staff did not discuss the bed rail usage with them. <Resident 35> According to a 04/01/2025 Quarterly MDS Resident 35 had short term and long-term memory impairment. The MDS showed Resident 35's daily decision ability was moderately impaired. Review of Resident 35's health records showed a 03/25/2025 physician order for the right-side bed rail. Resident 35's health records showed a 03/25/2025 safety device evaluation form for the right-side bed rail with resident typed in the information provided to box, no signature for consent. Resident 35's health records showed they had severe cognitive impairment and had a Power of Attorney (POA - designee to make decisions on part for the resident) for their healthcare decision making. Observation on 04/15/2025 at 12:57 PM showed a bed rail to Resident 35's right side of bed. In an interview on 04/17/2025 at 9:00 AM Staff O stated they were unaware Resident 35 was unable to consent at the time and during this interview observed Resident 35 had severe cognitive impairment and had a POA in place. Staff O stated Resident 35's POA was not notified of the risks and benefits of the bed rail use. In an interview on 04/18/2025 at 9:20 AM Staff O stated they were unable to provide a copy of the notification signed by the resident/representative or a confirmation email notification of risks and benefits for Resident's 7, 24, or 28's bed rail use. In an interview on 04/18/2025 at 9:26 AM Staff H (Maintenance) assessed Resident 35's bed rails to be loose. Staff H stated maintenance was responsible for installing the bed rails, and the nursing staff were trained on how to tighten them when they become loose. Staff H stated the bed rails never stayed put and always became loose. Staff H stated maintenance was not responsible for monitoring the ongoing proper installation of the bed rails and nursing staff were supposed to fix them when they noticed the rails were loose. 20264 <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly MDS dated [DATE] was assessed with a brain injury which caused the loss of muscle function and required partial to moderate assistance with rolling from lying on the back to left and right side. Observations on 04/14/2025 at 12:01 PM showed Resident 17 had loose bed rails on both the left and right side of the bed. These rails were noted perpendicular to the bed rather than parallel to the bed with the rails extending up over the mattress. In an interview at this time Resident 17 stated they used the rails for bed mobility but they were, loose. Similar observations of Resident 17's bed rails were noted on 04/16/2025 at 7:40 and 10:27 AM. During an observation on 04/16/2025 at 12:06 PM Staff C (Nurse Consultant) confirmed Resident 17's bed rails were loose and they should be checked on a regular basis and tightened as needed. When asked if the rails were properly installed (perpendicular rather than parallel to the bed) Staff C referred to Staff H. In an interview on 04/16/2025 at 1:02 PM Staff H confirmed the rails on resident 17's bed should not be installed perpendicular stating I put them (the rails) on there right, the aides keep changing it .I changed it back. Staff H confirmed the aides should not alter the application of the bed rails. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the Significant Change MDS dated [DATE] the resident was cognitively intact and was assessed with functional limitations in range of motion to both lower extremities and required partial/moderate assistance with bed mobility. Observations on 04/14/2025 at 1:22 PM showed bed rails were installed on both the right and left sides of Resident 30's bed. When the left rail was noted as loose, Resident 30 wiggled the right rail stating, Check this other one, it's loose too. Similar observations of Resident 30's loose rails were noted on 04/16/2025 at 8:17 AM and 12:56 PM. 45941 <Resident 22> According to the 03/13/2025 Quarterly MDS Resident 22 admitted to the facility on [DATE], and had chronic pain in their knees. Resident 22 was cognitively intact, was assessed with functional limitations in range of motion to both lower extremities, and required extensive assistance with bed mobility. Review of Resident 22's record showed the 09/23/2024 physician order under safety device for the bilateral bed rails for mobility. The 09/03/2024 physician order under nonpharmacological interventions to reduce pain for the resident was repositioning in bed. Review of the 09/23/2024 Safety devise CP showed Resident 22 had bed mobility bars related to muscle weakness and instructed staff to observe the safety device for changes regarding effectiveness of the safety device and report changes to the charge nurse. Observation and interview on 04/14/2025 at 12:04 PM showed Resident 22 lying in their bed on their back. The observation showed side rails were installed on both the right and left sides of Resident 22's bed. The rail on the right side bed rail was up and the rail on the left side of the bed was down. Resident 22 stated they reposition themselves with side rails in bed, but the left side of the bed rail was broken for a few days, and they could not reposition themselves in bed. Resident 22 stated staff knew about the left side rail was broken and maintenance director was supposed to fix it, but it was not done yet. Similar observations of the left, non-functional side rail were noted on 04/15/2025 at 10:12 AM, 04/16/2025 at 9:03 AM and 2:24 PM, on 04/17/2025 at 12:25 PM. In an interview on 04/17/2025 at 10:08 AM, Staff H stated they were not aware of the broken left side rail for Resident 22's bed. Staff H stated there was no record of Resident 22's left bed rail being broken on the maintenance log. In an interview on 04/17/2025 at 12:55 PM, Staff E stated they were not aware of the broken side rail on Resident 22's bed. Staff E stated they expected staff to notify the maintenance department about the broken side rail so maintenance could fix it, but staff did not. REFERENCE: WAC 388-97-1060(3)(g), -2100 (1).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 5 of 12 (Residents 61, 22, 62, 54, & 31) who were assessed to be dependent on staff for ADLs. The failure to provide ADL assistance including bathing, oral care, and nail care as required, left residents at risk for poor hygiene, soiled long nails, diminished feelings of self-worth, and other negative health outcomes. Findings included . <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly Minimum Data Set (MDS - an assessment tool) was assessed with a brain injury which caused the loss of muscle function and aphasia (a disorder that affects a person's ability to communicate), and was dependent on tube feeding (a method of delivering nutrients to individuals who cannot or will not eat or drink enough food to meet their nutritional needs). This MDS assessed the resident as dependant on staff for all care, including personal hygiene. According to the resident's 01/22/2025 Care Plan (CP) for ADLs staff should provide oral care every shift with a toothette or glycerin sponge. Observations on 04/14/2025 at 12:13 PM revealed Resident 61 had long fingernails to both hands and dried debris along the left side of their mouth. A partial view of the resident's mouth showed yellow film/debris on their teeth and along the gum line. Similar observations were made on 04/16/2025 at 1:02 PM and 04/17/2025 at 1:22 PM. During an observation on 04/18/2025 at 10:44 AM, Staff B (Director of Nursing) stated, (The resident) has really bad breath, the teeth look brown and do not look clean. Staff B confirmed it appeared no oral care was done stating, It does not look like oral care has been happening 45941 <Resident 22> According to the 03/13/2025 Quarterly MDS, Resident 22 had intact memory and had a diagnosis of depression and edema (swelling caused by fluid build up in body tissues) on both legs. The MDS showed Resident 22 was dependent on staff for showers, toileting hygiene, and lower body dressing. Resident 22 required one-person assistance with personal hygiene and transfers. The MDS showed Resident 22 did not refuse care during the assessment period. The 10/21/2024 revised ADL Self Care deficit CP showed Resident 22 was totally dependent on staff for bathing and Resident 22 preferred showers twice a week. The CP showed Resident 22 required extensive assistance from staff for personal hygiene. Observations on 04/14/2025 at 11:55 AM, 04/15/2025 at 9:21 AM, and 04/17/2025 at 12:08 PM, showed Resident 22's fingernails were long and dirty, their toenails were thick, and there was dry flaky skin on both feet. Their lower legs were wrapped with elastic bandages. In an interview on 04/14/2025 at 11:55 AM, Resident 22 stated they wanted to have showers twice a week, but staff provided only bed baths because of the bandages wrapped on Resident 22's legs. Resident 22 stated staff did not wash their feet for a few weeks. Review of the Certified Nursing Assistant (CNA) documentation from 03/25/2025 through 04/19/2025 showed Resident 22 received four bed baths in 30 days and no shower was provided. This documentation showed no nail care was documented as provided. There were no documented refusals of nail care assistance. In an interview on 04/17/2025 at 12:52 PM, Staff E (Assistant Director of Nursing) reviewed Resident 22's CP and stated Resident 22 should receive showers twice a week but staff provided bed baths. Staff E stated staff should remove Resident 22's bandages from their legs and provide showers but they did not. Staff E stated nail care was important for dependent residents. Staff E stated shower aides and nurses were educated to clip resident's nails weekly and as needed, but staff did not follow the instructions. <Resident 62> According to the 01/03/2025 Admission MDS, Resident 62 required one person assistance from staff with personal hygiene, toileting needs, and bathing. The MDS showed no refusal of care behaviors during the assessment period. The 01/08/2025 revised ADL Self Care deficit CP showed Resident 62 required extensive assistance from staff with personal hygiene needs. Observations on 04/14/2025 at 10:46 AM, 04/16/2025 at 7:38 AM, and on 04/17/2025 at 10:41 AM showed Resident 62 had long fingernails and had black debris under their nails. Resident 62 stated they need assistance from staff to clip their fingernails. In an interview on 04/17/2025 at 12:55 PM, Staff E stated staff should provide nail care to all residents weekly on their shower days and as needed. Staff E stated any refusals should be documented in resident's records and notify the supervisor. <Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility with rectal cancer and chronic pain, and required one person assistance from staff for bathing. The MDS showed no refusal of care during the assessment period. Observation on 04/14/2025 at 11:22 AM and 04/15/2025 at 12:40 PM showed Resident 54 had long, sharp, and broken fingernails and had black debris under their fingernails. Resident 54 stated they need help to cut their fingernails. Review of April 2025 CNA documentation showed no nail care was documented to be provided. There were no documented refusals of nail care assistance. In an interview on 04/17/2025 at 1:00 PM, Staff E stated staff should provide nail care to all residents weekly on their shower days and as needed. Staff E stated any refusals should be documented in resident's records and notify the supervisor. 46479 <Resident 31> According to the 02/25/2025 Admission MDS, Resident 31 was cognitively impaired, had clear speech, was usually understood, and could usually understand others. The assessment showed Resident 31 required supervision or touching assistance with personal hygiene. Observation on 04/17/2025 at 11:27 AM showed Resident 31 lying in bed, with their right foot exposed. The toenails were long, extending past the toes. At that time, Staff X (CNA) observed and confirmed Resident 31's toenails were long. Staff X removed Resident 31's sock on the left foot revealing long toenails to the resident's left foot. Review of Resident 31's April 2025 CNA task documentation showed staff were to document every day shift if staff provided nail care to the resident. This documentation showed staff documented Y for yes-nail care was provided to the resident on 04/15/2025. This documentation did not specify if the nail care provided was to the resident's finger or toe nails. Review of Resident 31's 04/16/2025 physician orders and 03/31/2025 Activities of Daily Living CP showed no orders or directions to staff regarding what assistance the resident required for finger or toe nail care, or who was to provide the care and when. In an interview on 04/21/2025 at 9:28 AM, Staff E stated nail care should be done as needed. Staff E stated they expected CNAs to report to the nurse if they noted long toe nails on a resident. Staff E stated they expected nurses to note long toe nails on weekly skin checks and provide trimming as needed. REFERENCE: WAC 388-97-1060(2)(c).

Based on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for 7 of 20 (Residents 36, 54, 30, 17, 7, 64, & 52) residents reviewed. Nursing staff failed to: follow or clarify physicians orders when indicated, document for only those tasks completed, monitor residents for significant medication dose changes, follow up on appointment recommendations from outside providers, and to monitor residents for side effects for the treatment received at appointments in outside clinics. These failures placed residents at risk for medication errors, delay in treatment, adverse outcomes, and diminished quality of care. Findings included . <Failure to Follow/Clarify Physician Orders> <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS-an assessment tool) received regularly scheduled and as needed pain medication. Review of March 2025 Medication Administration Records (MARs) showed a Physician's Order for a pain patch Apply to bilateral (both) knees topically one time a day for Pain Do not exceed 3 patches for up to 12 hours (hr) with 24 hr period. Wash hands after handling and remove per schedule. The order directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM next morning. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed. A second order directed staff to apply a pain patch to Bilateral shoulders topically one time a day for (joint disease). Do not exceed 3 patches for up to 12 hrs with 24 hr period. Wash hands after handling and remove per schedule. This order similarly directed staff to apply the patches at 9:00 AM and remove them at 5:59 AM. According to the MAR, staff applied the patches for 15 hours per day rather than the 12 hours as directed. After reviewing the MAR, in an interview on 04/16/2025 at 10:56 AM Staff C (Nurse Consultant) stated, The patch should only be on for 12 hours, the nurse should have clarified the order since the time code indicated a time of greater than 12 hours. Staff C also confirmed that the nurses, by following the physicians orders would exceed the do not exceed 3 patches directive and should have clarified the order. Observation of the resident on 04/15/2025 at 12:07 PM showed the resident had an undated white patch applied to the right shoulder. Observations on 04/16/2025 at 10:26 AM showed the resident had an undated white patch applied to the right shoulder. During observations of the resident on 04/16/2025 at 10:56 AM, Staff C stated the nurse who applied the patch to the right shoulder should have, but did not, initial and dated it upon application. Examination of the resident's left shoulder revealed no pain patch. The resident stated at this time My left shoulder is fine, it's my neck that hurts. Further examination showed staff applied a pain patch to the resident's neck without a physician order to do so. In an interview on 04/16/2024 at 10:56 AM Staff C stated, No, there shouldn't be a patch on the neck, there is no order. Nurses should not apply medicated patches without physician's orders. Examination of the resident's knees showed pain patches to each knee dated 04/14/2025. In an interview on 04/16/2025 at 10:56 AM Staff C stated, The patches should be dated for today (04/16/2025). Review of the April 2025 MARs showed nursing staff documented the 04/14/25 knee pain patches were removed and that new patches were applied and removed on 04/15/2025. In an interview on 04/16/2025 at 10:56 AM, Staff C confirmed Resident 52 did not get medications as ordered and that nursing staff signed for tasks that were not performed. Additionally, according to April 2025 MAR staff were instructed to obtain weights on 04/01/2025 but documented, NA, rather than a weight. In an interview on 04/16/2025 at 10:44 AM, Staff C stated, We don't force residents, but the nurses should reattempt the weight and document a progress notes as to why they couldn't get the weight, then reattempt it later. <Concomitant Medications> Review of March and April 2025 MARs showed Resident 52 had as needed orders for as needed muscle relaxant and as needed pain medication at the same time on 03/06,15, 24, 29 and 30/2025 and on 04/05/2025 and 04/09/2025. In an interview on 04/16/2025 at 10:39 AM. Staff C stated that nursing staff should give the muscle relaxant medications first to relieve the muscle spasms which might be causing the pain, then the pain medication if it was still needed. Staff C stated the medications should not be given together unless the order directs to do so. <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the Admission MDS dated [DATE] had diagnoses which included anxiety disorder which required the use of antianxiety medication. Record review showed Resident 17's antianxiety medication dose was doubled on 09/16/2024. Resident 17's records showed a 09/16/2024 progress note, Patient received new order antianxiety medication TID (three times a day) for Anxiety. There was no alert charting to monitor Resident 17 for any changes or effects of the significant increase in dosage. In an interview on 04/18/2025 at 9:41 AM Staff C stated Yes, there should be alert charting for doubling the antianxiety medication, but no there wasn't. Review of April 2025 MARs showed a physician order for (Medication used to treat heartburn) Give 1 tablet by mouth one time a day for GERD for 14 Days 30 minutes before other (medications). According to the MAR, this medication along with six other oral medications were scheduled for 0600. In an interview on 04/16/2025 at 10:39 AM. Staff C stated the nurse should have clarified the orders to ensure the heartburn medication was given on an empty stomach. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 Admission MDS had multiple medically complex diagnoses, including Vitamin D deficiency. Review of Resident 36's hospital discharge records showed orders for staff to administer Vitamin D supplement tablet once a week. Nursing staff transcribed this order for Resident 36 as daily and continued to administer it for nine days until 12/18/2024. Pharmacy review identified the vitamin D error for Resident 36. In an interview on 04/17/2025 at 1:07 PM Staff C acknowledged failure of the nurse to transcribe the physician orders correctly resulted in a medication error for Resident 36 and did not meet professional standards of practice. <Resident 30> Observation of medication pass on 04/14/2025 at 12:50 PM showed Staff J (Licensed Practical Nurse) obtain a blood sugar level of 230 from Resident 30, after the resident had started consuming their meal. Staff J then administered three units of an injectable medication based on the sliding scale order. In an interview on 04/16/2025 at 9:23 AM, Staff B (Director of Nursing) and Staff C confirmed the physician's order for blood sugar check and the injectable medication was scheduled at 11:30 AM, which was before lunch and obtaining blood sugars after Resident 30 initiated a meal placed the resident at risk for elevated blood sugars which would require higher doses of the injectable medication. 45941 <Resident 54> According to the 03/21/2025 Quarterly MDS, Resident 54 admitted to the facility on [DATE] and had diagnoses including rectal cancer, malnutrition, and chronic pain. The MDS showed Resident 54 was independent with daily activities and ambulation. In an interview on 04/14/2025 at 1:34 PM, Resident 54 was awake, sitting on the edge of their bed in their room, stating they were tired. Resident 54 stated they had cancer and had appointments with cancer doctors at least 4 days a week. Resident 54 stated they were going to be out of the facility for appointments on 04/15/2025, 04/16/2025, 04/17/2025, and 04/18/2025 and then had no appointments for two weeks. Observation on 04/17/2025 8:45 AM showed Resident 54 was walking in their room, stating their appointment was longer yesterday. Observation showed an Intravenous (IV) catheter on Resident 54's right chest, covered with a dressing. Resident 54 had a pump in their hand with tubing attached to their IV catheter and stated their cancer doctor provided them this pump for cancer medications. Review of Resident 54's health record showed nursing progress notes on 04/15/2025 and 04/16/2025 indicating Resident 54 was out of the facility for appointments. No documentation showed Resident 54 came back from the appointments with any new medication orders or recommendations. Review of Resident 54's April 2025 physician orders showed no order for the IV catheter, dressing change, to monitor the IV site for any symptoms of infection, and to monitor the resident for any side effects of chemotherapy medications Resident 54 received at the cancer clinic during the appointments. In an interview on 04/17/2025 at 1:03 PM, Staff E (Assistant Director of Nursing) stated they were not aware Resident 54 had an IV catheter on their right chest area or a pump for medication. Staff E reviewed Resident 54's record and stated there was no order for an IV line or pump. Staff E stated staff should check with the resident for any new orders from oncologist when Resident 54 returned from appointments and document in their record, but they did not. 46479 <Resident 64> According to the 03/11/2025 Admission MDS, Resident 64 had unclear speech, was usually understood, and was able to understand others. The MDS showed Resident 64 had diagnoses including stroke, malnutrition, and a swallowing disorder due to the stroke. The assessment showed Resident 64 received nutrition via a tube surgically placed in their stomach. Review of Resident 64's 04/16/2025 order summary report showed the resident had a 03/04/2025 order directing staff the resident was to have nothing by mouth. Review of Resident 64's April 2025 MAR showed an order directing staff to offer the resident a snack at bedtime and document the percentage of the snack consumed by Resident 64. The MAR showed from 04/01/2025 to 04/17/2025, staff documented Resident 64 ate 100% of the snack offered on 11 of 17 opportunities. Staff documented not applicable on one occasion and a dash or 0 on 4 occasions. In an interview on 04/18/2025 at 10:21 AM, Resident 64 stated staff did not bring them or offer snacks at bedtime because they were unable to swallow. In an interview on 04/21/2025 at 10:20 AM, Staff E confirmed Resident 64 had a nothing by mouth order. Staff E stated staff should not be documenting tasks that were not done and staff should have clarified the order to provide Resident 64 with a snack at bedtime. 47836 <Resident 7> According to a 11/08/2024 Annual MDS Resident 7 experienced frequent 6/10 pain on a pain scale of 1-10 with 10 being the worst pain they've experienced. The MDS showed Resident 7 received scheduled pain medication during the assessment period. Review of Resident 7's health records showed a 02/24/2025 physician order for an as needed pain medication without parameters. In an interview on 04/17/2025 at 9:24 AM Staff O (Resident Care Manager) stated Resident 7 had no pain level or maximum dose in 24 hours parameter in place for their as needed pain medication. Staff O stated Resident 7's pain medication should not exceed 3000 milligrams in 24 hours and the order should include this. REFERENCE: WAC 388-97-1620(2)(b)(ii).

Based on observation, record review, and interview the facility failed to ensure Care Plans (CP) were updated and/or revised as needed to reflect person-centered care for 4 (Residents 17, 61, 36 & 62) of 20 sample residents whose CPs were reviewed, and failed to provide CP meetings for 4 (Residents 62, 23, 66, & 28) of 7 sample residents reviewed for CP meetings. The failure to update and/or revise CPs or provide CP meetings left residents at risk for unmet care needs, inappropriate care, and other negative health outcomes. Findings included . <Facility Policy> Review of the facility's Care Planning Process policy revised 05/2023 showed the comprehensive CP was an interdisciplinary tool that must have measurable objectives with time frames and described the services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The CP must be reviewed and revised at a minimum on admission, quarterly, and with a significant change in condition. Review of the facility's Care Conferences policy revised 05/2023 showed the facility would ensure the resident/resident representative were part of the interdisciplinary team and participate in the development and ongoing review of the plan of care. The facility would schedule care conferences for residents upon admission, quarterly, with significant changes in condition, and per residents/representatives request and document the outcome of the care conference meeting and attendees in resident's record. <Failure to Review/Revise CPs> <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the most recent Quarterly Minimum Data Set (MDS- an assessment tool) dated 01/31/2025 was assessed with a brain injury which caused the loss of muscle function and required partial to moderate assistance with rolling from lying on the back to left and right side. This MDS also reflected the resident experienced a weight loss and was on a prescribed weight-loss program. Observations on 04/14/2025 12:01 PM showed loose rails/enabler bars on both the left side and right side of the bed. Review of the Safety Device - bed mobility bar/rail CP documents dated 07/26/2024, staff were directed to evaluate safety device use monthly and as needed. A second intervention directed staff to, Evaluate safety device quarterly. In an interview on 04/16/2025 at 12:06 PM Staff C (Corporate Nurse) stated nursing evaluates the rails quarterly, not monthly, and the CP should be clarified. The Therapeutic nutritional risk CP dated 08/01/2024 identified a goal of, No significant changes r/t (related to) inadequate oral intake, although gradual weight loss as able may be beneficial. Resident's goal weight is 175 lbs. Interventions included, Monitor weight per protocol. The CP did not define acceptable parameters of a gradual weight loss or how much weight could be lost safely in a certain period of time. The CP did not direct staff when to weigh the resident. Progress notes dated 04/11/2025 identified Resident 17 had a 14.2 pound (or 6.2%) weight loss in one month. In an interview on 04/17/25 at 1:39 PM when asked how staff knew when to weigh a resident, Staff C (Corporate Nurse) stated, It should be on the CP. In an interview on 04/17/2025 at 1:54 PM Staff D (Clinical Nursing Officer) stated, There should be a measurable goal for safe wt loss, for example 1-2 pounds per week. Staff D confirmed this information should be included in the CP. <Resident 61> Resident 61 admitted to the facility on [DATE] and according to the 04/04/2025 Quarterly MDS was assessed with multiple complex diagnoses, including aphasia (a disorder that affects a person's ability to communicate), that the resident's preferred language was one other than English and was dependent on tube feeding (a method of delivering nutrients through a tube into the stomach of individuals who cannot or will not eat or drink enough food to meet their nutritional needs). Review of Resident 61's CP showed no indication of alteration in communication related to the resident's preferred language nor were there interventions to improve communication related to a potential language barrier. Failure to ensure clear means of communication in a language the resident prefers and detracts from the resident to understand their healthcare status and the care being provided. According to the Nutrition risk CP dated 04/02/2025, interventions directed staff to Monitor/document circumstances surrounding mealtimes/refusals to eat. Attempt to determine pattern or cause. Where possible alter or remove the cause. A Potential for pain CP dated 12/26/2024 directed staff to Observe during eating for indications of dental, mouth and/or facial pain. A 04/01/2025 Bladder Incontinence CP directs staff to monitor and report change in eating pattern. A separate CP for Inadequate oral intake related to NPO (nothing by mouth) . dated 02/04/2025 was in direct conflict with CPs which indicated the resident could eat. The Inadequate oral intake CP also specified the resident received a brand of nutritional supplement tube feeding not specifically formulated to residents with diabetes at 65 cc (cubic centimeters) an hour for 20 hours a day. Review of the April 2025 MARs showed staff were instructed to administer a specific nutritional supplement for diabetics at 75 cc an hour. In an interview on 04/17/2025 at 9:24 AM Staff C confirmed staff should, but did not update the CP to reflect the tube feeding type and rate. Staff C also confirmed the CP was not individualized as it directed staff to monitor issues related to eating when the resident took nothing by mouth. <Resident 36> Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 Admission MDS had diagnoses that included bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels, ranging from periods of abnormally elevated mood and energy to periods of depression), demonstrated no indicators of psychosis which required the use of antipsychotic medication daily and utilized an indwelling urinary catheter. Review of MARs for April 2025 showed Resident 36 received an antipsychotic medication for Bipolar disorder with Psychotic Features. Review of Target Behaviors showed staff were monitoring for Angry Outbursts and Verbal Aggression. According to a Psychiatric Practitioner note dated 02/06/2025 staff were directed to, Continue to monitor for any increase in frequency or severity of auditory hallucinations . Review of the Uses antipsychotic medication (related to) Bipolar Disorder dated 12/09/2024 indicated that target behaviors included mood swings and angry outbursts. In an interview on 04/18/2025 at 9:16 AM Staff C confirmed the CP should, but did not, include the psychotic behavior (hallucinations) which required the antipsychotic medication and questioned the inclusion of the mood swings on the CP as they were not monitored. According to Resident 36's Alteration in Urinary elimination CP dated 12/06/25 the resident had a diagnosis of neurogenic bladder (a condition where nerve damage disrupts communication between the brain and bladder, leading to a loss of bladder control). In an interview on 04/18/25 at 9:23 AM Staff C confirmed the CP should indicate obstructive uropathy (a condition where a blockage in the urinary tract prevents the normal flow of urine from the kidneys to the bladder and then out of the body) not neurogenic bladder. 45941 <Resident 62> According to the 01/03/2025 Admission MDS, Resident 62 admitted to the facility on [DATE] and had diagnosis of complex medical conditions including one side of body weakness. This assessment showed Resident 62 required one person assistance with transferring and toileting. Review of a revised 01/08/2025 Activities of Daily Living (ADL) Care Plan (CP) showed Resident 62 required a mechanical Hoyer lift machine with two-person assistance for transfers and one person assistance with toileting. Observation on 04/14/2025 at 10:57 AM showed Resident 62 transferred independently from bed, on 04/15/2025 at 11:01 AM, and at 2:32 PM, and on 04/16/2025 at 10:55 AM, showed Resident 62 was walking in hallway with a walker. In an interview on 04/16/2025 at 11:00 AM, Staff M (Certified Nursing Assistant) stated Resident 62 did not need help with transfers, they transferred themselves and walked in their room and in hallways independently with their walker. In an interview on 04/18/2025 at 8:44 AM, Staff C (Corporate Resource Nurse) stated the facility updated resident's care plans with change in condition and change in medications and staff had to follow the care plans to provide safe care to residents. Staff C stated Resident 62 was independently transferring and ambulating everywhere with a walker. Staff C reviewed Resident 62's care plans and stated care plans were not updated according to Resident 62's status. Staff C stated care plans should, but were not, revised and updated. <CP Meetings> <Resident 62> According to the 01/03/2025 Admission MDS, Resident 62 admitted to the facility on [DATE], had clear speech, and no memory impairment. The assessment showed Resident 62 had complex medical conditions including hemiplegia (a condition characterized by paralysis or weakness on one side of the body) and depression. In an interview on 04/14/2025 at 10:48 AM, Resident 62 stated they did not have a CP meeting since they were admitted to the facility. Review of Resident 62's record did not show documentation Resident 62 had a CP meeting since their admission. In an interview on 04/18/2025 at 8:28 AM, Staff G (Social Service Director) reviewed Resident 62's record and confirmed there was no documentation regarding a CP meeting. Staff G stated the facility staff should have a CP meeting with Resident 62 and their representative, but they did not. 46479 <Resident 23> According to the 05/09/2024 Admission MDS, Resident 23 admitted to the facility on [DATE] and had diagnoses including kidney failure requiring dialysis (procedure that filtered waste from the blood), an autoimmune disease affecting the brain and spinal cord, and depression. The MDS showed Resident 23 was cognitively impaired, had clear speech, was sometimes understood, and could sometimes understand others. In an interview on 04/14/2025 at 10:32 AM, Resident 23 stated they were not aware of having any care conferences. Review of Resident 23's records on 04/21/2025 at 8:10 AM showed the resident did not have documentation of a care conference until 11/11/2024, over six months after they admitted to the facility. In an interview at that time, Staff G stated residents were supposed to have a care conference with the first 72 hours after admission and quarterly thereafter. Staff G confirmed Resident 23 did not have an admission or quarterly care conference until 11/11/2024. <Resident 66> According to the 03/21/2025 Admission MDS, Resident 66 had clear speech, was usually understood and could usually understand others. The MDS showed Resident 66 had diagnoses including an amputation, wound infection, and diabetes (inability to regulate blood sugar levels). In an interview on 04/14/2025 at 8:48 AM, Resident 66 stated they did not have a care conference since their admission to the facility. Review of Resident 66's records on 04/21/2025 at 8:07 AM showed no documentation the resident was offered or provided a care conference. In an interview at that time, Staff G confirmed the resident did not have a care conference as required. 47836 <Resident 28> According to a 02/28/2025 Admission MDS Resident 28 admitted to the facility on [DATE]. The MDS showed Resident 28 had no memory impairment. Review of Resident 28's health records showed a 03/14/2025 initial care conference evaluation. The evaluation showed only the daughter was in attendance. In an interview on 04/18/2025 at 8:55 AM Staff G stated expectations for offering/conducting care conferences were within 72 hours after admission to the facility, quarterly, and as needed. Staff G stated social services, rehab director, nurse manager, dietary, and activities attend resident care conferences. Staff G stated only the daughter and Staff G attended Resident 28's care conference on 03/14/2025. Staff G stated there was no documentation in Resident 28's health records as to why they were not invited to their own care conference and could not recall any reason for this. Staff G stated Resident 28 and other interdisciplinary team members did not, but should have, participated in Resident 28's care conference. REFERENCE: WAC 388-97-1020(2)(c-d)(f), (4)(b). REFER TO: F692-Nutrition/Hydration Status Maintenance. F700- Bedrails

Based on interview and record review, the facility failed to ensure Pre-Admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility for 3 of 5 (Residents 52, 24 & 35) and 1 supplemental resident (Resident 30) reviewed for PASRR's . This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs. Findings included . <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 Admission Minimum Data Set (MDS- an assessment tool) had diagnoses which included Anxiety Disorder (a mental health disorder with an excessive, irrational dread of everyday situations) and Depression (mental health disorder characterized by persistent feelings of sadness and/or lack of interest in daily activities). The Level 1 PASRR dated 02/12/2024 accurately reflected the resident's anxiety and depressive disorders but indicated the resident did not require a Level II evaluation. Review of a 12/05/2024 PASRR I Resident 52 had Serious Mental Illness (SMI) and required a Level II PASRR. In an interview on 04/16/2025 at 7:54 AM, Staff G (Social Service Director) indicated the PASRR rules changed in July 2024 and the 12/05/2024 PASRR requesting a Level II was late and should have been completed in July of 2024. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 Admission MDS Resident 30 had diagnoses which included anxiety disorder and depression. According to the Level I PASRR dated 09/04/2024, Resident 30 had no SMI's. Facility staff completed a second Level I PASRR on 12/05/2024 which reflected Resident 30's anxiety and mood disorder In an interview on 04/16/2025 at 7:24 AM, Staff G confirmed Resident 30's admission PASRR was incorrect. Staff G explained incorrect PASRRs should be corrected within the first 72 hours of admission. When asked why it took three months to correct the PASRR Staff G stated, It should have been done but we got behind and we did an audit in December. In an interview on 04/16/2025 at 8:20 AM when asked why PASRRs were not corrected timely, Staff G replied, It fell through the roof (like through the cracks) I didn't have a stable assistant. 47836 <Resident 24> According to a 10/07/2024 Quarterly MDS Resident 24 had diagnoses of, but not limited to, Depression and Schizophrenia (mental health disorder often characterized by hallucinations, delusions, and/or disorganized thoughts). Review of Resident 24's health records showed a 12/05/2024 PASSR I which indicated a PASSR II referral was made. Resident 24's records did not include a PASRR II. In an interview on 04/18/2025 at 8:55 AM Staff G stated they communicated with the state PASRR coordinator since questions came up during survey about PASRR's and the coordinator had informed them they had not received a PASRR II referral for Resident 24. Staff G stated they were responsible to follow up on PASRR's within 3 weeks after a referral was made but they did not follow up on Resident 24's because they were running behind. <Resident 35> According to a 06/29/2024 Admission MDS Resident 35 had diagnoses of, but not limited to, Depression and Anxiety Disorder. Review of Resident 35's health records showed a 06/22/2024 PASSR I with no SMI's documented and no level II referral necessary. Resident 35's records showed a 12/18/2024 updated PASRR I that included SMI's, documented a level II PASRR was indicated, and the PASRR II referral was made. In an interview on 04/18/2025 at 8:55 AM Staff G stated they were expected to review the PASRR I's after the resident admitted to the facility to ensure they were correct. Staff G stated Resident 35's PASRR I review was missed. Staff G stated they completed an updated PASRR I on 12/18/2024 to reflect the SMI's and that a PASRR II referral was indicated. Staff G stated they communicated with the state PASRR coordinator since questions came up during survey about PASRR's and the coordinator had informed them they had not received a PASRR II referral for Resident 35. Staff G stated they were responsible to follow up on PASRR's within 3 weeks after a referral was made but they did not follow up on Resident 35's because they were running behind. REFERENCE: WAC 388-97-1915(1)(2)(a-c).

Based on interview and record review, the facility failed to ensure the completion of a required Pre-Admission Screening and Resident Review (PASRR) Level 2 evaluation (a person-centered evaluation that is completed for anyone identified as having or suspected of having a Serious Mental Illness (SMI), intellectual disability, developmental disability, or related condition) prior to admission for 3 of 5 sampled residents (Residents 17, 52, & 62), and 2 supplemental residents (30 & 36) reviewed for PASRRs. These failures placed the residents at risk for unmet mental health care needs. Findings included . <Resident 17> Resident 17 admitted to the facility on [DATE] and according to the 07/31/2024 Admission Minimum Data Set (MDS-an assessment tool) had diagnoses which included anxiety disorder and depression. Review of Resident 17's health records showed a 07/17/2024 Level I PASRR reflected SMIs and recommended a Level 2 PASRR. Resident 17's records showed a second Level I PASRR was completed by the facility on 12/05/2024 and also indicated Resident 17 required a Level 2 PASRR. Review of Resident 17's records showed no indication facility staff attempted to coordinate a Level 2 PASRR until staff documented on 04/08/2025, SS (Social Services) sent an email to the WA PASRR (office who performs the Level 2 PASRR) regarding any updates on an evaluation for the resident's updated PASRR. Currently pending an evaluation at this time. SS to follow up with any updates. In an interview on 04/16/2025 at 7:51 AM, Staff G (Social Services Director) confirmed there was a delay in seeking Level 2 PASRRs. When asked why there were significant delays in referring residents for Level 2 evaluations, Staff G indicated they got behind because they had no assistant. <Resident 52> Resident 52 admitted to the facility on [DATE] and according to the 02/22/2024 Admission MDS had diagnoses which included anxiety disorder and depression. Review of Resident 52's health records showed a Level 1 PASRR dated 02/12/2024 accurately reflected the resident's anxiety and depressive disorders but indicated Resident 52 did not require a Level 2 evaluation. Resident 52's records showed a PASRR level I completed by the facility on 12/05/2024 indicated the resident required a Level 2 evaluation. Review of Rsident 52's progress notes showed no efforts to obtain a Level 2 evaluation until progress notes on 04/08/2025 showed, SS sent an email to the WA PASRR regarding any updates on an evaluation for the resident's updated PASRR. Currently pending an evaluation at this time. SS to follow up with any updates. Staff documented on 04/17/2025, On 4/14/25, SS received email from WAPASRR ., stating that they need supporting documents . Staff G, in an interview on 04/16/2025 at 7:51 AM, confirmed there was a systemic delay in coordinating Level 2 PASRRs stating, I should have contacted them earlier. <Resident 62> According to the 01/03/2025 Admission MDS, Resident 62 admitted to the facility on [DATE] and had diagnosis of depression. Resident 62 received antidepressant medication seven of seven days during the assessment period. Review of the 12/31/2024 Level I PASRR showed Resident 62 had SMI depression and required a level II PASRR. Review of Resident 62's records showed no indication the facility staff attempted to coordinate a Level II PASRR until Staff G documented on 04/08/2025 they sent an email to WA PASRR authority regarding updates on an evaluation for PASRR Level II. In an interview on 04/16/2025 at 11:02 AM, Staff G stated there was a delay in following up Level II PASRR. Staff G stated they should follow up with PASRR evaluator within 30 days from PASRR I updated, but they did not. <Resident 30> Resident 30 admitted to the facility on [DATE] and according to the 09/13/2024 Admission MDS had diagnoses which included anxiety disorder and depression. According to the Level I PASRR dated 09/04/2024, Resident 30 had no SMIs. Facility staff completed a second Level I PASRR on 12/05/2024 which reflected Resident 30 had anxiety disorder and mood disorder and recommended a Level II PASRR. In an interview on 04/16/2025 at 7:24 AM, Staff G stated the Level II request was sent to the evaluator on 02/06/2025; but it should have been sent prior to that. Staff G indicated there should be follow up after a few weeks if no response was received from the agency performing the Level II PASRRs. Staff G confirmed at this time there was a delay in coordinating a Level II PASRR for Resident 30. <Resident 36 > Resident 36 admitted to the facility on [DATE] and according to the 12/10/2024 Admission MDS had diagnoses which included depression and bipolar disorder. According to the 12/04/2024 PASRR level I, Resident 36 had SMI but did not trigger for a Level 2 PASRR. Facility staff completed a second Level I on 12/09/2024 which reflected the resident required a Level II evaluation. In an interview on 04/16/2025 at 7:24 AM, Staff G stated the request for coordinating a Level II evaluation for Resident 36 was not faxed until 02/07/2025, two months after it was determined a Level II was required. There was no further follow up for coordination until a progress note on 04/08/2025 when SS staff reached out to the agency responsible for Level II evaluations. In an interview on 04/16/2025 at 11:28 AM Staff G stated, We should have contacted the PASRR folk earlier . every few weeks. REFERENCE: WAC 388-97-1915(4). 45941

Based on observation, interview, and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR) to 1 of 1 resident (Resident 1) who was found unresponsive and had a physician order to initiate CPR and signed POLST (Physician Order for Life Sustaining Treatment- a form indicating the resident's wishes to have or not have CPR) for life-sustaining care and services. The failure to train staff on the facility's expectation how to respond to a resident requiring CPR, locate, for immediate reference, resident POLST/Advanced Directives, and accurately assess signs of irreversible death, resulted in staff not following Resident 1's CPR directives, and placed 38 of 69 other current residents (Resident 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) with CPR directives at risk of not receiving CPR and/or full medical interventions in an emergency which constituted an Immediate Jeopardy (noncompliance that has caused or is likely to cause, serious injury, harm, impairment, or death to a resident) The facility corrected the above deficient practice prior to the initiation of the abbreviated survey on [DATE]. This failure was a past noncompliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) Immediate Jeopardy situation and is no longer outstanding. The facility removed the immediacy by auditing the records of all residents, auditing the POLST binder, scanning the POLST forms into the resident's records for immediate access in emergencies, educating staff on the CPR policy and how to assess for irreversible signs of death, performed CPR drills on the day, evening and night shifts, and implemented a plan of correction to sustain ongoing compliance. Findings included . The ,d+[DATE] Facility CPR Policy showed a resident's POLST form communicated to medical personnel the medical treatments the resident would want based on their diagnosis, prognosis, and goals of care. The facility staff would review a resident's current POLST or assist the resident to complete a new POLST form at admission. The facility staff would obtain physician orders based on the resident's decision for CPR on the POLST form. The POLST form and the physician orders were to be kept in the electronic medical record for access and review in emergencies. The policy directed staff to perform CPR to residents who were a full code (had physician orders to perform CPR). The policy showed if there was an unwitnessed arrest for a resident with full code, the nurse would assess for obvious signs of irreversible death including liver mortis (lividity or pooling of blood in dependent body parts), rigor mortis (hardening of muscles, rigidity), and injuries incompatible with life such as decapitation. The policy directed staff to initiate CPR if no signs of irreversible death were present. Staff would continue CPR until emergency medical personnel arrived and took over responsibility for emergency treatment. The policy does not define who is permitted to pronounce death. Documentation of all cardiac arrests would include: time the resident was found without vital signs, significant events preceding arrest, resident's code status, presence of end-stage or terminal conditions, description of the resident's condition upon discovery, reason for decision to withhold CPR, notification of the physician, and resident responsible party and time notified, transfer order if transferred, person that pronounced death, name of the funeral home, and date/time of release of the body, coroner notification. Review of Resident 1's POLST form showed it was signed by the resident on [DATE] and signed by the Nurse Practitioner on [DATE]. The form showed Resident 1 wanted CPR if they were not breathing and had no pulse. The form showed Resident 1 wanted full treatment to prolong life by all medically effective means including transfer to the hospital and intensive care. A review of Resident 1's electronic medical record showed a physician order for CPR dated [DATE]. There was no POLST form scanned into the electronic record. The care plan showed the Advanced Directive would be followed but did not contain information about the contents of the POLST form or the CPR order from the physician. Review of the [DATE] nurse progress note showed Staff B (Licensed Practical Nurse- LPN) found Resident 1 at 6:30 AM passed on, the body was still warm to touch, there was no pulse and no respirations. Staff B did not document their assessment for obvious signs of irreversible death identified in the facility policy, their inability to locate the POLST form, the resident's code status, the physician's CPR order, the reason for their decision to withhold CPR, the time of notification of the physician, the time of notification of the power of attorney, the time and details of the 911 call, the time death, or who pronounced Resident 1's death as directed in the facility CPR policy. The [DATE] facility interview with Staff B showed Staff B reviewed the CPR order in the electronic medical record, went to the POLST binder at the nurse's station to verify the CPR order with the POLST form and was not able to find the POLST form in the binder. Staff B's interview stated they did not do CPR because Resident 1 appeared expired because Resident 1's skin was pale, they had no vital signs and their fingers were cold. Staff B stated they asked another LPN to assess Resident 1 for death, Staff B notified the physician of Resident 1's death, notified the power of attorney of Resident 1's death, and then called 911 and requested assistance with Resident 1's death . Staff B's interview showed the Emergency Medical Services (EMS) responders came to check Resident 1 and pronounced Resident 1 deceased . Review of the [DATE] EMS dispatch records showed the call from Staff B was received at 6:45 AM, 15 minutes after Resident 1 was found with no pulse and was not breathing. The record showed EMS dispatch was designated as non-emergent without lights and sirens. EMS personnel arrived at the facility 6:53 AM and assessed Resident 1 with no vital signs, rigor mortis-obvious sign of irreversible death, and pronounced Resident 1 as deceased at 6:58 AM. Review of the [DATE] 6:45 AM audio of the EMS call showed Staff B asked for the police department because Resident 1 passed away unexpectedly. The operator asked if Staff B wanted to try CPR. Staff B responded that Resident 1 died peacefully. The operator stated they would send EMS personnel to help. Review of the [DATE] facility investigation report showed findings that Resident 1 was a full code. The report showed the Staff B did not initiate CPR to Resident 1 who required CPR according to the facility policy and physician orders. The investigation showed the POLST form for Resident 1 was in the POLST binder at the nurse's station, the POLST was not scanned into the electronic medical record, the POLST was not located by Staff B in the emergency, and Staff B decided to not initiate CPR for Resident 1 who was a full code. A review of the electronic medical records, on [DATE], showed 38 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, & 39) had a current physician order to receive CPR according to the facility policy. These 38 residents all resided in the facility on [DATE]. In an interview on [DATE] Staff A (Interim Director of Nursing) stated all staff were expected to follow the physician orders and initiate CPR and call 911. Staff A stated Staff B did not perform CPR for Resident 1 who had a full code CPR status. Staff A stated the facility had completed an investigation, reviewed the facility CPR policy, audited all resident records, corrected records for identified residents, provided CPR policy training to staff, completed CPR drills with additional training, and initiated an ongoing plan of correction. REFERENCE: WAC [DATE](1).

Based on observation, interview, and record review the facility failed to ensure each resident had the opportunity to exercise their autonomy and Resident Rights regarding activities and preferences important to them. The failure to provide a safe designated smoking area on the campus that maintained quality of life for 3 of 3 residents (Residents 1, 2, & 3) who were not notified of the smoking policy on admission was a violation of their Resident Rights and placed them at risk for unnecessary frustration, feelings of discrimination, and diminished quality of life. This failed practice caused psychological harm to one resident (Resident 1), who described they experienced feelings of discrimination, increased anxiety, and hopeless frustration when the facility failed to act on the resident's repeated requests smoke and contributed to their actions of cutting themselves to cope with their feelings. Findings included . <POLICY> Review of the facility policy titled, Smoking-[NAME] Center NO Smoking dated 08/2022, showed the facility did not permit smoking in the center or on its grounds (campus). The policy showed all residents/representatives would receive, and were required to sign, the smoking policy upon admission. All residents would be screened for smoking via the nursing Admission Evaluation and a care plan (CP) would be developed. Residents who were assessed to smoke independently and were able to leave the campus according to the facility Leave of Absence policy, could leave to smoke. The smoking resident would use the Agreement to Accept Responsibility for Resident Smoking Log to document when they smoked. Residents assessed to need assistance to smoke would require a family member/visitor to assist them to leave the campus to smoke. Failure to follow the smoking policy could result in discharge. Review of the previous facility policy titled Smoking Policy & Procedure, undated, showed that all residents/representatives would be provided, and were required to sign, the Smoking Policy and Smoking Safety Guideline for a non-smoking campus, on admission, and with any changes. The facility would post a copy of the Smoking Safety Guidelines in the facility. On admission, all smoking materials would be collected, marked with the resident's name, and kept locked at the nurse station. For active smokers, a smoking evaluation would be completed on admission, quarterly, and as needed to evaluate their ability to smoke independently. The Smoking Safety Guidelines for a Non-Smoking Campus showed: If the resident was an independent smoker, they could follow the Leave of Absence policy and leave the campus to smoke. If they were not an independent smoker, they would have to be escorted by a visitor/representative off the property to smoke. Non-compliance with the Smoking Policy could result in a facility-initiated discharge, consistent with applicable regulatory requirements. If the resident continued to express desire to smoke after education of the Non-Smoking Policy, they would implement their Smoking Campus policy until time of appropriate discharge. The Smoking Safety Guidelines for a Smoking Campus showed: If the resident was assessed to be an independent smoker, they could smoke in designated areas of the campus. If the resident was assessed to not be an independent smoker, they could not smoke on the campus and had to be assisted off the campus by a visitor or representative to smoke. <Resident 1> According to the 05/25/2023 Annual Comprehensive MDS (Minimum Data Set - an assessment tool), Resident 1 admitted to the facility on [DATE]. Resident 1 had moderate memory problems, no behaviors or rejection of care, and needed supervision with bed mobility, transfers, and locomotion. Resident 1's diagnoses included asthma (breathing condition), seizures, and schizophrenia (a psychiatric disorder). Review of Resident 1's CP dated 12/07/2022 showed a focused Mood CP for depression due to Resident 1's history of isolation, irritability, negative thoughts/statements, history of suicidal ideations, and self-harm including wrist cutting and burning themselves. Interventions showed staff were to watch for behaviors and allow the resident time to express feelings. A 06/13/2023 CP update showed Resident 1 had cut themselves and was transported to the Emergency Department (ED). A 06/15/2023 CP intervention update showed Resident 1 had suicidal ideation, was placed on 15-minute checks for 24 hours and was moved to a room closer to the nurse station. Review of a Social Services Progress Note (SSPN), dated 05/19/2023 5:35 PM, showed Resident 1 had a pack of cigarettes and two lighters in their possession and told staff they desired to smoke. Staff C, Social Services Director, educated Resident 1 on the smoking policy and removed the smoking material from the resident's room. Staff C offered Resident 1 assistance to discharge to a smoking facility that would satisfy their desire to smoke, and the resident was agreeable. In an interview on 07/12/2023 at 4:45 PM, Staff C stated they still had the cigarettes and lighters locked up. Staff C stated Resident 1 signed the Non-Smoking policy on 05/16/2023 but was unable to find it in the clinical record. Staff C stated the smoking acknowledgement could still be in medical records to be scanned into the chart. Staff C was asked to provide the document, but no further information was provided. Review of a grievance form dated 06/01/2023, submitted by Resident 1, showed they wanted to smoke. The 06/02/2023 dated Grievance Summary Report showed Resident 1 was provided a copy of the smoking policy, the Administrator and Director of Nursing were consulted regarding smoking procedures, and Resident 1 was referred to the Physician for a smoking assessment. The 06/02/2023 dated Grievance resolution showed the grievance was not resolved and noted the IDT (Interdisciplinary Team) would review the smoking procedure and assess the resident appropriately. The signed smoking policy was not attached to the grievance documents. In an interview on 07/12/2023 at 4:50 PM, Staff C stated they spoke with the physician who told them they did not do smoking assessments; it was a nursing responsibility. Staff C stated it was discussed by the IDT but was unsure if a smoking assessment was completed. Review of NPN's dated 06/07/2023 at 4:40 PM and 06/11/2023 at 4:01 PM, Resident 1 continued to express the desire to smoke to nursing staff. One of the nurses informed the resident it was a non-smoking campus. There was no documentation in the NPN that the provider was notified, smoking cessation alternatives were offered, or Resident 1 was assessed to smoke. Review of a NPN, dated 06/13/2023 at 3:43 PM, showed Resident 1 exhibited increased anxiety from inability to smoke and had cut themselves. Resident 1 told the nurse they did it with scissors and refused to give the facility the scissors. Resident 1 then motioned with their finger, a line across their neck as if they were going to cut their neck with the scissors. The Resident was seen by psychiatry over telehealth and then transported to the ED for evaluation with Emergency Medical Services and Police escort. In an interview on 06/26/2023 at 8:50 AM, Resident 1 was observed sitting on the edge of their bed in their new room with their possessions still unpacked in boxes and bags around the room and in the closet. Resident 1 stated they were very upset about being moved to a different room and that the facility took their nail clipper kit, which included the scissors they used cut themselves. Resident 1 stated they told the facility they wanted to smoke over a month ago, but their requests were ignored. Resident 1 stated they smoked for [AGE] years. Resident 1 stated they had a pack of cigarettes and two lighters that were confiscated by the facility and were told they had to be evaluated first and could not smoke on the property because they were a non-smoking facility. Resident 1 stated there were two other residents who smoked, and they observed one of them on multiple occasions smoking on the property, outside the front entrance. Resident 1 stated they sat outside on the back patio; they were able to see staff smoking (and smelled the smoke) in the back of the facility. Resident 1 stated they felt punished because the facility would not let them do what other residents were allowed to do. Resident 1 stated they felt discriminated against, and it was unfair the facility expected residents to leave the property to smoke but the staff did not have to leave the property to smoke. Resident 1 stated they were so frustrated and upset the facility would not listen to their repeated requests to smoke, they cut themselves, because they didn't know what else to do. Resident 1 stated they were not going to let the facility play with their mind anymore and it was not a prison. On 06/27/2023 at 8:09 AM, the facility provided a delayed investigation report summary of Resident 1's 06/13/2023 self-harm event. The investigation showed the root cause of the incident was due to the resident's desire to smoke. The summary showed Resident 1 had no cognitive deficits, a history of self-harm, recent life stressors driving their desire to smoke again, and they would complete a smoking evaluation. The investigation included an attached copy of a 06/14/2023 PPN that showed Resident 1 was in obvious distress during the event and a 06/26/2023 12:34 PM Smoking Evaluation (41 days after Resident 1 first requested to smoke) that showed Resident 1 could safely smoke with supervision. In an interview on 07/12/2023 at 4:55 PM, Staff C stated the IDT team should have timely assessed Resident 1's smoking ability and provided Resident 1 with the opportunity to smoke, if able, but did not. Staff C stated they were unable to find Resident 1's signed smoking policy acknowledgements or Admission Agreement documents in the clinical record. In an interview on 07/12/2023 at 5:00 PM, Staff E, Social Services Assistant, stated the staff smoked in the back of the facility under the carport. In an observation on 07/12/2023 at 5:05 PM of the covered staff smoking area located behind the maintenance office and on the property, the back patio where Resident 1 stated they sat to enjoy the fresh air was visible and easily accessible from the staff smoking area. In an interview on 07/12/2023 at 5:45 PM, Staff A stated the residents were notified the facility was a non-smoking facility on admission, as part of the Admission Agreement process. Staff A stated the discharge planners at the hospitals were aware the facility was a non-smoking facility to help deter the admission of active smokers. Staff A stated they were unsure of the date the facility switched to non-smoking because they were not an employee at that time. Staff A stated Resident 1 should have had signed smoking policies in their clinical record, and they would continue to look in medical records. On 07/13/2023 at 12:57pm, Staff D, Assistant Director of Nursing, stated they were unable to find Resident 1's Admission Agreement packet, or any of the smoking policy documents signed by Resident 1. The facility could not show Resident 1 was ever notified of the smoking policy on admission, when the facility switched to non-smoking, or when Resident 1 first began requesting to smoke on 05/16/2023. <Resident 2> According to Resident 2's census record, they admitted to the facility 07/26/2019, discharged [DATE], and readmitted [DATE]. Review of Resident 2's 07/26/2019 Admission Agreement showed no information regarding the facility smoking policy. There was no Admission Agreement documentation for the 03/28/2023 re-admission in the clinical record. Review of a smoking evaluation, dated 04/05/2023 at 7:53 AM, showed Resident 2 was an independent smoker. Review of a 04/05/2023 smoking CP showed Resident 2 chose to smoke off the property during dialysis appointments. Record review showed no earlier smoking CP's. Review of the resident's clinical record showed no documentation that Resident 2 was provided with or signed the smoking policy on their original admission or their re-admission to the facility. A request for the signed smoking policies and the Resident Smoking Log was made on 07/12/2023. No further information was provided. Review of a 07/06/2023 3:34 PM Discharge Planning note showed Staff A, Staff C, and Staff D discussed transfer to another facility that allowed smoking. The resident declined because that facility was too far away from their family. In an interview on 07/12/2023 at 5:00 PM, Staff C stated Resident 2 smoked off the property and when they go to dialysis. In an interview on 07/14/2023 at 4:00 PM, Resident 2's representative, Collateral Contact (CC), stated Resident 2 smoked over a half pack per day and routinely smoked on the property, out the front door entrance, and within visual sight of the front offices. CC stated they never witnessed facility staff tell Resident 2 they could not smoke on the property. CC stated they attended a care conference recently and discussed Resident 2's healing progress and impact from smoking, but the facility did not say anything about not smoking on the property, or that Resident 2 was non-compliant with their smoking rules. CC stated they had never been notified they did not allow smoking on the property and was not aware they notified Resident 2 they could not smoke on the property. <Resident 3> According to the 04/18/2023 Admission MDS, Resident 3 admitted to the facility on [DATE]. Review of a 04/19/2023 smoking focus CP showed they were at risk for injury due to history of smoking and interventions were to offer smoking cessation support and review the smoking policy with the resident. Review of a PPN, dated 04/17/2023, showed Resident 3 smoked a quarter of a pack of cigarettes per day and smoked marijuana. A review of the clinical record showed no smoking evaluation was conducted, and no signed smoking policy was found in the record. Review of Resident 3's 04/11/2023 Admission Agreement documents showed patients would agree to follow the centers smoking policy and a copy would be provided to them. Each patient who wished to smoke would be evaluated for safety purposes and if allowed to smoke, they could only do so in designated areas, at designated times, and could not keep smoking materials in their personal possession. The Agreement was electronically signed by Resident 3 on 04/14/2023 at 3:55 PM. At the end of the Admission Agreement packet was an undated, unsigned copy of the Smoking Policy, and the smoking safety guidelines for both a smoking campus and a non-smoking campus. None of the three policies were signed by Resident 3. REFERENCE WAC: 388-97-0900 (3).

Based on observation, interview, and record review the facility administration failed to act swiftly and effectively to ensure the Emergency Exit (EE) doors were operable and in compliance with federal regulatory requirements. The failure to prioritize the life safety component of repairing the EE doors when found locked and inaccessible in emergent situations placed residents' health and safety at risk for serious harm including death and resulted in Immediate Jeopardy (IJ) on 12/01/2021. Administration failed to ensure supplies, including linens, wound care supplies, and over-the-counter medications were available to staff to provide care in a clean and comfortable manner and according to physician orders. This failure led to residents having inadequate linens on the beds, medication errors and alternate wound treatments. Administration failed to ensure an ongoing Quality Assurance and Performance Improvement (QAPI) program existed, was comprehensive, and sustainable through changes in facility management. This failure of administration detracted from the facility's responsibility to ensure quality care was provided to residents, identify areas for improvement and implement performance improvement plans to meet federal and state regulation compliance which placed residents at risk for decreased quality of care. CFR 483.70 Administration, F-835: A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 12/01/2022 at 4:55 PM, the Administrator was informed of an Immediate Jeopardy identified related to two locked, non-functioning EE doors. On 12/02/2022 the immediacy was removed. The facility unlocked the EE doors and installed magnetic door alarms to both doors. The EE doors remained disconnected from the fire alarm system when the immediacy was removed on 12/01/2022. Findings included . Emergency Exit Doors During a life safety inspection on 12/01/2022 from 8:45 AM to 9:50 AM, a Washington State Fire Marshal identified the two EE doors (door 2 and 3) on the east side of the building did not function as required. The Fire Marshal determined the EE doors were locked and could not be opened, which prevented residents and staff from exiting the facility in an emergency. The Fire Marshal found the EE doors were not connected to the fire alarm system and the keypad controllers which connected the doors to the fire alarm system were not functioning. The Fire Marshal called an IJ in Life Safety for K-222; the facility failed to maintain egress doors free of locks or latches requiring special knowledge or equipment. In an interview on 12/01/2022 at 12:10 PM with the Fire Marshal present, Staff A (Administrator) stated they discovered the two east hallway EE doors did not open during a building walk through last Friday (11/25/2022). Staff A stated they asked maintenance to repair the doors. Staff A stated they did not follow up with maintenance to ensure the two EE doors were repaired and functional. Staff A did not know how long the doors were locked but did acknowledge they were locked from 11/25/2022 to 12/01/2022, seven days. In an interview on 12/01/2022 at 3:13 PM Staff FF (Regional Maintenance Director) stated they were unsure why or when Staff I (Maintenance Assistant) disabled and locked the doors Staff FF stated the EE doors should never be locked. A 2022 12-month work order history log showed Staff I completed a test of the doors, locks, and alarms on 11/08/2022. The 11/08/2022 work order showed Emergency doors are not operational due to code alarm issues. The Director has been notified. In an interview on 12/12/2022 at 4:03 PM, Staff A stated they did not know Staff I had locked the doors. Staff A stated they interviewed Staff I and received information that Staff I locked the doors because the alarm kept going off and kept being set off. According to Staff A, Staff I also stated the keypad stopped working. Staff A acknowledged the work order history log which showed Staff I reported the non-functioning doors to a director on 11/08/2022. Staff A stated no staff reported the non-functioning door to them. Wound Supplies Observations on 11/30/2022 at 09:10 AM, 12/01/2022 at 11:02 AM, 12/02/2022 at 3:11 PM showed Resident 6 had a wound vacuum (equipment used for wound healing) in place on a sacral (lower back) wound. On 12/05/2022 at 10:07 AM Resident 6 was observed with no wound vacuum on their sacral wound. During an observation on 12/06/2022 at 10:46 AM, the wound team completed a wound assessment and treatment with Resident 6 and did not apply a wound vacuum. In an interview on 12/06/2022 at 10:49 AM, the wound care provider stated Resident 6 needed the wound vacuum and they did not know why the wound vacuum was not available from the facility. In an interview on 12/06/2022 at 1:37 PM, Staff C (Licensed Practical Nurse, LPN Unit Manager) stated Resident 6 required the wound vacuum treatment, but the facility ran out of the canisters for the wound vacuum. Staff C stated the wound vacuum treatment was discontinued because of no supplies. Staff C stated they notified the Administrator there were no more canisters last week on Friday (12/02/2022). Staff C stated there were no canisters ordered, and the wound care provider had to change the treatment orders until the supplies were received. In an interview on 12/12/2022 at 2:33 PM, Staff B (Director of Nursing - DNS) stated they were not informed of the wound vacuum treatment change or the canisters being out of supply. Staff B stated the supplies should always be available for the wound vacuum and should not run out. Staff B stated the Administrator oversees supply ordering. In an interview on 12/12/2022 at 3:46 PM, Staff A stated a nurse reported the canisters were out on Monday (12/05/2022) and they were ordered. Staff A stated a shipment was received on 12/12/2022, but Staff A did not know if the canisters were received in the shipment. Linens During an interview on 11/30/2022 at 8:53 AM Staff Y (Certified Nursing Assistant) stated the facility did not have enough fitted sheets and they told management for months there were not enough sheets. Observation at that time, of the linen carts, source of available linens to the caregivers, showed two of four linen carts had no sheets and one linen cart had four flat sheets. Observations on 11/30/2022 from 8:10 AM to 11:06 AM showed five residents (Residents 21, 33, 28, 8, & 55) lying on a bare mattress without any sheets. Observations on 12/06/2022 from 10:03 AM to 10:32 AM showed eight residents (Rooms 3, 6, 43, & 20) were lying on flat sheets instead of fitted sheets. In an interview on 12/05/2022 at 12:11 PM, Staff MM (Laundry Assistant) stated the facility did not have an adequate supply of fitted sheets. Staff MM showed the facility logs, dated August thru December 2022, documenting dates of when sheets were discarded due to holes, rips, and tares. Staff MM stated the facility had a new contracted laundry provider and the facility had not purchased linens in three months. In an interview on 12/12/2022 at 3:46 PM, when asked about the frequency of ordering sheets and other linens, Staff A stated the caregivers took all the linen and stored it in the resident rooms so there was none on the carts. Staff A stated there was plenty of linens if staff did not hide them. Staff A stated an order was placed and should be delivered soon. Staff A confirmed residents should have fitted sheets in good repair on the bed for comfort, dignity, and safety. Over-the-Counter Medications Review of November and December 2022 Medication Administration Records for seven sampled Residents (2, 42, 49, 4, 51, 65, & 32) showed Lidocaine (for pain) patches were not given consistently between November 1 thru December 10. Review of the resident progress notes for the dates a patch was not administered revealed the facility had no Lidocaine patches. In a medication pass observation and interview on 12/06/2022 at 09:28 AM, Staff Q (Licensed Practical Nurse) stated they were not able to administer two over the counter supplements because the facility supply was out. Staff Q stated if the medication was not on the cart, then the nurse checked the medication room, then went from cart to cart to see if there was any supply to give the resident. Staff Q stated the facility ran out of medications quite often, when asked to define quite often, Staff Q stated, this is not the first time. In an interview on 12/12/2022 at 2:33 PM, Staff B stated when they were informed about one of the over-the-counter medications being out of supply, a staff person was sent out to buy some from the local store. Staff B was not aware of the other supplement or the Lidocaine patches being out of stock. Staff B stated the nurses just need to ask for supplies or put a note under the DNS office door and the supplies would be ordered. In an interview on 12/12/2022 at 3:46 PM, Staff A described a par level system for ordering supplies and stated the staff responsible had been trained but was not keeping items in supply. Staff A stated they were not informed of being out of Lidocaine patches or other over the counter meds. Staff A stated there was an order form staff had to fill out to request supplies. Staff A was aware that prior to September orders were canceled by the corporate office but they had not been canceled since Staff A was doing the ordering. Quality Assurance Performance Improvement Program (QAPI) In an interview on 12/12/2022 at 3:46 PM Staff A stated since starting employment in September 2022 they held two monthly QA meetings on 09/29/2022 and 10/30/2022. Staff A stated in September 2022 the QA team discussed psychotropic drugs, survey readiness, recent citations, weight loss/gain and nursing documentation of showers. In October 2022 the QA team discussed administrative, pharmacy, Minimum Data Set assessments, business office items, ancillary items, staffing and nursing call lights, competency, citations, and discharges against medical advice. When asked if the QA team had any PIP's (Performance Improvement Plans) in place for identified areas, Staff A stated, No. When asked about QAPI documents or PIPs implemented prior to September 2022, Staff A stated there were no documents from any prior monthly or quarterly QAPI committee meetings. When asked if the Administrator was trained to facility and corporation policies and procedures, systems and expectations, Staff A stated they were not provided any training about the facility QAPI processes from the corporate staff or provided information on any current PIPs in place from prior administration. Refer to 689 Free of Accident Hazards/Supervision/Devices Refer to 584 Safe/Clean/Comfortable Homelike Environment Refer to 755 Pharmacy Services Refer to 736 Governing Body REFERENCE: WAC-388-97-1620(1). 42203

Based on observation, interview, and record review the facility failed to ensure food was prepared according to the required menu for modified food textures and thickened liquid consistencies and as ordered by the physician for 3 of 3 (Residents 42, 40, & 66) residents. This failure placed 27 total residents assessed to require altered food textures and/or thickened liquid consistencies, for safe swallowing, at risk for choking while eating, aspiration (inhalation of food/fluids into the lungs), pneumonia, and/or death. CFR 483.60 (c)(3)(5)(6) F-803 Menus meet Resident Needs/Prep in Advance/Followed. On 12/08/2022 at 5:31 PM, an Immediate Jeopardy was identified, and the Administrator was informed. On 12/09/2022 the immediacy was removed. The facility completed speech therapy swallowing screens of residents, reviewed and corrected breakout menus, updated recipes for altered textures, completed a crosswalk for dietary and facility diet types, reviewed resident diet orders and compared with the tray ticket system and care plans, educated dietary and nursing staff, and completed audits on the delivery of altered texture foods to the 27 residents. Findings included . Resident 42 According to the 09/06/2022 admission MDS (Minimum Data Set - an assessment) Resident 42 did not have a swallowing problem and was on a regular diet and thin liquids. The resident was assessed to require assistance with eating. The 09/26/2022 care plan (CP) showed Resident 42 required assistance for set up but could eat independently. According to a 09/14/2022 nursing progress note, Resident 42 choked (blocking of airway to prevent breathing) on a hotdog and required abdominal thrusts (a life-saving emergency procedure to remove an obstruction from a person's airway). Resident 42 was sent to the hospital, and treated for aspiration pneumonia (lung infection from inhaling food into lungs). The resident was newly diagnosed with a decline in their ability to chew and swallow, and discharged back to the facility on [DATE]. The resident's 09/26/2022 Physician Orders (PO) included a speech therapy evaluation for swallowing, a mechanically altered diet, thickened liquids, and one-to-one feeding assistance/supervision. Review of the December 2022 POs showed Resident 42's diet texture order was dysphagia (altered texture of foods and liquids that make swallowing safer) mechanical soft diet and nectar thick liquids. The 12/08/2022 lunch menu for dysphagia mechanical soft texture showed: ground sweet and sour pork (no pineapple), seasoned cream of rice, ground green beans, and a pureed roll. Residents who were on nectar thick liquids were designated a cup of nectar thick orange juice. Observation of the tray line on 12/08/2022 at 12:00 PM, showed Staff O (Cook) placed chopped broccoli on the plate for Resident 42. The tray ticket for Resident 42 showed ground green beans, dysphagia mechanical diet, nectar thick liquids. During a 12/08/2022 12:23 PM observation, Staff S (Certified Nursing Assistant) served Resident 42 their lunch tray. After setting the resident up at the edge of the bed, they did not remove the cover from the plate to observe what was being served or if the food matched the diet order on the tray ticket. Staff S left the room. On 12/08/2022 at 12:24 PM Resident 42 removed the cover from the plate where chopped broccoli was observed. The tray included a cup of thin milk and a bowl of un-chopped mandarin orange slices. On 12/08/2022 12:27 PM, Staff Q, LPN (Licensed Practical Nurse) in an interview, confirmed the chopped broccoli and thin milk was not the correct diet texture, removed them both from the tray, and took them to the kitchen for correction. An observation on 12/08/2022 at 12:32 PM showed Staff Q was provided nectar thickened milk, minced broccoli, and pureed orange slices from the kitchen staff, and delivered to Resident 42. Observation on 12/08/2022 at 12:39 PM showed Staff Q returned to Resident 42 who was found with a coffee mug of thin cocoa. Staff Q removed the thin cocoa and gave Resident 42 the correct broccoli, correct milk, and pureed oranges. Resident 42 began to consume the pureed oranges. Staff Q left the room, during ongoing observation no other staff provided one-to-one supervision for the meal as listed as an intervention on the CP. At 1:16 PM Staff Q reported that Staff S brought the thin cocoa to Resident 42. During a 12/08/2022 at 1:23 PM interview, Staff T (Licensed Speech Therapist) confirmed Resident 42's prescribed diet was dysphagia mechanical soft, nectar thick liquids, and supervision was required using strict precautions to prevent aspiration/choking. Staff T stated the only time it was safe for Resident 42 to consume thin liquids was during their speech treatment with the speech therapist. Staff T looked at the consistency of the chopped broccoli that was served to Resident 42 and stated the chopped broccoli pieces were not an appropriate substitution for ground green beans or a dysphagia mechanical soft diet. Staff T stated pureed mandarin oranges were not appropriate for Resident 42 because the consistency would be too thin for the resident to safely consume due to their swallow problem. Staff T said they would expect staff to supervise Resident 42 while eating as they would for any resident on altered texture diets due to chewing / swallowing problems. Staff T said the risk of not receiving the prescribed diet texture or liquid consistency placed the resident at risk for aspiration of food/fluids into the lungs and/or choking again. In a 12/08/2022 at 1:53 PM interview, Staff S stated they did not look at the tray ticket and compare it to the food on the plate when serving Resident 42. Staff S stated it was important that the resident received the diet ordered by the physician because they could choke and die if not served the correct diet. On 12/08/2022 at 4:15 PM Resident 42 said that sometimes they are served thin milk, cocoa, and coffee and sometimes it is thickened. They just drink drank what they were served. 44296 Resident 40 The 08/12/2022 PO showed Resident 40 was prescribed a regular diet with dysphagia mechanical soft texture, and nectar thick consistency fluids. The PO showed Resident 40 required implementation of standard aspiration precautions by staff to supervise size of bites, pace of eating, and alternating solids and liquids. Observation of the tray line on 12/08/2022 at 12:08 PM, showed Staff O placed chopped broccoli on the plate for Resident 40. The tray ticket for Resident 40 showed ground green beans, dysphagia mechanical diet, nectar thick liquids. Observation on 12/08/2022 at 12:21 PM showed Resident 40 sitting in bed with the head of bed at 30 degrees. The tray table was in front of the resident. The plate of food showed broccoli cut into one-inch pieces. Resident 40 was poking at the broccoli with the fork. No staff was observed in the room with Resident 40 while they were eating as directed in the CP. Resident 66 The 11/08/2022 PO showed Resident 66 was prescribed a regular diet with dysphagia advanced texture and thin consistency fluids. Resident 66's PO required supervision eating in the dining room to assist with aspiration precautions. Observation of the tray line on 12/08/2022 at 11:57 AM, showed Staff O (Cook) placed chopped broccoli on the plate for Resident 66. The tray ticket for Resident 66 showed ground green beans and dysphagia mechanical diet. In an interview on 12/08/2022 at 12:27 PM, Staff Q stated the chopped broccoli was not the correct texture for a dysphagia mechanical diet. Staff Q stated it should not be served to residents with swallowing problems due to risk of choking. Observation and interview during the tray line on 12/08/2022 at 12:10 PM showed Staff O began plating food for the room tray carts. Review of the 12/08/2022 menu for the lunch meal showed green beans as the vegetable of the day. When asked about the chopped broccoli instead of the green beans, Staff O stated, We don't have any [green beans]. Staff EE (Dietary Manager) was present and when asked if the broccoli was the right texture, Staff EE stated, Yeah. In an interview on 12/08/2022 at 1:27 PM, Staff T (Licensed Speech Therapist) looked at the chopped broccoli and stated it was not an appropriate substitution for ground green beans on the menu. Staff T stated the chopped broccoli was not the correct texture for a dysphagia mechanical diet and the broccoli should be minced into small pieces. Staff T confirmed Residents 42, 40 and 66 were assessed to require altered textured food and/or liquids. Staff T stated residents with swallowing problems are at high risk for choking if served the incorrect diet textures. REFERENCE: WAC 388-97-1160(1)(a)(b)(c)(iii-iv), -1180(1), -1200(1)(2). 42203

Based on observation, interview, and record review the facility failed to ensure 1 of 18 residents (Resident 45) received necessary care and services in accordance with professional standards of practice related to hospitalization , significant change in condition, edema management, and medically related appointments. The facility's failure to recognize, accurately assess, and provide ongoing monitoring for worsening heart failure and kidney function; assess and adequately monitor progressively significant weight gain and edema; implement repeated physician orders for daily weights and multiple referral requests to Nephrology (kidney specialist); and ensure reliable transportation was established for appointments resulted in harm to Resident 45 who sustained avoidable acute kidney injury and acute respiratory failure, required two likely avoidable hospitalization s and one emergency room visit, avoidable psychological stress, and significantly diminished quality of life. Findings included . Resident 45 According to the The Fundamentals of Nursing -The Art and Science of Person-Centered Care, 9th edition (pages 1554-1578), alterations in fluid balance and electrolytes (potassium) are commonly caused by a malfunction of the kidneys ability to excrete excess fluids and heart failure that results in fluid accumulating (edema/swelling) in the lungs and dependent parts of the body (lower legs). Accurate assessment of fluid and electrolyte balance when symptoms occur is critical because such imbalances can have serious negative outcomes and could even be life-threatening. The Care Plan (CP) should include monitoring of fluid intake and output, daily weights- at the same time every day preferably in the morning, and routine labs. Daily weighing is the most accurate way to depict changes in fluid volume. A rapid increase or loss of 2.2 pounds is equal to one liter of fluid. Edema is graded from 1+ to 4+ and brawny (swelling that is so significant it will no longer show pitting) edema by pressing on the affected area and evaluating the level or pitting. A more accurate way to measure edema is measuring the affected body part, in the same area each day or routinely. A physical assessment should include an assessment of the skin, oral membranes, vital signs, oxygen saturation, respiratory and cardiac assessment - including lung sounds, edema grade and location, and weight changes. Moist crackles heard in the lungs is an indication of fluid in the lungs and may indicate fluid volume overload. According to the 09/17/2022 Annual Minimum Data Set (MDS, an assessment tool), Resident 45 had no cognitive deficits and had diagnoses including heart failure, kidney disease, high blood pressure, and diabetes. Resident 45 required supervision with ambulation and bed mobility and required limited assistance with transfers and toileting. Resident 45 did not have breathing difficulty. The MDS showed a weight of 258 pounds, which triggered a significant unplanned weight gain. Review of the 09/23/2022 revised CP showed no identification of problems related to heart failure, kidney disease, edema / weight gain, respiratory problems, or dental problems. There were no interventions to direct staff how to care for Resident 45 related to these medical care areas identified in the MDS assessment. In an interview on 11/30/2022 at 11:10 AM, Resident 45 stated they were very unhappy with the physician services provided by the facility and believed the provider did not know how to manage their care and was incompetent. Resident 45 stated they would have to start dialysis (treatment for filtering blood when the kidneys no longer functioned) much sooner than expected due to the medical mismanagement they experienced. Resident 45 said they were hospitalized several times over the past year because they did not receive the care they needed. Resident 45 stated their quality of life was severely impacted by the medical complications experienced in February 2022 when they were hospitalized for an oral gum infection after requesting to see the dentist and hospitalized again in October 2022 when they had such bad edema they had to go to the hospital, resulting in respiratory failure and diuresis (removal) of 74 pounds of water weight. Resident 45 said their medical circumstances had caused a considerable decline in their mood and made their anxiety almost unmanageable at times. According to record review, Resident 45 admitted to the facility on [DATE] and weighed 218 lbs. An 08/23/2021 Physician note showed Resident 45 was referred to Nephrology due to multiple abnormal kidney function labs and recurrent high potassium (an electrolyte) levels. The note showed Resident 45 weighed 220 lbs. A 12/10/2021 Physician note showed Resident 45's lower leg edema worsened over the past week and the provider adjusted Resident 45's medications to help decrease their edema. The provider failed to identify Resident 45 was not seen by Nephrology as ordered. Resident records showed on 12/10/2021 Resident 45 weighed 237 pounds. A 12/21/2021 Physician note identified the resident had edema but did not address the status of the Nephrology appointment or question why it was not followed up on. A 12/21/2021 document of blood work results showed Resident 45's kidney function had worsened. According to a 02/21/2022 hospital history and physical note, Resident 45 was admitted to the hospital due to an oral gum infection. The hospital admission weight showed Resident 45 weighed 252 lbs, an increase of 15 pounds. Resident 45's kidney function labs were abnormal, and Resident 45 received treatment to stabilize their kidney function. According to Resident 45's census record, they returned to the facility on [DATE]; they weighed 241 lbs. Review of the Physician Progress Notes showed from the date of the first Nephrology referral request on 08/23/2021 to 05/03/2022 (over 8 months), Resident 45 was evaluated by or received consult by facility Physician (or designee) providers 100 times. Facility staff and Physician providers failed to identify or question why Resident 45 had not been referred to a Nephrologist as ordered. On 05/03/2022, Staff II (Physician) placed another order into the electronic record, saying, Refer to Nephrology. A 06/02/2022 nutrition note identified Resident 45 weighed 258 lbs., an increase of 12 lbs. in two days. The note showed the interdisciplinary team (IDT) felt the weight was miscalculated and they would re-weigh Resident 45. The note indicated Resident 45 had a pending Nephrology referral for end stage renal disease (a condition in which the kidneys cease functioning on a permanent basis) and did not address issues with the residents's fluid balance or abnormal lab values. Resident 45's weight record showed the next weight assessed was 11 days later, on 06/13/2022, they weighed 242 lbs. A 07/06/2022 Physician note showed Resident 45 was seen for fluid volume overload, lower leg edema, and high blood pressure. The note showed there were no new labs drawn and no current weight. The plan for Resident 45's worsening chronic kidney disease was to avoid medications toxic to the kidneys, encourage the resident to increase fluids, and referenced abnormal labs drawn on 05/17/2022, which were not current labs. On 07/07/2022 Resident 45 weighed 266 lbs. (a 24-pound weight gain in 24 days). This weight gain triggered a significant increase alert to the nursing staff in the electronic medical record. There was no nursing assessment of the weight gain. There was no re-weight conducted and no evidence the provider was notified. A 07/17/2022 nursing note showed Resident 45 had significant edema to both legs, hips, low back, and now crackles were heard in the resident's lungs (an indication of increase fluid volume overload, worsening heart failure and/or kidney function). A 07/17/2022 after hours physician provider note showed nursing staff notified the provider of Resident 45's elevated blood pressure, severe edema from their hips to lower legs, and crackles heard in both lungs and that Resident 45 requested to go to the hospital. The provider noted they [Provider] did not think Resident 45 needed to go to the hospital and ordered an additional dose of their diuretic and lab work again. Resident refused the order and insisted to go to the hospital. According to the 07/17/2022 hospital notes, Resident 45 was treated for edema and was scheduled for a follow up with a Nephrologist on 08/23/2022 as the previously ordered Nephrology consults were never implemented by the facility. According to a 07/20/2022 Physician order (PO) staff were directed to obtain daily weights. Review of Resident 45's weight record showed staff failed to implement the daily weights, only weighing the resident on one day between 07/20/2022 to 08/31/2022. A 08/31/2022 Physician provider note showed Resident 45 had edema to both lower legs and had a newly identified heart murmur (abnormal heart sound). The provider again wrote refer to nephrology, encouraged increased fluid intake, and repeat the blood work. The provider documented, start daily weights if greater than 3-pound weight gain in 1 day or 5 pounds in 1 week, notify provider. The provider said to continue current medications. The provider note did not address the lack of daily weights in the resident's record or delay in obtaining the nephrology appointment. On 08/23/2022 Resident 45 had a Nephrology appointment scheduled. Resident 45 was ill that day and the appointment was rescheduled for 10/04/2022. Resident 45's weight record for September 2022 showed staff failed to obtain daily weights on six of 30 days. A 09/28/2022 Physician provider note repeated the order to, Refer to Nephrology. On 10/04/2022 Resident 45 missed their appointment to Nephrology due to the facility's failure to ensure transportation. The appointment was re-scheduled for 11/01/2022. Review of Resident 45's October 2022 weight record showed facility staff failed to obtain daily weights on five days between 10/01/2022 and 10/13/2022. Weight record showed on 10/04/2022 (281 lb.), on 10/02/2022 (288 lb.), and on 10/13/2022 (292 lb.- a 37 lb. weight gain in 30 days, a 51 lb. weight gain in 120 days, and 72 lb. weight gain in 245 days - the date of the first Nephrology referral request). Resident 45 was subsequently sent to the hospital related to significant edema from their lower legs to their abdomen, causing the resident breathing complications. According to the 10/13/2022 emergency room Physician note: Resident 45 had chest tightness and shortness of breath, lower leg swelling and abdominal edema. Their labs indicated acute kidney injury. The hospital physician stated Resident 45's declining kidney function was concerning. The physician note identified the resident never received the Nephrology referral recommended from the July 2022 emergency room visit. The physician documented, now today [their] renal function continues to decline, and [their] swelling has worsened significantly. The resident was admitted to the hospital with acute respiratory failure and acute kidney injury. According to a 10/14/2022 hospital Nephrology consultation, Resident 45 had acute kidney injury with chronic disease and Nephrotic Syndrome (a kidney disorder that caused the body to excrete too much protein). According to this Nephrology consult, the diuretic medication prescribed by the facility physician did not help control Resident 45's ongoing and worsening fluid overload. The kidney specialist prescribed a plan to use medication and fluids to remove the excess fluid from the resident's body and manage their recurrent critical electrolyte imbalance. Review of hospital documents showed on 11/05/2022 Resident 45 readmitted to the facility weighting 204 lbs.; a decrease in weight of 88 pounds in 23 days. According to the 11/12/2022 5 day Quarterly MDS, Resident 45 had diagnoses of acute respiratory failure and kidney disease. Resident 45 required extensive assistance with their bed mobility, transfers, walking, and toileting, which was a decline in function from the previous assessment. Resident 45 required oxygen therapy which was new for the resident. Resident 45 had a newly acquired Foley catheter (flexible tube inserted in the bladder to drain urine). Resident 45 weighed 229 pounds (lb.) and had a significant planned weight loss. The revised 09/23/2022 CP showed no new updates related to respiratory failure, oxygen, kidney disease, heart failure, edema, or daily weights. In an interview on 12/09/2022 at 3:45 PM with Staff B (Director of Nursing) and Staff KK (Corporate Clinical Nurse), Staff B stated they were not aware of the initial Nephrology referral ordered August of 2021. Staff B stated the process for referrals was the provider wrote a referral order and/or notified the nurse. The nurse notified transportation staff who would schedule the appointment and transportation. Staff B and Staff KK were not aware of transportation concerns or residents missing appointments due to transportation problems. Staff B stated, once referred, it was their expectation residents were evaluated by specialists as soon as possible, depending on the specialist availability. Staff B stated 15 months of repeated requests for referral was not an acceptable timeframe for Resident 45 to wait and other avenues should have been explored to obtain the referral but were not. Staff B stated they would call to other provider groups, get on cancellation lists, and do whatever it took to make sure the referring provider was aware of what the facility was doing to meet the residents' needs. Staff B stated if a resident had heart failure or problems with edema, their expectation was the resident would be weighed routinely according to the frequency ordered by the provider. Staff B expected nursing to monitor Resident 45's level of edema, skin condition, respiratory, and urinary status, and to document their findings and notify the provider as soon as possible of any changes or abnormalities identified. Staff B verified Resident 45 should have been seen by a specialist in a timely manner but was not. Staff B verified Resident 45 should have daily weights but did not. Staff B stated nursing staff should have notified and documented their communication to the provider when Resident 45's weight gain was outside the parameters of professional standards for fluid volume management and the provider's order, but they did not. In an interview on 12/13/2022 at 2:40 PM, Staff II (Physician) stated they were not aware of Resident 45's extent of referral requests for Nephrology because they didn't start seeing the patient until recently. Staff II stated they did not necessarily follow up with the nursing department management after daily weights were ordered for Resident 45 because they just expected to order it and it be done. Staff II stated there were some problems with transportation regarding Resident 45's appointments. Staff II stated they put orders for nephrology in the electronic ordering system and that is the process providers should be following. Staff II stated they will even print out the orders and deliver to the nurse on duty and provide a list of the residents seen for that day and orders to implement. REFERENCE: WAC 388-97-1060(1)(2)(a)(3)(i)(4). 44296

Based on interview and record review, the facility failed to administer [MEDICATION(S)] (a [CONDITION(S)] medication) according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed Resident 1 at significant risk for seizures and associated injuries. Resident 1 suffered a [CONDITION(S)] and required a transfer to the hospital, after missing doses of [MEDICATION(S)] (a [CONDITION(S)] medication) in a 3 day period. Findings included . Review of a 03/03/2022 hospital History and Physical in Resident 1's medical record showed the resident had a [CONDITION(S)] disorder, with the last [CONDITION(S)] on 12/27/2021. Review of a 03/09/2022 progress note showed Resident 1 admitted to the facility, was alert and oriented, and able to make their needs known to staff. A 03/9/2022 medical provider note showed Resident 1 admitted with complex medical diagnoses, to include a recent neck surgery and a history of seizures. This progress note showed Resident 1 was to continue with [MEDICATION(S)] and [MEDICATION(S)] (a [CONDITION(S)] medication). Review of Resident 1's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of this MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 03/09/2022 e-MAR (electronic MAR) note written at 10:26 PM showed, awaiting pharmacy supply. A 03/10/2022 at 12:29 PM e-MAR note showed, Not available, a 6:39 PM e-MAR note showed, None available, awaiting supply, and a 8:36 PM e-MAR note showed None in stock; awaiting pharmacy supply. Review of the medical record showed no documentation of the steps staff took to ensure Resident 1 received the [MEDICATION(S)] as scheduled when they identified the medication was not available for administration, like calling the pharmacy for availability. Review of the medical record showed no documentation the staff alerted the provider of the missed medication doses. On 03/18/2022 at 2:41 PM, a pharmacy collateral contact stated that the pharmacy notified the facility on 03/09/2022 at 9:30 PM via FAX and a phone call, of the pharmacy's concern with the high [MEDICATION(S)] dose, and the pharmacy's hold on supplying the medicine until the physician contacted the pharmacy to discuss the high dose. The Collateral Contact also stated that the pharmacy called the facility on 03/10/2022, and received no response from either the phone call message or faxes. Review of the medical record showed the facility was in receipt of a 03/10/2022 pharmacy fax that alerted the staff that the pharmacy must consult with the provider before dispensing the extremely too high, past the point of safety [MEDICATION(S)] dose. The fax showed no documentation staff acknowledged or acted upon the pharmacy alert. A 03/11/2022 9:14 AM e-MAR note showed that Resident 1 was a, new admit, [and the medicine] not available. A 03/11/2022 11:17 AM progress note showed that staff placed a call to the pharmacy to ask why the [MEDICATION(S)] was not delivered. This note showed that the pharmacy, sent memo to the facility with concern that [[MEDICATION(S)]] dose is too high, past the point of safety, and wanted consult with provider before dispensing the medications. Staff notified the provider who then reviewed the [MEDICATION(S)] dose. This note showed the provider would call the pharmacy to inform them to continue the orders for the [MEDICATION(S)] as written. A 03/11/2022 provider progress note showed, I was called today by nursing in relation to this patient. Patient has a history of seizures and is on multiple [CONDITION(S)] medicines. Patient also has chronic pain and some of these medications treat pain as well. The pharmacy did not send patients [MEDICATION(S)] because the dose is too high . I called [the] pharmacy and told them to send the [MEDICATION(S)] with the 1:00 PM delivery. It is not the role of pharmacy to just stop the medicine thus putting patient at risk for [CONDITION(S)] activity. Pharmacy will send patient's prescription today by 1:00 PM. Another 03/11/2022 note by the provider showed they acknowledged Resident 1 has not received [MEDICATION(S)] to be given twice daily. A 03/11/2022 progress note written by Staff C, Licensed Practical Nurse/Unit Manager (LPN/UM), showed that Resident 1, has been yelling and cursing at staff regarding the missing [MEDICATION(S)] doses although calls have been made to pharmacy in order to obtain medication. Writer informed the resident sternly to ensure point was made that there are 3 options, Resident can go to hospital and be medicated in the ER [emergency room ], resident can go AMA [Against Medical Advice] if unhappy with care in the facility, or resident could wait until pharmacy delivered the medication. This note showed that the staff called the pharmacy around 5:00 PM for an update on [MEDICATION(S)] and [pharmacy] reported medication would be delivered tonight. Resident was angry, aggressive and walking the hallways . DON [Director of Nursing] notified, physician notified, neurology notified. A 03/11/2022 progress note written by Staff B, DON, showed that Resident 1, was concerned that [they] hadn't received [their [MEDICATION(S)] as ordered. Staff B informed Resident 1 that if the resident were so concerned, that the facility could arrange for them to go to the hospital for treatment. Staff B assessed that Resident 1 had no signs or symptoms of [CONDITION(S)] activity and that Staff C raised their voice to get Resident 1's attention and explain to the resident that if they were really concerned that the facility could send them home or back to the hospital. Staff B informed Resident 1 that the facility had no control over pharmacy deliveries and [the] [MEDICATION(S)] would be delivered sometime today. Staff B wrote that Resident 1 told them that the unavailability of the [MEDICATION(S)] was the facility's problem and that the facility would be in trouble because we were somehow responsible for the pharmacy delivery. Staff B again informed Resident 1 of the options of either discharging home or return to the ER [emergency room ] if they were concerned. A 03/11/2022 provider note showed, I was called for [the] second time in relation to this patient. Patient was getting physical therapy and stopped talking and became unresponsive. Vital signs were unchanged and are stable. 911 was called and ER determined [Resident 1] had a [CONDITION(S)]. Review of 03/12/2022 progress notes showed that Resident 1 returned from the hospital at 12:05 AM. Resident 1 received 450 mg of [MEDICATION(S)] at the hospital, who also instructed the staff for the, Resident to continue taking [their] medications for [CONDITION(S)] as scheduled. An 11:34 AM progress note showed staff received a phone call from a doctor at the local hospital, who ordered the staff to administer one time doses of [MEDICATION(S)] and [MEDICATION(S)] as the resident did not receive [MEDICATION(S)] before going to hospital, and due to the recent [CONDITION(S)] episode. The hospital doctor also gave orders that modified the current [MEDICATION(S)] orders and kept the current [MEDICATION(S)] order. On 03/18/2022 at 11:31 AM, a Neurology Collateral Contact stated, Missing doses of [MEDICATION(S)] [[MEDICATION(S)]]? That's a big deal. Yes, it's a bit concerning, indeed. The Collateral Contact stated that because of [MEDICATION(S)]'s short half-life (the time it takes for the amount of a drug's active substance in the body to reduce by half), missing doses placed Resident 1 at significant risk for harm. On 03/21/2022 at 11:30 AM, in a joint interview with Staff C and D (LPN/UM), Staff D acknowledged the facility received the 03/10/2022 pharmacy fax that notified the facility a provider needed to consult with the pharmacy before the release of the high-dose [MEDICATION(S)]. Staff D stated, Typically the Charge Nurse followed-up on the faxes that come in, and that the Night Nurse must have placed the pharmacy fax in the Medical Records box, probably didn't know what to do with it, and Medical Records then scanned it into the electronic record, and staff were unaware. Staff D stated that if a medication is not available, the nurses must call whoever is on-call to procure it. Staff D attributed the medication error to a failure in communication between the facility and the doctor and that, We could've prevented a citation, if they [the nurses] would've said something. They need to speak up. They have a legal obligation. The above findings were shared with Staff A, Administrator, and Staff B on 03/18/2022 at 4:31 PM. Staff B stated that Resident 1, missed 3 days worth of [[MEDICATION(S)]] doses. Staff B stated that the facility identified that, We found we had an issue with some of the medication delivery and so we looked at our whole system. The Pharmacy did not send the medications. The nurses did not report it [the missing doses] until two days later when the nurse managers discovered the resident did not get it [[MEDICATION(S)]]. We did find deficient practice in our system honestly. On 03/21/2022 at 1:24 PM, Staff B clarified that the facility discovered Resident 1 missed the [MEDICATION(S)] doses when the resident told Staff D on 03/11/2022. When asked if offering Resident 1 the option to leave the facility AMA or as a planned discharge addressed the missing doses of [MEDICATION(S)], Staff A stated, No, it doesn't. A 03/14/2022 progress note showed that Resident 1 left the facility AMA. Resident 1 stated in an interview on 03/18/2022 at 12:07 PM, It was a horrible experience. I feel it was the worst experience. I didn't care when I left if I didn't even have pain medications. I walked out. It wasn't worth my life. Refer to F607, F655 and F684 Reference WAC 388-97-1060 (3)(k)(iii).

Based on interview and record review, the facility failed to identify the presence of, put interventions in place for management of, and provide accurate treatment with the Vagal Nerve Stimulator (VNS, an implantable device that prevents or decreases [CONDITION(S)] episodes) for 1 (Resident 1) of 8 residents reviewed for seizures. This failure caused Resident 1 to experience an adverse event, consequences associated with seizures, and subsequent hospitalization . Findings included . Review of the April 2020 VNS Therapy - Patient's Guide for [CONDITION(S)] showed that VNS therapy involves a small electrical device, like a pacemaker, which is implanted under the skin of a person's chest. It is designed specifically for people still living with seizures despite trying multiple medications. It is used as an add-on treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . VNS therapy helps reduce and makes seizures less severe. A person with a VNS implant is given a PATIENT INFORMATION CARD which shows the name of the person, the implantation date, generator and lead information, the physician and their contact number, and the model/serial numbers of the implant. The VNS implant has a battery inside that usually lasts a number of years. When the battery wears down, the generator will need to be replaced during a new procedure. The VNS implant can be set at different modes in an effort to prevent, stop, or shorten [CONDITION(S)] episodes. The VNS implant also has different types of programming which allows customization based on the person's lifestyle preferences or side effect management. VNS therapy can give an extra stimulation at the onset of and during a [CONDITION(S)] with the use of a small magnet. Each person who has a VNS implant is given a set of magnets. The VNS therapy magnet serves two functions, provide an extra dose of therapy on demand or temporarily suspend therapy to manage side effects during activities such as singing, public speaking or exercising. When a [CONDITION(S)] happens, the person feeling the [CONDITION(S)] or someone who sees it, can swipe the magnet over the VNS implant for less than two seconds. Each time the magnet is swiped this way, an extra burst of stimulation is given. This may help stop the [CONDITION(S)], make it shorter, less intense, or improve the recovery period following the [CONDITION(S)]. VNS implant carriers are taught to teach others how to use the magnet and make it a routine part of their [CONDITION(S)] first aid plans. When the magnet is held directly over the generator, the switch inside the generator is closed and stimulation will not be delivered. When the magnet is removed, the switch opens and the device is able to deliver stimulation. VNS implant carriers must always carry the magnet with them, available for use as soon as a [CONDITION(S)] occurs or to temporarily suspend therapy for side effect management. Two magnets are provided to VNS implant carriers, along with a wristband and a belt clip. When worn with the wristband, the magnet should be on the inside of the wrist. VNS therapy magnets must be kept at least 10 inches away from credit cards, televisions, computers, microwave ovens, or other magnets. If dropped, it can break if it falls on a hard surface. The magnet can be used more than once during a [CONDITION(S)]. The VNS therapy magnet is the only magnet that should be used with the VNS therapy system. Physicians must be contacted to get additional magnets. The most common side effects seen with stimulation of the VNS implant include hoarseness or change in speech pattern, cough, tightness or pain in the throat or neck area, difficulty swallowing, headache, and difficulty breathing. Other adverse events reported include ataxia (loss of the ability to coordinate muscular movement), indigestion, impaired sense of touch, [CONDITION(S)], pain, prickling of the skin, and vomiting. Therapy may also cause new onset sleep apnea (a sleep disorder in which breathing repeatedly stops and starts) in patients who have not previously been diagnosed with this disorder. A malfunction of the VNS therapy system could cause painful or direct current stimulation, which could result in nerve damage. The doctor must be notified if the person experiences troublesome or painful side effects from VNS therapy for an extended period of time. Patients should use the magnet to stop stimulation if they suspect a malfunction, and contact their physician immediately for further evaluation. On 03/18/2022 at 12:07 PM, Resident 1 stated that the VNS was placed right underneath the collar bone on the left side. Resident 1 stated that when they admitted to the facility, no one did a skin assessment and, I asked for the charge nurse or any nurse so I could teach them how to use the magnet in case I had a [CONDITION(S)]. Never once did they come in or get the nurse to come in to learn. I told them immediately. I lifted up my shirt, and told them what [the VNS] was. I asked them if they can get the other nurses to show them. They wouldn't even do that. On 03/18/2022 at 11:31 AM, a Neurology Collateral Contact stated that, Resident 1's VNS was active after the neck surgery. The Collateral Contact stated that the VNS was visible to others because Resident 1's body build was thin, the implant scar was visible in the upper left chest area, and the VNS is also palpable [can be touched] beneath the skin. [Resident 1] can point that out to others, and that's where magnet should be swiped should they have a [CONDITION(S)]. Review of a 03/03/2022 hospital History and Physical note showed Resident 1 had a [CONDITION(S)] disorder, with the last [CONDITION(S)] on 12/27/2021, and a history of a VNS implant surgery. A 03/09/2022 medical provider note showed Resident 1 admitted to the facility on [DATE] with complex medical diagnoses, to include a recent neck surgery and a history of seizures. This progress note showed Resident 1 had a past surgical history of a stimulator - VNS. Review of a 03/09/2022 progress note showed Resident 1 was alert and oriented and able to make their needs known to staff. This progress note showed Resident 1's skin was intact and no documentation staff assessed for or identified the presence of a VNS. Review of 03/09/2022 admission assessments completed by Staff C, Licensed Practical Nurse/Unit Manager (LPN/UM), showed no documentation staff identified the implant scar or the visible and palpable VNS. An unsigned 03/09/2022 Admission Skin Assessment showed the same. A 03/11/2022 progress note written by Staff B, Director of Nursing, showed, [Resident 1] has a vagal device for seizures that we were unaware of and needed guidance for its use. Staff B wrote that Resident 1 wanted to explain the use of the VNS to the staff and have the staff follow the resident's direction. Staff B wrote, [Resident 1] had no signs or symptoms of [CONDITION(S)] activity and the fact that we needed orders [for the VNS] was explained to [them] numerous times by numerous staff. The resident continued to shout in the hallway at this writer and [Staff C]. A 03/11/2022 progress note written by Staff C showed a call was placed to the neurologist, regarding resident's vagus nerve stimulator . Neurologist out of facility until Monday and unable to give orders until Monday [03/14/2022]. Staff C wrote that Resident 1 was unhappy with the resolve and Staff C told Resident 1 that they could leave the facility if unhappy with care in the facility. Staff C described, Resident was angry, aggressive, and walking the hallways. A 03/11/2022 6:13 PM progress note written by Staff K, Licensed Practical Nurse, showed that Resident 1, was having therapy in [their] room and had a small [CONDITION(S)]. Staff described Resident 1 was unresponsive and that they started to use a vagal device while another nurse was on the phone with the medic. Resident 1 was transferred to the local hospital for evaluation. On 03/22/2022 at 9:13 AM, Staff K stated that on 03/11/2022, it was the first time they were assigned to care for Resident 1. Staff K stated that when they found the resident lying in bed, they shook the resident, who was unresponsive. Staff K stated that they sought the help of another LPN, Staff J, while they notified the doctor. Staff K stated that they were not present when Staff J, LPN, used the vagal device during Resident 1's unresponsive episode. Staff K stated that they received no training on [CONDITION(S)] management or the role of a VNS and was assigned to Resident 1 on 03/11/2022, 03/12/2022 and 03/13/2022. On 03/22/2022 at 9:54 AM, Staff J stated that when they arrived at Resident 1's room on 03/11/2022, they found the resident in bed and breathing. Staff J stated that they were unfamiliar with Resident 1's medical background and care. Staff J was told by an aide that walked in the room that, if [Resident 1] became unresponsive there was like a magnet, you put it on the device on the left side of the chest. And that's what I did. I took the magnet and put it on the device [they] had in the chest. Staff J stated that they placed and maintained the magnet directly over the device on the left side of the chest until the medics arrived (an action that would turn off the VNS). Staff J stated that the vagal device was visible, like a pacemaker, under the resident's skin. I thought it was a pacemaker. I didn't know anything with this [vagal] device. Staff J stated that the aide told them where to find the magnet, it was inside the drawer of the bedside table. Staff J stated that they received no education on [CONDITION(S)] management or the role of VNS therapy in [CONDITION(S)] management. On 03/22/2022 at 2:38 PM, Staff L, LPN, stated that they were assigned to Resident 1's care on 03/11/2022 on night shift, when Resident 1 returned from the emergency room . Staff L stated, I've never worked with or seen it [VNS] before. When asked if they heard about the magnet therapy, Staff L stated, What do you mean magnet? Are they two different things [the magnet and the VNS]? I thought the VNS is the magnet you place on Resident 1's chest when they have a [CONDITION(S)]. Staff L stated that Staff M, LPN, told them to, Just pass it on top of [Resident 1], like run it randomly around their chest, and then they will wake up from the [CONDITION(S)]. Staff L stated that they received no training on [CONDITION(S)] management or the VNS. A 03/12/2022 11:34 AM progress note showed staff received a phone call from a doctor at the local hospital, who instructed the staff to Swipe [the] magnet across the implanted pacemaker to LT [left] clavicle [collar bone] in case of [CONDITION(S)] activity noted as needed. In a joint interview on 03/21/2022 at 11:35 AM with Staff C and Staff D (LPN/UM), Staff D stated that, Typically, I review the hospital records for a resident who comes in the building. I review the History and Physical and the Discharge Summary. Staff D stated that he took report from the hospital but did not recall a mention of the VNS. Staff D stated, The hospital didn't know it [VNS] existed because [Resident 1] had it in her purse. Staff C stated that they assessed Resident 1's skin integrity the day of admission, along with Staff D. Staff C related that Resident 1 lifted their shirt up, but did not observe the VNS scar location. Staff C stated that they became aware of the presence of the VNS on 03/11/2022, when Resident 1 told them that staff did not know about the VNS. Staff C stated that Resident 1 had the VNS locked in their purse. Staff C was asked to explain how an implant was locked inside a purse, if it was implanted under the skin. Staff C described the VNS as a small black box, and that Resident 1 told Staff C to place it over their left chest and that is when Staff C saw something sticking out like a pacemaker. On 03/21/2022 at 11:20 AM, Staff H, LPN, stated that they could not recall having any education on [CONDITION(S)] management and did not know what a VNS was. At 11:35 AM, both Staff C and D stated that they received no education on [CONDITION(S)] management and the role of a VNS. At 11:55 AM, Staff I, LPN, stated that they received no education on [CONDITION(S)] management or what a VNS was. Staff J, LPN, stated at 12:15 PM that they could not recall when they last had [CONDITION(S)] management education, and that a VNS was used by the therapy department on the patients. I've never heard about it. Review of the medical record showed no documentation the facility understood and identified the role of a VNS in [CONDITION(S)] management, to include side effects associated with VNS use, throughout Resident 1's stay in the facility. Review of the medical record showed no documentation the facility identified and developed interventions for the role of and appropriate use of magnet therapy for VNS side effect management or first aid use. A 03/14/2022 progress note showed Resident 1 left the facility Against Medical Advice. On 03/18/2022 at 12:07 PM, Resident 1 stated, I was upset. It was a horrible experience. I feel it was the worst experience. I didn't care when I left if I didn't even have pain medications. I walked out. It wasn't worth my life. The above findings were shared with Staff A, Administrator, and Staff B. No further information was provided. Refer to F607, F655 and F760 Reference WAC 388-97-1060 (1).

Based on observation, interview and record review, the facility failed to ensure two of four Residents (Residents 1 and 3) reviewed for insulin administration, were free from significant medication errors. This failure resulted in harm to Resident 1, who had insulin held when according to Nurse Practitioner (NP) orders should have been given, resulting in a life-threatening episode of [CONDITION(S)]. This failure also resulted in potential harm for Resident 3, and all other residents with diabetes, for complications related to the administration of insulin without prior blood sugar monitoring or when physician ordered parameters were not followed to hold insulin administration. Findings included . Resident 1 Review of a [DATE] admission nursing assessment showed that Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to professional nursing standards a blood sugar reading must be obtained prior to administration of insulin. The [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A [DATE] 9:00 PM progress note written by Staff E, Licensed Practical Nurse (LPN) showed that Resident 1's BS was 243 (within the administration parameter). Resident 1's daughter requested the insulin to be held, as the resident only ate 50% of dinner. Review of the [DATE] progress note from Staff E showed, that the insulin was held per the daughter's request, but the Nurse Practitioner (NP) was not consulted or that orders to hold the insulin were provided. In an electronic correspondence on [DATE] at 4:48 PM, Staff A, Administrator, stated she was, unsure why the nurse took instructions to hold insulin from the daughter and it should be a consultation with the physician. Review of a [DATE] 1:51 AM nurse progress note subsequently showed that Resident 1 had a BS level of 480 at 1:40 AM with signs of [CONDITION(S)] (high blood sugar); the resident was very thirsty and asking for ice chips and insulin. The NP was contacted and no orders for insulin were provided, only orders to increase Resident 1's oral water intake. The progress note did not indicate if the NP was informed that the previous insulin was held. The [DATE] 6:49 AM progress note showed, the last blood sugar was taken at 5:45 [AM] was 500 and reported to the oncoming nurse and follow up from there. A [DATE] 8:25 AM progress note written by Staff F, LPN, showed that the NP was contacted for high blood sugar and Staff F received orders for insulin one time only. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] progress notes showed no documentation of nurse follow up or assessment after the insulins were given, including no follow up BS monitoring. The [DATE] 10:54 AM progress note showed that an (unidentified) nursing assistant called Staff F to Resident 1's room at 9:40 AM. Resident 1 was found not breathing and without a heartbeat. Cardiopulmonary Resuscitation (CPR) was intiated and 911 was called. The paramedics were unable to revive the resident, and Resident 1 was pronounced dead. Resident 3 Upon observation and interview on [DATE] at 3:46 PM, Resident 3 stated the nurses check my blood sugar every day and always give me insulin. Review of a [DATE] quarterly minimum data set (MDS, an assessment tool) showed Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a [DATE] 12:00 AM progress note from the NP showed Type 2 Diabetes Mellitus, uncontrolled [difficult to treat]. Hold insulin before meals if blood sugar is less than 100 and notify provider, continue monitoring blood sugars as ordered. Review of [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of the medical record showed no documentation that staff monitored Resident 3 after the insulin was given. In an interview on [DATE] at 2:50 PM, Staff D, Assistant Director of Nursing, confirmed that insulin should have been held for Resident 3 if the blood sugar was below 100. In a phone call on [DATE] at 4:15 PM, the findings were shared at the exit conference with Staff A, Staff B, LPN, and Staff D. The three staff acknowledged the findings without any further questions. Refer to F726 Reference WAC [DATE](3)(k)(iii).

Based on interview and record review, the facility failed to check the blood sugar and administer insulin as ordered by the physician for two of four residents (Residents 1 and 2) reviewed for medication administration. These failures resulted in harm to Resident 1, who did not have blood sugar monitoring for 27 hours and experienced a life-threatening hypoglycemic (low blood sugar) incident that required paramedic response. Resident 1 also experienced an incident of not receiving scheduled insulin that resulted in a hyperglycemic (high blood sugar) episode requiring medical treatment. These failures also placed Resident 2 at risk for unmet diabetic care needs and risk of blood sugar imbalance. The failure of not having a system in place to ensure professional standards of quality in diabetic management placed all residents with diabetes at risk for potential unmet needs and life-threatening incidents. Findings included . Resident 1 Review of a 03/28/2021 admission nursing assessment showed that Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 03/28/2021 admission care plan showed no interventions that included staff monitoring Resident 1 for signs of [CONDITION(S)] or [CONDITION(S)]. Review of the March 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's blood sugar monitoring record from 03/29/2021 at 7:30 AM, to 03/30/2021 at 11:10 AM, showed no blood sugar results documented, a 27-hour time span without nurse staff monitoring blood sugar levels, as instructed by the NP. On the same date of 03/30/2021 at 4:45 PM, a progress note from Staff E, Licensed Practical Nurse (LPN) showed that Resident 1 was in bed when the nursing assistant found the resident unresponsive, and three nurses rushed to check on the resident. Staff E assessed Resident 1 with shallow respirations, and a blood sugar of 25 (dangerously low). Upon arrival of the paramedics, intravenous (IV - by vein) [MEDICATION(S)] (medication to raise blood sugar) was administered three times before Resident 1 started to wake up and respond. Staff failure to monitor Resident 1's blood sugar resulted in a life-threatening episode of [CONDITION(S)], with loss of consciousness, and required emergency intervention with administration of IV medication. In an electronic correspondence interview on 04/13/2021 at 4:11 PM, Staff A, Administrator, stated the facility was unable to find blood sugar records for Resident 1 on 03/29/2021 (7:30 AM, 11:30 AM, 4:30 PM) and 03/30/2021 (7:30 AM), because they were not documented. Review of the 04/13/2021 investigation timeline for Resident 1, confirmed there was no record of blood sugar monitoring for 03/29/2021 at 7:30 AM, 03/29/2021 at 11:30 AM or 03/30/2021 at 7:30 AM. Staff A also stated, If not recorded, then not done. The March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Professional nursing standards allow for medication administration to occur one hour before and one hour after the scheduled medication time. In both instances the 03/30/2021 insulin at 7:30 AM, before breakfast and 11:30 AM, before lunch was given at incorrect times, resulting in a medication error. Review of a 03/31/2021, 1:51 AM, the night shfit nurse progress note stated, [Resident 1] around 1:40 AM started complaining of increased thirst and asked this [nurse] to give her ice chips and insulin. [The nurse] checked [the resident's] blood sugar, it [was] 480, no other s/s [signs/symptoms] of [CONDITION(S)] reported by the resident. Call made to the on call NP who ordered staff to push fluids [water by mouth] to resident, no orders received for insulin. Per the 03/28/2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was an episode of [CONDITION(S)] as a result of Staff E, incorrectly holding scheduled 03/30/2021 9:00 PM insulin without contacting the NP for instructions, thus made a medication error. In an interview on 04/15/2021 at 2:50 PM, Staff D, Assistant Director of Nursing (ADON), stated competency evaluations would include medication pass observation, parameters on holding insulin, and notification of physician. Staff D, a nurse, stated he started working at the facility a few months ago and had not received a skills competency evaluation when hired. Staff D stated that the competency evaluation should have been completed when a nurse was hired and on an annual basis. In a 04/13/2021 at 3:54 PM electronic correspondence, Staff A stated that there were no records of evaluation of staff competency or skill set for the sample of four nurses (Staff C, D, E and F). Staff A stated that nurse competency evaluations had not been completed for the past three years. Resident 2 Review of a 03/31/2021 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue to monitor sugars before injecting insulin. Continue to monitor for any symptoms of [CONDITION(S)] and [CONDITION(S)]. Review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 03/02/2021 at 7:00 PM, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current electronic care plan dated 4/14/2021 showed Resident 2 was admitted to the facility on [DATE] and, eight months after the admission, and there were no interventions directing staff to monitor Resident 2 for signs of [CONDITION(S)] or [CONDITION(S)]. Review of the March 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/15/2021, Resident 2's care plan was revised by the facility and included a diabetic management plan and provided with the investigation documents. In an interview on 04/15/2021 at 2:50 PM, Staff D, stated that insulin should not be given to Resident 2 until a blood sugar was checked first. Staff D stated, the care plans were completed on the day of admission, by the admission nurse. Staff D stated he would expect to see diabetic monitoring on the care plan of all residents with diabetes, including Resident 1 and Resident 2. In a phone call on 04/15/2021 at 4:15 PM, the findings were shared at the exit conference with Staff A, Staff, B and Staff, D. Refer to F760 Reference WAC 388-97-1080(1).

Based on interview and record review, the facility failed to provide sufficient food and fluids to meet the hydration and nutritional needs for 1 of 1 resident reviewed (Resident 1). The facility failed to provide six consecutive meals to Resident 1 after she admitted to the facility. This caused harm to Resident 1 who experienced a five pound (lb) weight (wt) loss, was diagnosed with [REDACTED]. Findings included . Record review of the facility's undated procedure titled, admission orders [REDACTED]. RESIDENT 1 A 02/26/2021 3:06 PM nurses note, indicated Resident 1 had just admitted to the facility and was resting comfortably in bed. Review of Resident 1's hospital transfer/discharge paperwork showed she had [DIAGNOSES REDACTED]. Review of the 02/26/2021 admission orders [REDACTED]. The resident is assisted to eat as much as he or she wants. Meal assistance is stopped if the resident starts to choke or becomes agitated. The diet order did not include what type of diet (e.g. Regular, Diabetic) was to be provided or what texture. Review of the facility's February and March 2021 meal monitor, showed Resident 1 had no food or fluid intake on 02/26/2021, 02/27/2021 or 02/28/2021. For each meal facility staff documented Not Applicable. A 02/28/2021 9:24 PM nurse's note, indicated Staff C, Registered Nurse, was notified by a nurse's aide that Resident 1 did not receive a dinner tray. Staff C contacted the dietary department, and was informed the kitchen did not receive a diet order for the resident. Staff C then notified the on-call practitioner and obtained orders for a regular diet, pureed texture and nectar thick liquids. Record review confirmed the first diet slip (form used to communicate diet orders to the dietary department) was initiated on 02/28/2021 by Staff C. A 02/28/2021 11:14 PM provider note by Staff D, Advanced Practice Nurse Practitioner, showed she was informed Resident 1 did not receive food or fluids, other than with medications, for two days. After reviewing Resident 1's clinical record and vital signs, Staff D determined obtaining venous access for a intravenous infusion was unlikely due to dehydration. Staff D subsequently ordered one Liter of normal saline to be infused via hypodermoclysis (a small gauge needle inserted under the skin into subcutaneous tissue). Review of the facility's 02/28/2021 investigation showed the facility determined Resident 1 had lost five pounds since admission to the facility. On 02/26/2021 the residents wt was 154.2 lbs. On 03/03/21 her wt was 148.8 lbs. During an interview on 03/16/21 at 3:37 PM, Staff A, Administrator, and Staff B, Director of Nursing, acknowledgd the facility's failure to communicate Resident 1's diet orders to the kitchen, and staffs' failure to identify that meals were not provided, until six had been missed, resulted in Resident 1's experiencing weight loss, dehydration, and an avoidable invasive procedure (hypodermoclysis.) REFERENCE: WAC 388-97-1100(1).

Based on observation, interview and record review, the facility failed to operationalize all components of the infection prevention and control program to provide a safe, sanitary environment to help prevent the transmission and control the spread of COVID-19, a highly transmissible infectious disease caused by [MEDICAL CONDITION]. The facility failed to communicate, and implement a system that ensured all staff, vendors, and visitors were screened for COVID-19 prior to being allowed access to resident care areas. Additionally, the facility failed to consistently utilize Personal Protective Equipment (PPE) in accordance with federal and state regulations, and facility policy and procedure. The failure to implement interventions to mitigate the risk of spread of COVID-19, by screening all individuals upon entering, and failure to ensure consistent use of PPE, increased the likelihood of serious harm or death to the residents related to increased exposure of residents and staff to COVID-19, a highly transmissible infectious disease. The facility was determined to be in Immediate Jeopardy (IJ) from 12/12/2020 at 5:00 PM, when staff were observed entering through a back door, directly into a resident care area, without being screened as required. The IJ was removed on 12/15/2020 when the facility's IJ removal plan was accepted/validated. Findings included . Review of the CMS April 02, 2020 guidance titled, COVID-19 Long-Term Care Facility Guidance showed the following direction: 1) Long-term care facilities should immediately implement symptom screening for all. 2) In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers, vendors, etc.) should be asked about COVID-19 symptoms and they must also have their temperature checked. 3) Facilities should limit access points and ensure that all accessible entrances have a screening station. An 08/04/2020 CORNERSTONE COVID-19 INTERIM INFECTION PREVENTION AND CONTROL GUIDANCE . policy stated, The facilities have limited access points to the buildings and are ensuring that there is a screening station at all entrances. Facility staff are required to sign an attestation regarding the presence of signs/symptoms of Covid -19 and document their temperature in the presence of another staff member/designee who will validate that all information has been entered, is accurate and meets criteria for entrance. STAFF SCREENING According to a 12/12/2020 9:32 AM email, a DOH representative was onsite at the facility on 12/11/2020 and made the following PPE recommendations: While supplies last, don gown and gloves at resident door when entering, doff gown and gloves at door when exiting, and perform hand hygiene. Keep face shield and N95 (respirator) on at all times. After being let in the front door 12/12/2020 at 1:45 PM, by Staff O, Licensed Practical Nurse (LPN), she directed surveyor to a screening table located on the right side of the lobby. At the screening table hand hygiene was performed, temperature checked, and a COVID-19 screening questionnaire was completed. After reviewing the questionaire, Staff O explained the facility's current PPE requirements were to wear a N95 mask and face shield at all times in resident care areas. If entering a resident room, a gown and gloves were also required. When asked how many entrances staff or visitors could enter through Staff O stated there were two. One entrance for the green (COVID free) unit, and one entrance for the red (COVID-19 positive) unit, to prevent cross contamination. Staff O then explained each unit had dedicated staff. On 12/12/2020 at 2:14 PM, an unidentified staff member opened the back door to the red unit (by room [ROOM NUMBER]) and let Staff Q, Certified Nursing Assistant (CNA), enter the building directly into a resident area, without being screened first. Staff Q proceeded to enter the conference room across from room [ROOM NUMBER], Staff N (CNA), Staff P (LPN), and Staff R (LPN) were also noted to be in the room. Staff Q placed her personal items down, conversed briefly with a co-worker, removed her face covering and applied a N95. When Staff Q was approached several minutes later and asked which door staff should enter through (before Staff Q could respond) Staff R intervened and directed Staff Q to put on a face shield, and follow her to the front lobby to be screened. Staff R then led Staff Q through the hallways to the lobby. On 12/12/2020 at 2:33 PM Staff S, Human Resources/Administrator in Training, stated she was in the building representing Staff L Administrator. When asked about entry points to the building Staff S stated all individuals should enter the building (Red unit) through the front door and get screened for COVID-19, prior to entering resident care areas. When informed that Staff Q was let into the building through the back door, Staff S indicated up until yesterday (12/11/20) staff entered and were screened at the back door, but the the Red and Green units were rearranged to accomadate the increased COVID-19 + population. At that time, the entrance was changed to the front. Staff S confirmed there was no screening area at the back door, where Staff Q had entered. On 12/12/2020 at 2:37 PM, Staff S indicated the change from entering through the back door to entering only through the front door may not have been communicated to all staff. Observation of postings on the outside of the back door showed a sign that stated Please be patient, care in progress. There was no signage or direction to staff indicating the entrance door had changed. During a telephone interview on 12/12/2020 at 2:43 PM, Staff L, Administrator, stated, That (back door) shouldn't be an entrance. Staff L acknowledged the change was not communicated effectively, which resulted in some staff going to the back door, and being let in without screening. PERSONAL PROTECTIVE EQUIPMENT On 12/12/2020 at 2:43 PM, Staff Q was observed standing in the hallway without a face shield. On 12/12/2020 at 3:03 PM Staff P, LPN, and Staff R, LPN, were observed at the nurses station without face shields. On 12/12/2020 at 3:07 Staff R, LPN, walked from the nurses station (by front lobby) to the conference room by the back door without a face shield. In an interview at that time, when queried about when staff should wear their face shields Staff S stated, At all times .I forgot mine in here. During a telephone interview on 12/12/2020 at 2:43 PM, Staff L, Administrator, stated that it was the expectation that staff wore N95 masks and face shields at all times. On 12/12/2020 at 12:11 PM Staff P, LPN, entered room [ROOM NUMBER]-2. Upon exiting Staff P removed her gown at the door, rolled it up, and then carried it down the hall to dispose of it in an overflowing un-lidded bin, located outside the conference room. Staff P then entered the conference room and performed hand hygiene. During an interview at that time, Staff P stated she was instructed by a DOH representative the day before (12/11/2020), to remove her gown and gloves at the resident's door, discard them, then perform hand hygiene and exit. Staff P indicated she was unable to discard her gown because there was no trash can by the door and added (DOH) told the facility they needed to buy more trash cans. REFERENCE: WAC 388-07-1320(1)(a)(c) Z

Based on observation, interview, and record review, the facility failed to ensure a safe resident environment was maintained, free of accident hazards, for two (#s 1 & 3) of three residents reviewed for accidents. The facility failed to implement a system which assessed residents' ability to safely handle hot beverages, or a system to check the temperatures of hot beverages prior to serving residents from the kitchen or after being microwaved by floor staff. These failures resulted in harm to Resident #3, who sustained a second degree burn to his right thigh, after spilling coffee in his lap. Additionally, the facility failed to ensure glass slats in a window were secured in place, and inaccessible for resident removal and failed to implement planned interventions for Resident #1 to prevent accidents. These failures placed residents at risk for accidents and injury. Findings included . Refer to CFR: 483.12 (c)(2)(3), F-610, Investigate/prevent/correct Alleged Violations According to the facility's January 2018 Hot Food and Beverage Safety policy and procedure (P&P), staff were directed to: 1) Attend residents at risk for hot food injury when serving hot food or beverages; 2) Disperse heat or chill as appropriate .add appropriate liquid or ice per resident preferences.; 3) Do not exceed hot food or beverage temperature of 190 degrees Fahrenheit (dF) on the serving line .; 4) Monitor and record beverage serving temperatures prior to meal service using Food Temperature Record.; 5) Hot Food/Beverage Spill Quickly cool area with cold water and pull clothing away from the skin to prevent penetration of a thermal injury. Notify a licensed nurse to check the resident. According to the facility's January 2018 Microwave: Heating Food P&P, staff were directed to Heat food or beverages in the microwave and follow safe guidelines for heating and transporting. a) Monitor food continuously while heating to avoid overheating. b) Stir food at intervals to heat evenly. c) Prior to use sanitize thermometer, ensure internal temperature reaches 165 dF for a minimum of 15 seconds. Food exceeding 190 dF should not be served to resident. If the heated food (or beverage) exceeds 190 dF .DO NOT SERVE IT TO RESIDENT UNTIL COOLED. According to the Centers for Disease Control (CDC) Time and Temperature Relationship to [MEDICAL CONDITION], dated March 14th, 2014, the time required for a third degree burn to occur, is as follows: water temperature of 155 dF = one second; 148 dF = two seconds; 140 dF = five seconds; 133 dF =15 seconds; 127 dF one minute. RESIDENT #3 Resident #3 admitted to the facility on [DATE]. According to the 08/03/2020 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact, had [DIAGNOSES REDACTED]. Review of Resident #3's 05/08/2020 History and Physical (H&P), showed the resident was involved in a 1975 motor vehicle accident (MVA), sustained a T7 (location along the spine) spinal cord injury with subsequent [MEDICAL CONDITION]. Additionally, all fingers on Resident #3's right hand were amputated, and digits 3-5 on his left hand were assessed to be contracted. (Permanent shortening of tissue, such as muscle, tendon or skin, as a result of disuse, injury or disease. Contracture leads to the inability to straighten joints fully and to permanent deformity and disability.) A 10/21/2020 12:21 AM nurse's note stated Resident #3 spilled coffee in his lap, resulting in a burn to his right thigh with multiple blisters and a large open area . A 10/21/2020 Skin Grid Weekly Skin Evaluation showed Resident #3 had a 15.5 centimeter (cm) by 23 cm by 0.1 cm burn to the right proximal thigh, with scant serous drainage. According to the 10/21/2020 investigative documents, on 10/20/2020 at around 8:00 PM the licensed nurse was notified that Resident #3 had a reddened area on the right inner thigh with blisters present. While the nurse was inspecting the area, Resident #3 reported he spilled coffee on himself sometime after lunch, but before dinner, but was unable to give a specific time. The nurse observed the burn and estimated it to be six inches long and three inches wide (Resident #3 refused measurements) with multiple blisters and one large open area on the outermost part of the burn. The day shift Certified Nursing Assistant (CNA) on 10/20/2020, Staff K, reported she brought Resident #3 a new cup of coffee at 12:50 PM, as the resident did not drink the first cup of coffee that came with lunch because it had sugar in it. Staff K stated that she returned to Resident #3 at 1:30 PM and performed a check and change. At that time Resident #3 had not spilled his coffee. The evening shift CNA for Resident #3 on 10/20/2020, Staff D, stated at 3:00 PM she observed Resident #3 had a coffee stain on his top sheet, but when Staff D offered to change his linen, Resident #3 refused. Staff D then stated she notified the nurse. Record review showed no indication the nurse went to assess the resident for a potential burn or to address why he was refusing care until around 8:00 PM approximately five hours later. During an interview on 10/29/2020 at 12:20 PM, when asked what action she would expect a nurse to take if notified that a resident had spilled coffee in their lap and was refusing care Staff B, Director of Nursing, stated that the nurse should immediately go and assess (the resident). When asked if she had determined when Staff D, CNA, reported the coffee spill and refusal of care to the nurse, and what action the nurse took when informed Staff B stated, I don't know, and acknowledged there was no indication the nurse attempted to determine why Resident #3 refused care or attempted to assess the resident for a potential burn until around 8:00 PM, approximately five hours later. HOT BEVERAGE SCREENING According to the Hot Food and Beverage Safety P&P, staff were directed to Attend residents at risk for hot food injury when serving hot food or beverages. Review of facility nursing assessments on 11/02/2020 showed no indication Resident #3 had been assessed upon admit, or periodically thereafter, to determine his ability to safely manage hot beverages. Review of Resident #3's comprehensive care plan (CP) showed the resident had contractures to digits 3-5 on his left hand, and that he previously had all fingers amputated on his Right hand. However, the CP failed to address what effect those limitations had, if any, on the resident's ability to safely handle hot beverages. The comprehensive CP also failed to identify or give any direction to staff, as to how much assistance Resident #3 required with meals. During an interview on 10/29/2020 at 12:20 PM, when asked if the facility had a system to assess residents for safety with handling of hot beverages Staff B indicated the facility did not. On 11/30/2020, 12/03/2020, and 12/04/2020 Staff B was asked (via email and telephone) how staff knew which residents were at risk for hot food or beverage injury, so they could Attend to those residents when serving hot beverages, as directed by the facility hot beverage policy? No reply was provided. On 12/09/2020 at 3:33 PM Staff L, Administrator (New Administrator), acknowledged Resident #3's comprehensive CP failed to address whether the resident required assistance with meals or could handle hot beverages safely. Staff L then acknowledged There is no effective system in place. HEATING FOOD/BEVERAGES IN THE MICROWAVE In an interview with Resident #3 on 10/29/2020 at 11:43 AM, when asked how he burned his leg, Resident #3 stated, I am not sure really what happened, when you bump the (overbed table) it shimmeys, (causing the cup to slide) because they are at a slight angle, it just fell .maybe I bumped it (cup) I don't know I know what they did . they microwaved it .I can't prove they microwaved it because I was right here, but it was hot . so I put it down to wait awhile. I am sure I bumped (the table or the cup itself) it and it fell right here. Resident #3 motioned toward his right thigh. In an interview on 10/29/2020 at 1:24 PM, when asked what she would do if a resident requested their meal or coffee be heated up Staff E, Licensed Practical Nurse, stated she would .go to the microwave in the break room and warm it up. When asked what temperature the coffee should be Staff E stated, I don't know .a little steam coming off the top. When asked if she could show where she obtained the thermometer to check the temperature Staff E stated, I don't know where one is in the break room, and acknowledged she did not check the temperature of the food/beverages she microwaved. In an interview on 10/29/2020 at 1:38 PM, when asked about heating up food/beverages for residents Staff F, CNA, stated, Oh ya, all the time and indicated he uses the microwave in the break room. When asked how hot the food or coffee should be Staff F stated, not sure. When asked if he could show where he obtained the thermometer to check the temperature of the heated item Staff F stated, No, and acknowledged he does not check the temperature of the food/beverages he heats for residents. In an interview on 10/29/2020 at 12:20 PM, when asked what the facility policy was for reheating food and beverages Staff B stated she did not know. When asked how her staff would know what the expectation was, if she didn't know herself Staff B stated, (That is) a fair question. HOT BEVERAGE TEMPERATURES In an interview on 10/29/2020 at 12:00 PM Staff G, Dietary Service Manager (DSM), explained kitchen staff checked the temperature of hot beverages prior to leaving the kitchen. When asked what the company policy was for temperature ranges on hot beverages Staff G stated, Not above 151 dF and not below 140 dF. However, according to the facility's Hot Food and Beverage policy, hot food and beverages should not exceed a temperature of 190 dF on the serving line. No further direction was given related serving temperatures. Review of the kitchen temperature logs showed there was space for one Hot beverage temperature to be recorded per meal. Review of the 15 days (10/05/2020 to 10/19/2020) preceding the 10/20/2020 incident showed, of the 45 potential entries: 28 times the temperature was greater than or equal to 190 dF; Seven times the temperature was between 187 and 189 dF; three times it was between 150-155 dF; and on seven occasions no temperature was recorded. During an interview on 10/30/2020 at 12:21 PM Staff I, Registered Dietician (RD) explained that she was in the building on 10/21/2020 (the day after the incident) and reviewed the facility's process for checking the temperatures of hot beverages. Staff I stated I understand it (coffee) is temp' d when it comes out of the machine (coffee pot) and (then) again (prior to leaving the kitchen) before it is recorded. Staff I then acknowledged it was her expectation that hot beverages be temp' d before leaving the kitchen for service. When asked if that was actually happening in practice Staff I stated, No. When asked about the facility policy that hot beverages should be less than 190 dF Staff I stated, .I would say 190 dF would be extremely hot for this population. Review of the hot beverage temperature log for 10/20/2020 (the day of the incident) showed at breakfast, the temperature was recorded as 194 dF, but someone had clearly altered the document, and wrote 159 dF over it. During an interview on 10/30/2020 at 11:41 AM, when asked why the 10/20/2020 recorded temperature of 194 dF had been altered Staff G stated she had altered it, and explained the 194 dF was the temperature (of the coffee) while still in the coffee pot . so she re-checked the temperature right before the beverages went out for service, then recorded there 59 dF over the 194 dF that was prior recorded. Review of the temperatures from 10/05/2020 through 10/19/2020 showed, no other temperatures had been altered, just the one on the morning of the incident. In an interview on 11/03/2020 at 11:04 AM, when asked if she altered the temperature log on the morning of 10/20/2020 in real time, or if it was done after the fact Staff G stated, I don't remember. Staff G then explained in March 2020 when she was hired, she identified kitchen staff were recording the coffee pot temperature, instead of the temperature of the coffee in the serving container before it left the kitchen. When asked why she had not taken action to correct the issue, if she had been aware of it for seven months Staff G stated, My mistake. The investigation concluded, Coffee temps leaving kitchen were evaluated and within appropriate range (151-159). On 11/03/2020 at 2:13 PM, Staff B was asked if she had reviewed any day on the temperature log other 10/20/2020. Staff B stated, No. When asked if she was aware that Staff B 35 of 45 recorded temperatures between 10/05/2020 and 10/19/2020 were 187 dF or higher. Staff B stated, No. When asked if she identified the temperature on 10/20/2020 had been altered from 194 dF to 159 dF Staff B stated, No. Additionally, Staff B, Director of Nursing, identified the acceptable hot beverage temperature range as 151-159 dF, Staff G, Dietary Service Manager, identified it as 140-151 dF, and the actual policy states less than or equal to 190 dF. Demonstrating the facility had not implemented a functional system which ensured residents were provided hot beverages at safe temperatures. No matter which temperature range (of the three different ones provided) is used, the facility failed to adhere to it, as evidenced by 28 of 45 hot beverage temperatures recorded in the two weeks prior to the incident, were 190 dF or greater, and no corrective action taken. According to staff statements obtained during the facility investigation it was determined: Staff K, CNA delivered a cup of coffee to Resident #3 at 12:50 PM. Staff K returned at 1:30 PM and cleaned and changed the resident. No coffee had been spilled at that time. At 3:00 PM Staff O, CNA, observed coffee stains on Resident #3's top sheet over his lap. This established that the coffee spill and subsequent second degree burn, occurred between 1:30 PM and 3:00 PM. During an interview on 11/03/2020 at 2:13 PM,Staff B acknowledged the coffee spill must have occurred between 1:30 pm and 3:00 PM When asked if it was reasonable to conclude the coffee delivered by Staff K at 12:50 PM was still hot enough, if spilled, to cause a large second burn to Resident #3's thigh 40 minutes to 2 hours after it was delivered, or if it was more plausable that a staff member brought a new cup of coffee or microwaved the old cup of coffee, which subsequently, when spilled, resulted in a second degree burn. Staff B stated it was likely Resident #3 was provided another cup of coffee or someone reheated it. When asked if she interviewed other staff on duty to determine if another staff member, other than the assigned CNA, provided the coffee to Resident #3 Staff B stated, No. The facility's failure to assess the residents' ability to manage hot beverages, given his identified functional deficits, failure to determine the amount of assistance Resident #3 required with meals, and failure to implement a system which ensured hot beverages were served to residents at a safe temperatures, resulted in harm to Resident #3. RESIDENT #1 Resident #1 admitted to the facility on [DATE]. According to the 10/26/2020 Annual Minimum Data Set (MDS, an assessment tool) the resident had severe cognitive impairment, [DIAGNOSES REDACTED]. According to the October 2020 Incident Log, Resident #1 was involved in an incident on 10/02/2020. The nature of occurrence was listed as other. Review of the 10/02/2020 investigation showed, under Incident description staff documented Resident #1 was noted with a large piece of rectangular glass, which she brought to the nurses station and refused to give up. The investigation later determined the glass slat was removed from the jalousie window located at the end of the hall. (A Jalousie window is composed of parallel glass slats joined onto a track so they may be tilted open and shut in unison, similar to levolor blinds). Resident #1, accessed the window unsupervised, and pulled an approximately 3 foot long and 6 inch wide unsecured glass slat from the window. Review of Resident #1's comprehensive care plan (CP) showed: An elopement CP, revised 08/12/2020, that stated, When resident is actively exit seeking, she must be placed on an immediate 1:1 (one to one); and a Resident was verbally and physically abusive towards (another resident) CP, revised 08/12/2020, that directed staff to Place on 1:1 monitor when aggressive behavior noted during e(vening) shift. Record review showed a 10/02/2020 shower refusal sheet,initiated by Staff N, Certified Nursing Assistant (CNA) that identified Resident #1 was In very agitated mood. this form was co-signed by Staff M, Registered Nurse (RN). Similarly, a 10/02/2020 11:26 PM nurses note, authored by Staff M, RN, stated, After dinner, resident noted to have very aggressive behavior, pacing in the hallway, redirected many times, didn't listen to anybody . Although, both Staff M and Staff N were aware of, and documented Resident #1's marked agitation, facility staff failed to implement the planned intervention of Place on 1:1 monitor when aggressive behavior noted during e(vening) shift. The failure to provide increased supervision, as the resident was assessed to require, resulted in Resident #1 having unsupervised access to the Jalousie window at the end of the hall. Additionally, the facility failed to provide a environment free of accident hazards, as evidenced by having unsecured glass slats, accessible to residents. Reference (WAC): 388-97-1060(3)(g)

Based on interview and record review the facility failed to protect Resident #1 from further abuse when Staff (D), left the resident in the room after witnessing a physical assault by the alleged perpetrator (Staff C). In addition, the facility failed to thoroughly investigate incidents of potential abuse of four (#s 1, 2, 4 & 9) of five residents reviewed for abuse; substantial injuries to Resident #1 & #2, and allegations of abuse to Residents #4 & #9. Additionally, the facility failed to ensure staff were trained and demonstrated understanding of when and how to identify, react or handle abusive situations. These failures prevented the facility from determining the extent to which incidents were related to abuse and/or neglect and placed all residents at risk for being abused and/or neglected. These failed practices resulted in an Immediate Jeopardy on 06/04/2020. Findings included . Refer to: CFR 483.12(a)(1), F-600, Free From Abuse and Neglect CFR 483.12(c)(1)(4), F-609, Timeframe: Abuse Reported to Administration / State Agency The undated facility, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source , policy included, When allegations that meet the definition of abuse, neglect .including injuries of unknown source .the center shall: Thoroughly investigate all alleged violations and retain documents showing that all alleged violations are thoroughly investigated .Prevent further potential abuse .while the investigation is in progress . In addition, the undated facility Prevention and Reporting: Resident Mistreatment, Neglect, Abuse . policy showed the center shall, Provide Annual training for all staff who provide care and service with ongoing training programs .Provide training for all new employees .through/during orientation .How to provide protection .Require center staff, which included's employees, consultants, contractors .Provide for the immediate safety of the resident upon identification of potential abuse . RESIDENT #1 According to the 03/12/2020 Quarterly Minimum Data Set, (MDS, an assessment tool), Resident #1 exhibited unclear speech patterns, was cognitively impaired and unable to make decisions, experienced disorganized or incoherent thinking and other behavioral problems not directed toward others, required one person physical assistance for activities of daily living, and had [DIAGNOSES REDACTED].#1's clinical record a [DIAGNOSES REDACTED]. Review of the 03/27/2020 Care Plan showed Resident #1 required one-on-one care. PHYSICAL ABUSE Review of a 05/30/2020 facility incident investigation showed, staff to resident abuse was reported to Staff H, Licensed Practical Nurse (LPN) by Staff E, housekeeper. Staff C, Certified Nursing Assistant (CNA), slapped Resident #1 on the left side of his face two times. The information was given to Staff E, by eyewitness Staff D, Housekeeper. Staff H went directly to Staff D, who was in the break room, to confirm the information. Staff D then reported that she was in the room cleaning when she saw Staff C slap the resident two times across the face. Staff D stated that she walked over to Staff C and said, I saw what you did. Stop. Staff D left the room, reported the incident to her co-worker, Staff E. After interviewing Staff D, Staff H went to Resident #1's room, and removed Resident #1 from Staff C's care. Staff B, in an interview on 06/01/2020 at 2:45 PM, reported that Staff D did not leave Resident #1 alone with Staff C, the accused perpetrator. But in an 06/02/2020 email response to a request for documents, Staff B stated that, .(Staff D) had a different version (of the incident response) than was reported to me by staff. She did initially intervene, but then did leave the room . During an interview on 06/02/2020 at 2:00 PM, Staff B, Director of Nursing, stated that the facility, found deficits with the housekeeper who was contracted staff. Staff B stated that education was provided to Staff D on the morning of 06/02/2020. When asked what the deficit was, Staff B stated, She left the room with the caregiver (alleged perpetrator) in the room with the resident. Review of the facility investigation documents did not include the facility identification of the staff deficit, nor did the facility identify that as soon as Staff E alleged abuse to Staff H, Staff H failed to remove Staff C from resident care and failed to ensure Resident #1 was safe prior to initiating an investigation. Witness statements were provided by the facility on 06/09/2020 at 3:43 PM. Review of a Statement of Staff C, dated 06/01/2020 showed that when Staff C started on 05/30/2020 around 6:00 AM, Resident #1 was asleep and in the company of Staff K, CNA. At about 7:00 AM, Staff C noticed that Resident #1's face was reddish, mostly the cheeks. Staff C documented going on break at around 10:00 AM and leaving Resident #1 in the company of Staff L, CNA. Staff C documented Resident #1 was exhibiting behaviors through the morning, including, scratch his face and hair, and kept waking up and sit on the bed. The facility investigation did not include statements from Staff K or Staff L regarding the presence of reddish cheeks, Resident #1's and/or Staff C's behaviors. Abuse Prevention Education documents for staff were requested on 06/01/2020 at 3:18 PM, and received on 06/03/2020 at 2:38 PM, including information that Staff C, had received computer training on abuse prevention on 03/02/2020. A copy of the curriculum was requested but not received. Review of this list of trainees showed that the list did not include the housekeeping Staff D and E. Computerized records were obtained by the facility from the contracted management company who provided housekeeping services, indicating Staff D received abuse training in general orientation and electronically signed a 09/12/2019 document. Similar documentation was received for Staff E that showed this staff was trained and acknowledge the training on 10/04/2019. In an interview on 06/03/2020 at 9:50 AM, Staff D stated that after witnessing Staff C strike Resident #1, Staff D left Resident #1 to tell Staff E about the incident. When asked, Staff D stated they had never received training in abuse prevention. Staff E, in an interview on 06/03/2020 at 10:00 AM, stated that they had not received training in abuse prevention, but knew reporting the incident was, the right thing to do. Staff B, in a 06/03/2020 2:12 PM interview and email stated that the contracted housekeeping management company, not the facility, provided background checks and abuse prevention education to housekeeping staff. SUBSTANTIAL INJURIES BRUISING RIGHT FLANK Review of Progress Notes dated 05/16/2020 at 9:45 PM showed, Certified Nursing Assistant reported to LN (Licensed Nurse), multiple bruises behind knees. Bruise on right lower flank area (area between the lower rib and hip bone/torso/side). Resident placed on alert charting to monitor for multiple bruises . Review of the facility 05/16/2020 incident investigation showed the investigation was not completed within five days as required. The conclusion dated 05/28/2020 stated that when resident attempts to reposition he has poor control when sitting back down hitting his flank on the armrest of the wheelchair and back of knee on wheelchair frame. The investigation did not identify who the one-on-one staff member on duty was, statements from staff to determine a timeframe of when the bruises may have occurred, if an incident had occurred that was not previously reported, or what data the facility used to draw the conclusion. The facility failed to rule out abuse or neglect. Staff B, interviewed on 06/05/2020 at 9:58 AM, was asked if the facility had procedures for investigating possible abuse/neglect and if the facility investigated Resident #1's right flank bruising. Staff B stated that she was not sure if the facility had a policy or procedure for investigating potential incidents of abuse/neglect. Staff B stated that, sometimes the Residential Care Managers can initiate an investigation. HEMATOMA TO HEAD Review of a 04/25/2020 11:00 PM Progress Note showed, Resident was sleeping in the wheel chair, when he fell down and hit the floor on top of the head and sustained a hematoma. Neuro checks initiated and DNS (Director of Nursing Services), MD (Medical Doctor), and family member .notified. Put on alert charting. Review of a 05/01/2020 physician progress notes [REDACTED]. The patient was sleeping in his wheelchair, and fell forward, hitting the frontal portion of his head on the ground, resulting in a hematoma. Neuro checks were performed and the patient continues to maintain his baseline. The hematoma appears to be healing well. Review of a 05/04/2020 physician progress notes [REDACTED]. He was talking but was not making any sense. I was informed today that he fell ,[DATE] days (ago) and hurt his head and developed hematoma on top of the head. Patient has slurred speech. Hematoma is still there, size of tennis ball. Patient could not provide any history. I ordered CT head to r/o (rule out) SDH (Subdural Hemorrhage, a condition in which blood collects on the brain's surface beneath the skull) or [MEDICAL CONDITION] (bleeding in the brain). Staff B, interviewed on 06/05/2020 at 9:59 AM, stated that the facility incident log was up to date and correct. If an incident was not on the log there was no investigation. Review of the April 2020 Reporting Log showed the incident and resulting injury was not logged. The incident was not investigated to rule out abuse and/or neglect. BRUISING TO FOREHEAD Review of progress notes dated 04/15/2020 showed, CNA watching him saw him bumping himself accidentally on the forehead while trying to position self, little bruise noted. Review of physician progress notes [REDACTED]. The caregiver reports that the patient has been exhibiting episodes of increased agitation and sometimes aggressive behavior in as trying to reach out and strike being or someone. The patient did sustain a small bruise to his forehead, a couple days ago when he bumped himself on the forehead. He has small bruises on his upper back and right upper arm. Staff B, interviewed on 06/05/2020 at 10:05 AM, stated that, Resident #1 does that, bump his head, that is why the facility initiated the seat belt. In response to being questioned about the facility's investigation and notifying the Department, Staff B stated that, The facility's log is complete and if the incident is not logged or there is no designation the Department was notified there is no investigation and the Department was not notified of the potential abuse/neglect. Review of the April 2020 Reporting Log showed the incident and resulting injury was not logged. The incident was not investigated to rule out abuse and/or neglect. BRUISING TO CHEST AND BACK Review of progress notes dated 04/14/2020 showed, Resident had a shower, the Aide noted old bruises on upper arm, chest and back, yellowish in color/purplish in color. Continues on 1:1 monitor with no behavior issues today. Staff B, in an interview on 06/05/2020 at 10:05 AM, stated that if the incident is not on the log and there is no notation the Department was notified, there is no investigation and the Department was not notified of the potential abuse/neglect. Review of the April 2020 Reporting Log showed the injuries of unknown origin to areas not generally vulnerable to trauma were not logged. The bruising of unknown origin were not investigated to rule out abuse or neglect. RESIDENT #2 According to the 04/01/2020 Quarterly Minimum Data Set, (MDS, an assessment), staff assessed Resident #2 as able to communicate, cognitively aware and able to make their own decisions, exhibiting no behaviors, and requiring one person supervision/oversight for activities of daily living. Review of the 10/07/2020 Risk for falls/injury CP showed interventions included, Ensure that resident is wearing appropriate footwear. The 09/26/2019 Self Care Performance Deficit CP showed the resident required one staff participation to dress. Review of progress notes dated 05/06/2020 01:00 AM showed, Called to room [ROOM NUMBER]-1 by CNA. Reported that resident was on the floor. When this LN went to room, resident had placed himself back into his w/c. Resident states he was attempting to stand when he slipped on the slippery floor. Floor was noted to be dry. Resident was wearing nonskid sock on his left foot and a slipper on his right foot. Resident assessed for injuries and found to have a 5 cm hematoma to his left forehead with some noted bleeding. Area cleansed with normal saline and pressure applied which stopped the bleeding. Ice was applied, but resident didn't tolerate it for long. Neuro checks were initiated. Resident denies dizziness or lightheadedness. No orthostatic drop. Denies pain/discomfort. BS 206. Resident refused to go to hospital. MD notified. Will place on alert charting for fall with injury. Review of the facility incident investigation dated 05/06/2020 did not include a caregiver statement regarding the resident's footwear, or identify the location of the left slipper. The incident investigation showed the Resident sleeps in his wheelchair and concluded, Resident possibly was asleep and had leaned forward in wheelchair and fell to the floor resulting in head injury. The CP did not show a resident behavior of sleeping in the wheelchair. The facility failed to interview staff on duty at the time of the incident to determine when the resident had last been seen, and doing what, where. An additional comment on the incident investigation showed that while LN was investigating fall in the resident's room a bottle of coke with rum was sitting on his bedside stand. The investigation failed to identify how long the resident had the alcohol, where the resident obtained the alcohol, if the resident exhibited behaviors indicative of having consumed the alcohol. During an interview on 06/02/2020 at 1:30 PM Staff F, LPN, RCM, stated I have not seen (Resident #2) drink, but I have removed many bottles from his room. In addition, the notes concluded, It is very likely that resident had weakness secondary to needing a blood transfusion. The facility failed to conclude the investigation, determine the circumstances of the event and rule out neglect of staff to provide care and supervision of Resident #2 to ensure the resident's safety. Staff B, interviewed on 06/05/2020 at 10:10 AM, stated that there was no investigation to rule out abuse and neglect. RESIDENT #4 Review of the progress notes dated 05/28/2020 at 2:00 PM showed, Patient reported that another resident came into her room last night and hovered over her in bed and patient stated that the other patient in her room threatened to hit Resident #4. Resident #4 reported feeling unsafe. Informed (Resident #4) that SS (Social Services) discussed with the other patient and that the patient was put on 20 minute checks for the night. Patient was agreeable to this intervention. Review of the May 2020 Reporting Log showed the allegation of abuse was not logged. Interviewed on 06/05/2020 at 10:10 AM, Staff B, stated that the incident, if not logged was not investigated and the Department was not notified, if this action was not indicated on the log. Staff B, continued stating that, the perpetrator, Resident #8, was placed on twenty minute observations by staff. When asked how this would protect Resident #4, considering Resident #8 was self-ambulatory and had easy access to all areas of the facility, Staff B had no reply. RESIDENT #9 Review of progress notes dated 03/31/2020 showed Resident #9 complained about Resident #10 waking him up and night and wanting to fornicate with him. Review of Resident #10's record showed a 03/10/2020 at 1:32 PM physician documentation that Staff reports that he has been having an increase in inappropriate sexual behavior . Review of the 03/31/2020 5:11 PM facility report to the Department, showed at 5:30 AM Resident #9 told Staff B that his roommate (Resident #10) approached his bed and began making inappropriate comments .Resident #9 told Staff B, If he touches me, I'm going to punch him in the face. Staff B told Resident #9 that it would be considered assault and the police would be called if he touched another resident. Resident #9 asked that Resident #10 be moved to another room. Staff B assured Resident #9 that she would discuss this with the IDT (Interdisciplinary Team) and find a solution and get back to him. In addition, in the report to the Department, Staff B stated that later in the afternoon, Resident #9 told another staff member in more graphic detail what Resident #10 said, including the statement, I'm going to f**k you in the ass and that he was, very upset about this. Review of a 03/31/2020 12:36 PM Progress note showed Resident #10 was, provided room change following verbal conflict with roommate. The facility failed to identify alleged sexual abuse, and failed to protect Resident #9 from his roommate, Resident #10 pending investigation. The facility investigation was requested. On 06/08/2020 the facility provided a report which indicated an investigation was initiated, but failed to include investigative documents, statements from staff working at the time of the alleged incident, behavior monitoring, or similar information the facility would use to conclude if abuse or neglect occurred. The facility failed to conduct a thorough investigation. REFERENCE: WAC 388-97-0640(6)(a)(b).

Based on observation, interview and record review, the facility failed to provide adequate monitoring and supervision of five (#s 2, 3, 4, 6 & 7) of six sampled residents who smoked. The facility failed to accurately assess each resident's smoking safety, failed to ensure precautions were implemented for residents' safety, including ensuring residents smoked only in designated areas, supervising residents whose assessments and care plans indicated a need for assisted and supervised smoking, limiting the accessibility of lighters by residents who needed supervision when smoking for safety reasons. The facility's failure to ensure that their smoking policy was implemented regarding smoking safety and supervision of residents who smoked, resulted in an Immediate Jeopardy on 06/04/2020. Findings included . Review of the facility undated Smoking Policy and Procedure showed, All residents who smoke will be screened using the Smoking Safety Data Collection UDA, to assess their ability to smoke independently upon admission, quarterly, and with a significant change of condition to determine any special needs and to assess their ability to smoke independently.; All residents who meet the criteria to smoke independently may smoke in the Center's designated smoking areas without staff supervision. Residents who are assessed as independent smokers may retain possession of their smoking materials .such residents must adhere to the following requirements No smoking materials will be given to another resident. Residents who fail to adhere to these requirements after counseling will be required to have all their smoking materials stored in a secure area at the nurse's station. Review of the facility Smoking Evaluation template section F2 showed instructions to evaluating staff, Has resident demonstrated non-compliance with smoking policy requirements? If yes, resident is unsafe to smoke. On 06/02/2020 around 2:30 PM in the company of Staff B, Director of Nursing Services (DNS), Resident #2 was observed smoking outside on the cement pathway leading to the smoking area, with Resident #3 and Resident #4. No ashtrays were observed in the area. Staff B stated that Resident #2 was not supposed to be out smoking at all and was super non-compliant. At this time, Staff B informed the residents they were to smoke in the designated smoking area. Resident #3 stated I tried to get to the smoking section, but I can't get through. Resident #4 was observed blocking the pathway to the smoking area. Resident #2 was observed to discard a cigarette butt in a trash can located on the back patio. Staff B instructed the resident to use the ashtray in the smoking area. When asked if all three residents were assessed as independent smokers, Staff B stated, Yes. RESIDENT #2 Review of the Smoking Evaluation dated 12/09/2019 showed Resident #2 was assessed as an Independent Smoker. Review of the 02/21/2020 Care Plan, showed Resident is a daily smoker. The only intervention listed was, Provide smoking policy and ongoing safety surveillance. Review of Progress Notes dated 01/12/2020 at 10:20 PM showed Resident was found to be smoking in his room. Went in the room and resident stated that he had fallen asleep in his chair and woke up and automatically lit a cigarette, and then put it out. Explained to the resident that this is a fire hazard and will not be tolerated. Cigarettes and lighter removed from his room. The facility failed to reassess the resident's smoking safety after the resident demonstrated non-compliance with the smoking policy. Review of a Progress Note dated 03/17/2020 at 9:24 PM showed, Staff member reported to this writer that he caught this resident smoking in the room. Upon asking the resident, resident denied. Resident stated he keeps cigarettes buts in his jacket and that's what's smelling. Resident educated the dangers of smoking in his room and advised not to put cigarettes buts in his jackets due to risk of fire and resident voiced understanding. Review of a Progress Note dated 03/19/2020 at 9:55 AM showed, Spoke with resident regarding smoking in his room. Resident denies smoking in his room. He tells LN (Licensed Nurse) that he collects his cigarette butts in his pack because he can not reach the ashtray. He tells LN he was not smoking in his room and he knows how to use his locking draw. Resident is noted to be a/o x 4 (alert and oriented times four) and has never been known to be non compliant with smoking policy. The facility failed to reassess the resident's ability to demonstrate use of an ashtray after the resident reported an inability to reach the ashtray. Review of the 04/06/2020 Discharge Minimum Data Set (MDS - an assessment tool) showed that on 04/06/2020 Resident #2 had an unplanned discharge, return anticipated. Review of the 04/16/2020 Entry Tracking MDS showed that Resident #2 readmitted to the facility on [DATE]. Review of a Progress Note dated 04/16/2020 at 10:18 PM showed, reported by DON (Director of Nursing) that resident was back to facility this morning . resident went outside couple of times this shift for smoke, resident is in isolation, encourage resident not to socialize with other resident's all the way to other side of smoking zone, resident is ok with that, admission paper work has been done . The resident was not assessed for smoking safety until 04/22/2020. According to the 04/22/2020 Smoking Evaluation, the resident was assessed as safe to smoke independently. According to this evaluation the resident had not previously demonstrated non-compliance with the smoking policy requirements. Review of Progress Notes dated 05/16/2020 at 2:48 AM showed, Resident in and out smoking most part of the night. He denied having any pain, swelling on the eye due to a fall slightly gone down with no bleeding noted. Will continue monitor. Review of Progress Notes dated 05/28/2020 at 10:25 AM showed, This AM (Resident #2) was outside on the patio (not the smoking section) lighting up a cigarette. Writer of this note approached resident about the smoking policy. Writer of this note stated that it was a safety issue and that this was for everyone that smoked here at Auburn. (Resident #2) stated, I was just about ready to give you a compliment but now I find out you are like the rest of the people here. Resident then immediately went towards the smoking section to smoke the rest of his cigarette. Review of progress notes dated 06/01/2020 at 06:42 AM showed, At this time resident again is out of his room on the back patio smoking under the no smoking sign. Resident informed again that he is under self quarantine and should not be in the hall or smoking in non smoking areas. The facility failed to reassess the resident's smoking safety after the resident demonstrated non-compliance with the smoking policy. Additionally, record review showed Resident #2 signed an acknowledgment of having read the smoking policy, and agreement to abide by the Center's Smoking Policy on 11/13/2019. The facility did not have the resident review the smoking policy when readmitted to the facility, or after demonstrated non-compliance. RESIDENT #3 Review of the Smoking Evaluations dated 09/16/2019, 12/09/2019, and 04/02/2020 showed Resident #3 was deemed an Independent Smoker. According to the 09/25/2018 Care Plan, Resident #3 was At risk for injury when smoking. The Interventions listed were, Complete Smoking Data Collection and Assessment, and Due to homeless people in our community resident to ask staff to escort to the smoking area. and Store smoking materials at nurses station. During an interview on 06/02/2020 at 2:55 PM, when asked about smoking materials, Resident #3 stated, I keep them in my pocket. If I go to sleep, I lock them up. RESIDENT #4 Review of the Smoking Evaluations dated 10/17/19 and 12/09/19 showed Resident #4 was deemed an Independent Smoker. Review of the resident's Care Plan showed the resident was identified as At risk for injury when smoking on 10/17/2019, and non-compliant with smoking rules on 12/13/2019. Interventions included, Monitor compliance to smoking policies and Review smoking rules when non-compliant. Review of a Progress Note dated 03/22/2020 at 8:15 PM showed, Resident has been noted to be going out the back door to smoke, has been explained that there is a designated smoking area, and this is where residents need to smoke. Resident has been noted outside on the sidewalk after asking her to go to designated area. Review of the 11/06/2019 Resident signed facility Smoking Policy and Procedure, showed the resident had not reviewed the smoking policies when non-complaint, as directed in the resident's plan of care. In addition, the facility failed to reassess the resident's smoking safety after the resident demonstrated non-compliance with the smoking policy. Similar findings were noted for Resident #6 & #7 for whom the facility failed to reassess residents for smoking safety, or provide an increased level of supervision after the facility became aware of increased safety risks. RESIDENT #6 Review of the 04/28/2020 Care Plan showed Resident #6 was Non Compliant with smoking rules. Interventions listed include, Educate risk of non-compliance (e.g. potential discharge, risk of center fire), Encourage resident to follow smoking rules .Encourage resident to provide own smoking materials to prevent the need to bum/borrow from other residents Review of the Smoking Evaluation dated 04/30/2020 showed Resident #6 was deemed an Independent Smoker. Review of a progress note dated 04/20/2020 at 10:22 PM showed, Resident was found sitting on the floor on the outside patio, walker in front of her. Resident in no apparent distress laughing and joking around with nursing staff. Resident wearing slippers. Resident had gone out for a smoke. Walker unlocked. 'I tried to sit on my walker but I forgot to lock it. I slipped down and hit the floor on my butt. Just help me get up already, I am not hurt. Review of a progress noted dated 05/29/2020 at 8:35 AM showed, SSA (Social Service Assistant) and admissions director talked to rsd (Resident) about not giving cigarettes to other residents. Rsd seemed to understand that she might lose her smoking privilege if she continues to give cigarettes to other residents. RESIDENT #7 Review of the 01/31/2017 Care Plan showed Resident #7 was At risk for injury when smoking r/t (related to) deconditioning. Interventions included, Due to homeless people in our community resident to ask staff to escort to the smoking area, Review smoking policy with resident/responsible party, Rsd to keep cigarettes and lighter secured on person or in room locked up, Store smoking materials at nurses cart. The resident will turn in smoking supplies on return from smoking . Review of progress notes dated 04/13/2020 at 04:08 AM showed, Resident also likes to go out to smoke at night she knows she is suppose to call LN (Licensed Nurse) using the walkie talk to call for door to be opened. However sometimes the resident refuses to use it. Resident needs a reminder of clear policy on smoking and timings of smoking going forward while in isolation room. Resident also not comfortable smoking in that area at night but we can't have the door open. Review of the facility Smoking Policy and Procedure, showed the resident had not reviewed and signed the smoking policy and procedure since 09/19/2019. Review of the Smoking Evaluation dated 04/17/2020 showed Resident #7 was deemed an Independent Smoker and demonstrated no non-compliance with smoking policy requirements. REFERENCE: WAC 388-97-1060(1)(3)(g)

Based on observation, interview and record review, the facility failed to ensure one (#1) of one resident reviewed for abuse, was free from actual physical abuse by not recognizing, potential prior abuse, in the form of uninvestigated bruising on the face, chest, and torso of the resident; failed to immediately protect the resident by removing the person responsible for slapping the resident. The failure of the facility to protect Resident #1 from actual physical abuse, even though signs were there, caused physical and psychosocial harm and created an atmosphere of continued ongoing physical abuse. Failure of the facility to ensure residents were free from abuse and staff understood when and how to identity, react or handle abuse situations resulted in an Immediate Jeopardy on 06/04/2020. Findings included . Refer to: CFR 483.12(c)(1)(4), F-609, Timeframe: Abuse Reported to Administration/State Agency CFR 483.12(c)(2)-(4), F-610, Investigate Abuse/Protect resident during investigation Report Investigation Results State The Code of Federal Regulation (CFR) defines abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. The undated facility, Prevention and Reporting: Resident Mistreatment, Neglect, Abuse , policy included, Physical Abuse includes hitting, slapping .A resident has the right to be free from abuse, neglect .The center shall: not use verbal, mental, sexual, or physical abuse, corporal punishment .Require center staff, which included employees, consultants, contractors .Provide for the immediate safety of the resident upon identification of potential abuse Prevent further potential abuse .while the investigation is in progress . RESIDENT #1 According to the 03/12/2020, Quarterly Minimum Data Set, (MDS), an assessment tool. Resident #1 exhibited unclear speech patterns, was cognitively impaired and unable to make decisions, had experienced disorganized or incoherent thinking and other behavioral problems not directed toward others, required one person physical assistance for activities of daily living, and had a mental health disorder diagnosis. The clinical record showed the resident had a [DIAGNOSES REDACTED]. According to the 03/27/2020 revised Care Plan based on the MDS and clinical diagnoses, staff were to provide, 1 on 1 care, redirect the (resident), and provide (psychological) consult as needed. and, Anticipate needs, Be [MEDICATION NAME] . Review of Progress Notes dated 05/30/2020 showed that, at around 12:30 PM, Housekeeper reported that around 11:20 AM she witnessed Resident hitting at the one on one staff member (Staff C, Certified Nursing Assistant (CNA)) for Resident. The one on one Staff member then slapped Resident in the face twice. Left side of face is red . Although, the Housekeeper did take some actions, there was an hour delay in protecting Resident #1, by leaving Staff C alone and unsupervised, before reporting to the nurse that Staff C had slapped the resident. In an interview on 06/01/2020 at 2:45 PM, Staff B, Director of Nursing, was asked if Staff C, slapped Resident #1, Staff B, stated, The abuse was witnessed. Review of a written statement by Staff H, Licensed Practical Nurse dated 05/30/2020, showed Staff E, Housekeeper asked Staff H, what to do if someone had seen a staff member slap a Resident. Staff E stated that he would tell a nurse right away. Staff H asked Staff E if someone was slapped, and Staff E said yes. When asked who saw the Resident get slapped, Staff E stated that he promised he would not say anything. During an observation on 06/02/2020 at 2:05 PM, Resident #1 was seated in a wheelchair, in his room, accompanied by Staff I, a one-on-one caregiver. Resident #1 was observed with discolorations to left cheek and a dark discolored area above the left eye. During an interview at this time, when asked if staff treated him well, Resident #1 replied, No. When asked if staff were nice to him, Resident #1 replied, No. Resident #1's attempts to respond in full sentences were difficult to understand due to rambled and slurred speech. For this resident who was unable to express the full effect of having been slapped, the psychological as well as physical effects of such abuse can be inferred by any reasonable person. In an interview on 06/03/2020 at 9:30 AM Staff D, a Housekeeper/witness, stated (Resident #1) was swinging his hands, it looked like horse play. (Resident #1) didn't hit (Staff C,). (Staff C), got up from the chair in which he was sitting close to (Resident #1), and slapped (Resident #1) pretty hard, twice. (Staff C) told me to close the door. When asked how Resident #1 seemed after the incident, Staff D, stated, (Resident #1) was upset, he wasn't crying, he just didn't look right. Staff D stated this incident was subsequently reported to Staff E, another housekeeping staff. In an interview on 06/03/2020 at 9:50 AM, Staff D stated that after witnessing Staff C strike Resident #1, Staff D left Resident #1 to tell Staff E about the incident. When asked, Staff D stated they had never received training in abuse prevention. During an interview on 06/03/2020 at 10:00 AM, Staff E, stated that they had not received training in abuse prevention, but knew, reporting the incident was, the right thing to do. Further review of Resident #1's clinical record showed the resident had previously sustained substantial injuries that were not reported to the Department and that the facility failed to thoroughly investigate to rule out abuse. Review of the facility investigation documents, showed the facility did not identify how long Resident #1 was left alone in the room with the alleged perpetrator, Staff C. In addition, the facility failed to identify that as soon as Staff E alleged abuse to Staff H, Staff H failed to remove Staff C from resident care and failed to ensure Resident #1 was safe prior to initiating an investigation. Additionally, the facility failed to ensure four staff (D, E, H & F) reported abuse of Resident #1 as mandated, which placed all residents at risk for unidentified, ongoing abuse. Review of documentation by the ARNP (Advanced Registered Nurse Practitioner) on 05/30/2020 showed, Nurse (Staff H) called at approximately 1600 to report a housekeeper witnessed a nursing assistant slapped this patient across the face. Altercation resulted in a red mark to patient's right (sic) cheek .Patient placed on alert charting to monitor for latent injury, pain, and psychological harm . Nurse instructed to contact provider for any complaints of pain, psychological harm, or other . injury as stated. Review of documented monitoring in the Progress Notes on 05/31/2020 showed, Resident was tearful X 1 this shift. I could not understand what he was saying. Decreased Redness to left side of face. Blotchy red areas/bruising noted. The 06/01/2020 2:40 PM Progress Notes showed the resident sustained [REDACTED]. Dark bruising around left eyebrow. A colored picture was provided by the facility on 06/03/2020 at 3:22 PM, taken on 06/02/2020, that showed a large dark purple periorbital (surrounding the eye) bruise that extended up the left forehead, into the scalp, and down the left cheek and towards the left ear. Staff G, Licensed Practical Nurse (LPN), MDS Nurse, stated in an interview on 06/01/2020 at 2:37 PM, that Resident #1 had a mark on the face. During an interview on 06/02/2020 at 1:30 P.M. Staff F, LPN, Resident Care Manager (RCM) stated, I saw his face yesterday, and oh God it was bruised. Past incidents of unexplained bruising Review of progress notes dated 04/14/2020 showed, Resident had a shower, the Aide noted old bruises on upper arm, chest and back, yellowish in color/purplish in color There was no evidence this was investigated by the facility to rule out abuse. Review of physician progress notes [REDACTED]. He has small bruises on his upper back and right upper arm. There was no evidence this was investigated by the facility to rule out abuse. Review of a 05/04/2020 physician progress notes [REDACTED].Hematoma is still there, size of tennis ball. There was no evidence this was investigated by the facility to rule out abuse. Review of Progress Notes showed on 05/16/2020 at 9:45 PM, Certified Nursing Assistant reported to LN (Licensed Nurse), multiple bruises behind knees. Bruise on right lower flank area (area between the lower rib and hip bone/torso/side). There was no evidence this was thoroughly investigated by the facility to rule out abuse. The resident had a one on one care giver to keep the resident safe. Due to the lack of investigations of the bruising, the facility failed to identify if the above bruising was a result of abuse. REFERENCE: WAC 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 12 (#s 73, 39, 71, 30, 18, 83, 29, 47, 33, 48, 49, & 55) of 21 residents reviewed. Nursing staff failed to obtain, follow or clarify physicians orders (PO) when indicated for (#s 73, 39, 71, 30, 18, 83, 29, 48), document for only those tasks completed for resident (#s 48, 49, 55 & 30) and forward consulting practitioners' recommendations to the Primary Care Physician (PCP) for approval for (#s 73 & 29), and ensure site rotations for injections for one (#71) resident reviewed. These failures placed residents at risk for medication errors, delayed treatment, adverse outcomes, and resulted in harm to Resident #73, for whom nursing staff initiated invasive procedures without physician orders. Findings included . REFER to: CFR 483.45(d)(1)(5), F-757, Drug Regimen is Free From Unnecessary Drugs CFR 483.45(d)(F)(1), F-759, Free of Medication Error Rates of 5% or More CFR 483.45(f)(2), F-760, Free of Significant Medication Errors FAILURE TO OBTAIN/CLARIFY/IMPLEMENT PHYSICIAN ORDERS RESIDENT #73 Record review revealed nurses notes dated 12/17/19 at 11:05 PM which showed, .Midline (a specialized intravenous access line inserted in the antecubital (forearm) area with the tip advanced at or below the axillary vein) placed to left (arm), will start abo (antibiotic) at 11:00 PM. Record review showed no Physician Order or direction in the record for nursing staff to initiate a Midline or to initiate antibiotics to Resident #73 on 12/17/19. Progress notes dated 12/20/19 at 10:41 PM showed, Resident c/o (complained of) pain to left bicep at midline site. Area red, warm to touch and tender. Called on call MD (Medical Doctor), got an order to obtain a Doppler (ultrasound) and call IV (Intravenous) nurse to switch midline to right arm . A provider note dated 12/21/19 at 8:15 PM showed, .yesterday patient's IV site infiltrated to left arm and at that time was presenting with redness, swelling and tenderness to touch .Doppler to be completed to rule out blood (clot). On 12/24/19 at 8:30 PM the provider documented, (Resident #73) is being seen today for follow-up on Doppler ultrasound to left upper extremity status [REDACTED]. Preliminary result shows positive for thrombus (blood clot) of left cephalic vein, however, final result concludes with no [MEDICAL CONDITION] ([MEDICAL CONDITION]. Mobile ultrasound services was contacted. Ultrasound tech(nician) agrees with conflicting results. On 12/22/19 the results of an additional ultrasound concluded there was no [MEDICAL CONDITION], but, There is thrombus in the superficial cephalic vein. In a 12/27/19 at 12:22 AM progress note, Resident #73's provider documented concerns stating, I contacted patient's wound care clinic requesting them to fax over patient's report from his recent visit that was on the 26th of Dec(ember), since reports from the last visit on [DATE]th as well as his recent visit was not available for me to review and that the staff at facility was unable to provide me with any report from resident's last and recent visit to wound care clinic . Upon reviewing the patient's results which was (sic) faxed to me by the wound care clinic, there was no indication of (the) patient being on IV antibiotics .(in a telephone call) wound care provider stated she did not start the patient on IV antibiotics on 12/17/19 .The order for IV antibiotics was entered by facility staff on the 17th of (MONTH) without my knowledge . Review of the facility's (MONTH) 2019 incident log showed a 12/30/19 entry for a medication error involving Resident #73. According to the 12/27/19 investigative document under the heading Description: Medication error (was) noted regarding resident rx (prescription) of [MEDICATION NAME] (an antibiotic) .Review of the 12/17/19 AVS (after visit summary - a brief summary of what occurred at the visit, frequently given to patients) showed under Instructions the doctor documented no instruction to start IV [MEDICATION NAME] for an infection. The 12/27/19 Medication Error investigation concluded that Staff C, Licensed Practical Nurse - LPN, Assistant Director of Nursing, Mistakenly saw an order for [REDACTED].#73 receiving 28 doses of IV [MEDICATION NAME] without an order. According to the investigation, There is significant risk for harm as resident was treated with ABO and no apparent infection . During an interview on 01/09/20 at 12:44 PM, Staff B, Director of Nursing, confirmed there were no instructions to nursing staff to initiate a Midline access IV or administer IV [MEDICATION NAME] for Resident #73. Staff B indicated the nurse who implemented these interventions mistakenly entered orders from an outdated medication list which referenced a course of IV [MEDICATION NAME] that was discontinued on 08/08/19, greater than four months prior. The nurse's decision to initiate IV antibiotics without an order, resulted in Resident #73 undergoing two unnecessary invasive procedures (Midline placements), which infiltrated causing pain, redness, and swelling to Resident #73's left arm, and ultimately resulted in a cephalic vein blood clot. These multiple failures to follow nursing professional standards of practice, resulted in harm to Resident #73. RESIDENT #39 Observation during medication pass on 01/05/20 10:21 AM showed Staff P, LPN, prepare medications to administer to Resident #39. Upon review of the Physician Orders (POs) Staff P indicated she should administer Vitamin B12 extended release 1000 mcg (micrograms) and retrieved two different bottles of vitamin B12 from the medication cart, neither of which were in the form of extended release. Staff P looked at the bottles stating, it does not say extended release. Review of the (MONTH) 2019 and (MONTH) 2020 Medication Administration Records (MAR) showed nursing staff consistently signed that the extended release form of the Vitamin B12 was administered each day. In an interview on 01/05/20 at 10:38 AM, Staff U, Central Supply Clerk, stated that Vitamin B12 was a house supply medication which she ordered. When asked to supply any documentation to support Vitamin B12 was ever ordered in the extended release form, Staff U indicated she had never ordered any ER form of Vitamin B12 and stated, I do not believe I can get extended release. In an interview on 01/05/19 at 10:44 AM, Staff E, LPN, indicated nursing staff should have identified the ER version of the Vitamin B12 was not available and clarified the order to reflect the medication which was being administered. A review of the (MONTH) 2019 PO's revealed an order dated 11/02/19, [MEDICATION NAME] (Oseltamivir [MEDICATION NAME]) give 75 mg (milligrams) by mouth in the evening for Flu [MEDICATION NAME] (prevention) for seven days. A review of (MONTH) 2019 MARs showed Resident #'s 71, 30, 18, 47 and 83 had orders for [MEDICATION NAME]. According to the documentation on the resident's MAR, the residents received their first dose on 11/03/19 at 6:00 PM, with the last dose administered on 11/08/19 at 6:00 PM, indicating staff administered the medication for six days rather than seven days for which it was ordered. In an interview on 01/08/19 at 2:06 PM, Staff G (Licensed Practical Nurse) was asked if the resident's received the medication for seven days as ordered . Staff G replied, based on the documentation, it looks like they only received the medication for 6 of the 7 days. Staff G said, we received the PO's on (MONTH) 2nd, 2019, However, we didn't get the medication from the pharmacy until (MONTH) 3rd, 2019. Therefore, first dose was administered. until 11//03/19. Staff G said, I guess we should have notified the provider that there had been a delay in starting the medication and extended the stop date to ensure the residents received the medication for the full 7 days. RESIDENT #73 Additionally, review of Resident #73's (MONTH) 2019 Medication Administration Record (MAR) showed orders for [MEDICATION NAME] 15 mg (milligrams) as needed (PRN) for pain 7-10, and [MEDICATION NAME] 10 mg PRN for pain level 4-6. According to the MAR on 12/07/19 at 1:23 AM, 12/08/19 at 9:05 AM, 12/15/19 at 11:23 PM, 12/20/19 at 12:18 PM, and 12/21/19 at 11:53 AM, the resident reported a pain level of 6, and nursing administered 15 mg of [MEDICATION NAME], instead of the 10 mg that was ordered. During an interview on 01/15/2020 at 8:03 AM, Staff C acknowledged on the above occasions the resident should have received 10 mg of [MEDICATION NAME] instead of 15mg. When asked if nursing followed the Physicians Order (PO) Staff C stated, No. RESIDENT #29 Record review showed a 12/26/19 PO for a complete blood count (CBC), comprehensive metabolic panel (CMP), and a wound culture of a boil to the resident's right breast which, has burst open on its own and is draining pus. The resident was also started on Bactrim DS (an antibiotic) for five days. Review of the (MONTH) 2019 MAR showed direction to staff to obtain, CBC, CMP and wound culture one time only for right breast abscess.12/26/19 and 12/27/19 had blanks where the nurses were to sign. Record review revealed no results were present for the CBC, CMP, or wound culture. During an interview on 01/13/19 at 9:09 AM, when asked where the results for the CBC, CMP, and wound culture were Staff D, Assistant Director of Nursing, looked in the lab book and indicated there was no lab slip in the book for the ordered labs. Staff D then called the lab and stated that the lab had no record of the labs or culture. When asked whose responsibility it was to ensure the lab requisition was completed, and that the labs were drawn and the culture obtained as ordered Staff D stated, Nursing and acknowledged nursing failed to carry out the physicians order. A 12/23/19 dental hygienist consult stated SDF (Silver Diamine [MEDICATION NAME]) applied today to arrest [MEDICAL CONDITION], applied to all [MEDICAL CONDITION] and crown margins. and recommended Patient brushing own teeth 2x/day with ACT [MEDICATION NAME] rinse. The consult was noted by Staff C. Review of Resident #29's (MONTH) 2020 MAR and Treatment Administration Record (TAR) revealed no direction to staff to ensure Resident #29 rinsed her mouth with ACT [MEDICATION NAME] rinse twice daily after brushing. There was a order on the MAR for the resident to swish and spit twice daily with Chlorhexadine solution, a germicidal mouth wash that decreases bacteria. During an interview on 01/15/2020 at 8:42 AM, when asked why the recommendation to use ACT [MEDICATION NAME] rinse after brushing was not implemented Staff C, who noted the consult, stated, No, she has a different mouthwash Chlorhexadine .she uses that. After discussing that Chlorhexadine was a germicidal mouth wash and ACT was a [MEDICATION NAME] rinse, and the dental hygienist treated the residents [MEDICAL CONDITION] with SDF and then recommended Act [MEDICATION NAME] rinse, Staff C was asked if the two rinses were equivalent and served the same purpose to which Staff C stated, No. Staff C then acknowledged the hygienists recommendation for ACT should have been forwarded to the MD for approval. When asked if there was any indication that occurred Staff C stated, No. RESIDENT #33 Resident #33 admitted to the facility on [DATE]. In an interview on 01/06/20 at 2:38 PM, when asked if he had a Urinary Tract Infection [MEDICAL CONDITION] while in the facility, Resident #33 stated yes. I'm mad about it because I still have the problem. When asked to clarify the problem, resident #33 replied It stings when I urinate. Record review showed that following a Urinalysis report dated 11/12/19 with a handwritten note of, Kidney stones, urology appoint(ment). This report was noted by Staff H, RN on 11/13/19. Progress notes written by Staff H dated 11/13/19 showed, Called .Urology r/t (related to) insurance issue faxed referral noted . The progress notes showed no further follow up on the Urology referral and record review showed no indication the resident was seen by a Urologist. Staff H was interviewed on 01/09/20 at 12:36 PM, 49 days after the last progress note regarding the referral. Staff H confirmed that no urology appointment was scheduled. NURSES SIGNING FOR TASKS NOT COMPLETED RESIDENT #48 Review of the (MONTH) 2019 MAR showed an order to obtain a CBC and CMP. It was signed off as completed on 12/03/19. However, record review showed no indication a CBC or CMP were drawn on 12/03/19. A CBC and CMP were drawn on 12/09/19. In an interview on 01/09/2020 at 11:25 AM, Staff C explained the purpose for putting labs on the MAR was so nurses could verify the labs were drawn as ordered, and then sign off. When asked if the nurse that signed of on the CBC and CMP on 12/03/19 was signing that she verified the lab was drawn Staff C stated, Yes. When asked if Resident #48's labs were drawn on 12/03/19 as the nurse signed for Staff C stated, No and acknowledged they were not drawn until 12/09/19. When asked if the nurse signed for a task she did not complete Staff C stated, Yes. Review of the (MONTH) and (MONTH) 2019 MARs showed Resident #48 had orders for: [MEDICATION NAME] 10 mg PRN for pain level of 4-6, and [MEDICATION NAME] 15 mg PRN for pain level of 7-10, on a scale to 10. According to the MARs on 11/28/19 at 6:54 AM the resident reported a pain level of 6, and was medicated with 15 mg of [MEDICATION NAME] instead of 10 mg as ordered. On 12/01/19 the resident reported a pain level of 8 and was medicated with 10 mg of [MEDICATION NAME] instead of 15 mg as ordered. During an interview on 01/09/2020 at 11:25 AM, Staff acknowledged Resident #48 was administered the wrong dose of [MEDICATION NAME] on the above occasions. When asked if nurses followed the Physician's order Staff C stated, No. RESIDENT #49 On 01/05/19 at 1:01 PM, Resident #49 was observed with long untrimmed nails, with dark brown debris noted under the nails. When asked if staff trimmed his nails weekly Resident #49 stated, No, they need cut. When asked about his toenails the resident indicated they get cut every month or so. The toenails were not observed at this time. On 01/13/19 at 11:29 AM Resident #49 was again observed with long untrimmed nails with brown debris noted under the nails, observations of his toenails revealed they were long untrimmed with the great toenails jutting medially. On 01/13/19 at 1:08 PM Staff C was present in Resident #49's room. When asked to describe the residents fingernails Staff C stated, They look long. At which time the resident called out They are long, I don't like them long they need cut. When asked if she saw anything under his nails Staff C stated, dark debris. When observing Resident #49's toenails Staff C stated, They need clipped. When asked if it appeared either the toenails or fingernails had been trimmed in the last several weeks Staff C stated, It does not appear they have been cut recently, no. Review of the (MONTH) 2020 TAR showed direction to staff with the weekly skin check to every Sat(urday) trim finger and toenails. According to the TAR nurses signed that this was completed on 01/04/2020 and 01/011/19. When asked if it appeared that the nail care had been done Staff C stated, no. and acknowledged nurses signed for tasks they did not complete Review of the (MONTH) 2020 TAR showed direction to staff to Monitor tube site to include marking of the tube. The tube will be marked with a black line at insertion upon admission and verified with each medication/tube feeding administration . Observation of Resident #49's gastric tube on 01/09/19 at 8:11 AM and 01/13/19 at 11:29 AM, revealed there was no black line on the tube (which staff used to verify placement/ensure no migration). According to the (MONTH) 2020 TAR, staff signed off three times daily that they verified the black line at the insertion site. During an observation/interview on 01/13/19 at 1:13 PM, when asked if there was a black line on the gastric tube at the insertion site Staff C stated, No. After reviewing the (MONTH) TAR where staff were signing off that they verified the black line Staff C acknowledged nurses were signing for a task they did not complete/perform. Review of the (MONTH) 2020 TAR showed direction to staff to change tube feeding syringe and tubing every 24 hours. This task was signed of on 01/13/19 at 12:06 AM. Observation on 01/13/19 at 1:13 PM showed a opened 60 cc syringe dated 01/12/2020. Another undated, unopened syringe was next to it. This was validated by Staff C who was present in the room. When asked why it was necessary to change the syringe every 24 hours Staff C indicated it was for infection control purposes. Review of the (MONTH) 2020 MAR showed the resident had already received his morning bolus tube feeding. When asked if it was reasonable to conclude that the nurse used the syringe from the prior day to administer the bolus feed Staff C stated, yes, as the undated syringe was still sealed. Staff C indicated the nurse should have checked the date on the syringe prior to using it. RESIDENT #55 Review of the (MONTH) 2019 and (MONTH) 2020 TAR revealed direction to staff to check the bruit/thrill to the right chest every daily. According to the TARs staff are signing off that they verified the bruit/thrill. Observation revealed the resident had a triple lumen Central Venous Catheter (CVC) to the right chest. CVCs do not have a bruit/thrill. According to Resident #55's record she has a fistula to the left arm. During an interview on 01/13/2020 at 11:59 AM, when asked if a CVC had a bruit/thrill Staff C stated, No. Staff C acknowledged that nurses were signing for a task that could not have been completed. When asked if a nurse should have identified that the order was inaccurate Staff C stated, Yes. RESIDENT #30 A review Resident #30's (MONTH) TAR (treatment administration record) revealed staff signed they provided nail care on 01/07/20. On 01/09/20 at 11:20 AM, Staff [NAME] observed the resident's finger nails and acknowledged the residents fingernails on her left hand were long and jagged and untrimmed and indicated it did not appear staff provided the nail care that was documented as completed. MEDICATION PASS During a medication pass observation on 01/13/20 at 1:56 PM, Staff U Licensed Practical Nurse, administered five of ten medications to Resident #49 that were scheduled to be administered between 8:00 AM-11:00AM. Review of (MONTH) 2020 Medication Administration Records (MAR) showed staff U administered partial medication and three hours after the allotted time frame. During an interview on 01/08/20 at 11:55 AM, Staff U, LPN, confirmed that she administered partial medication to Resident #49 and did not provide medication as scheduled. During an interview on 01/15/20 at 10:30 AM, Staff B, Director of Nursing Services confirmed that Staff U, LPN did not follow physician orders to administer partial medication. All medication were to be administered the same time not partial. SITE ROTATION RESIDENT #71 According to the (MONTH) 2020 PO's, Resident #71 had Physician Orders dated 02/13/19 for [MEDICATION NAME] insulin, inject 10 units daily at 6:00 AM. Also, there were additional orders for [MEDICATION NAME] 8 units daily at 6:00 PM. A review of the (MONTH) 2019 Location of Administration Report revealed over the period of three days Resident #71 received three injections in the left arm. On 11/26, 11/27 and 11/28/19 staff documented three injections in the Arm-left. In an interview on 01/09/20 at 2:24 PM, with Staff C said, The expectation was that nurses would rotate injection sites with each injection. Failure to consistently rotate sites of injection placed the resident at risk for pain at the injection site and alteration in the rate of absorption REFERENCE: WAC 388-97-1620 (2)(b)(i)(ii).

Based on observation, interview and record review the facility failed, for one of five residents, (Resident #1), reviewed for abuse and neglect, to ensure staff implemented care planned interventions to transfer Resident #1. This failure caused Resident #1 to suffer a compound fracture that required hospitalization . Findings included: According to the 08/13/19 quarterly Minimum Data Set, an assessment, Resident #1 had difficulty making decisions, had [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility and not available for interview or observation. The undated Clinical Care Plan Detail included instruction to direct-care staff to, .TRANSFER: Requires Mechanical Aid: hoyer lift and assist of 2 for transfer. In brackets were the initials CNA indicating the task was assigned to the direct-care staff or Certified Nursing Assistant to provide this service. The full Care Plan indicated Resident #1 was assessed (MONTH) 18, (YEAR) for their ability to transfer resulting in the entry to all staff but carried out by direct-care staff, .TRANSFER: Requires Mechanical Aid: hoyer lift and assist of 2 for transfers . Resident #2, Resident #1's roommate, was interviewed on 09/10/19 at 2:15 PM. When discussing her roommate, Resident #1, Resident #2 stated .I think (Resident #1) fell . She (Resident #1) said 'I'm alright.' The fall was not on the floor but maybe she jumped on the bed . Staff D, the Certified Nursing Assistant (CNA), said in an extensive interview on 09/10/19 at 2:40 PM, that the facility called Staff D to work extra on the day shift and she had also agreed to work on the evening shift. Staff D recounted and demonstrated how they transferred Resident #1 for lunch from the bed into the wheelchair employing a stand-pivot transfer method. This method required the resident to be lifted with a gait belt, stand from one seated position to another seated position and required resident cooperation for a successful transfer. Staff D continued their description of the second time they transferred the resident around 7:45 to 8:00 PM on 09/08/18. Staff D said they were asked by the nursing staff to put the resident to bed as the resident was in the wheelchair for an extended period of time. Staff D recounted the use of the same stand-pivot transfer method employed earlier. Staff D denied the resident expressed any discomfort or concern but when Staff D removed the resident's clothing in preparation for bedtime Staff D discovered a wound around the knee and blood at the hem of the resient's pants with a wound on the left leg. When asked if the care plan was followed and how Staff D came to use the stand-pivot method of transfer, staff D responded they were informed by direct-care colleagues on the day in question that the resident was transferred using the stand-pivot method of transfer. Staff C, the Residential Care Manger, interviewed on 09/10/19 at 4:00 PM, said when CNA's were interviewed just after identifying Resident #1's fracture and as part of the initial investigation, .they (CNA's) didn't tell me they transferred (Resident #1) with the hoyer (mechanical lift). Suggesting staff had routinely employed other means to transfer Resident #1 from the bed to the wheelchair and vice versa. Review of the facility's investigation into the cause of the injury to Resident #1 revealed Staff E, the evening Registered Nurse identified Resident #1 suffered a fracture. Staff B, the Director of Nursing documented Staff D failed to implement the care planned interventions for transferring Resident #1. Staff D and other direct-care staff should have been aware of Resident #1 s' care needs that were based on an assessment made two years prior to the event, and the results of which were included in Resident #1's care plan. There was no other identifiable reason staff would not employee the required transfer method that resulted in the traumatic [MEDICAL CONDITION] femur. Refer to: WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure two (#'s 64, & 6) of seven sample residents reviewed for Mobility/Limited Range of Motion (ROM), received the splinting and ROM services they were assessed to require to improve and/or maintain range of motion and/or prevent further decline. These failures placed residents at risk for unmet care needs and resulted in harm to Resident #64 who experienced a decline in ROM and progression of contracture. Findings include: Refer to CFR: 483.25(b)(1)(i)(ii), F-686, Treatment/Services to Prevent/Heal Pressure Ulcers RESIDENT #64 Resident #64 admitted to the facility on [DATE]. According to the 09/24/18 Quarterly Minimum Data Set (MDS, an assessment tool) the resident had [DIAGNOSES REDACTED]. The RNP for ROM was provided on three of seven days and splint placement on one of seven days during the assessment period. The resident was also assessed to have severe cognitive impairment and was only sometimes understood. According to a 01/17/18 Occupational Therapy (OT) evaluation Resident #64 had impaired ROM secondary to a stroke. Per the evaluation the resident's LUE (left upper extremity) and BLE (bilateral lower extremities) were flaccid (lacking muscle tone). The resident's right upper extremity ROM was impaired secondary to weakness and left upper extremity was flexed of left hand/digits with increased tone .no active ROM of the (left) wrist wrist/elbow/shoulder with tightness. The impression was the resident had a .L(eft) hand contracture with flexed digits .(the degree of contracture was not measured) According to the treatment notes the resident was fitted with a left hand grip splint for .skin integrity and ROM . A 01/31/18 treatment note stated .discussed leaving splint on at all times except remove before meals and suggested PROM (Passive ROM) of L(eft) digits to improve functional mobility . According to the 02/05/18 OT discharge summary Patient responded positively to passive techniques to stimulate functional performance and enhance safety to prevent further decline and patient's functional performance has improved as a result . OT recommended a .splinting/orthotic schedule of L hand splint in order to preserve current level of function . Resident #64 was discharged from OT services on 02/05/18 with a recommendation for RNP: to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): splint of left hand . Resident #64's prognosis (for preventing decline in ROM and progression of contracture) was assessed to be Good with consistent staff follow through. Review of the facility RNP flowsheets between 02/09/18 and 04/18/18 revealed no RNP to include ROM and splint application was provided to Resident #64. On the morning of 10/10/18, Staff G (Resident Care Manage indicated the Restorative Aide (RA) may have documentation elsewhere (not part of the resident's medical record). Review of the documents provided, for the above timeframe, revealed the RA documented hold.(splint and ROM programs) According to a hand written key provided by the RA hold usually means therapy picked up. However, record review revealed OT discharged the resident 02/05/18 and Resident #64 was not seen by OT again until 09/27/18. On 10/03/18 at 9:13 a.m. Resident #64 was observed with bilateral hands clenched/flexed, appearing to be contracted, with a hand roll in the right hand and no device in the left hand. Similar observations were made on: 10/04/18 at 9:32 a.m. a hand roll was observed in the left hand and no device in the right hand; and 10/05/18 at 10:03 a.m. the resident was observed with hand rolls in both hands. In an interview on 10/10/18 at 11:08 a.m. when asked why Resident #64's ROM and splinting programs were not provided 02/22/18 to 04/18/18 as she was assessed to require, Staff C (Deputy Director of Nursing, and Restorative nurse) indicated there was concern that Resident #64 had a wrist fracture, so the splint was discontinued. The order to discontinue the splint was requested but facility staff were unable to find an order discontinuing the splint. Staff C indicated that Staff S (Director of Rehab and the treating OT for Resident #64) may have further information. On 10/10/18 at 11:17 a. m. Staff S stated, .I recommended to hold the splint pending confirmation of a fracture or not .in the clinical meeting I recommended a palm protector (while the splint was on hold pending confirmation of a fracture.) Record review revealed a 02/07/18 2 view X-ray of the left hand stated, .there is a linear lucency in distil ulna which may represent an acute non-displaced hairline fracture versus artifact. On 02/09/18 a 3 view X-ray of the wrist was performed at the hospital and concluded no significant radiographic abnormalities (no fracture). On 10/10/18 at 11:28 a.m. when asked, if a resident's splinting program was placed on hold out of concern for a potential wrist fracture, and then it was determined two days later that there was no wrist fracture, what should have occurred, Staff L stated the resident should have been referred back to rehab. When asked if this occurred Staff C stated, no. When asked if there was any indication that Resident #64 received the palm protector or ROM program between 02/22/18 and 04/18/18 Staff C stated, When I took over Restorative I noticed she was not receiving her program and I restarted them in (MONTH) (2018). Record review revealed a 04/19/18 Restorative Note that stated, PROM to all extremities. 2 sets of 10 then apply palm guard to left hand after providing hand care, 6-7 days a week re-started resident on restorative for ROM to all extremities . There was no explanation why the resident had not been receiving the ROM program or indication as to why the splint was not being applied as the resident was assessed to require. Additionally, the RA's were placing a hand roll instead of a palm protector Review of the RNP flowsheets, after the program was re-started, revealed facility staff failed to consistently provide the program 6-7 days per week. In a 14 day period from 8/31/18 to 9/13/18 the resident should have received the RNP a minimum of 12 times. The program was only provided six times. A 09/27/18 Nursing/Therapy Communication form stated, Please eval(uate) 2/2 (secondary to) Bilat(eral) hand contractures, possible splint placement, ROM .RA reported increased contractures/decreased ROM to Bilat hands/wrist. According to a 09/27/18 OT evaluation Resident #64 was referred to therapy .due to exacerbation of decrease in range of motion, decreased skin integrity and pain placing the resident at risk for contracture(s) . OT's assessment of the left upper extremity revealed .contracture of left/hand wrist .digits flexion < (less than) 90 degrees, deformity of the 3rd (digit) .Patient + noticed of worsen L hand contracture/ worsen skin integrity with funky smell of left hand . The long term goals for the left hand were identified as .will wear least restrictive splinting/orthotic device for L hand all the time or 4 hours on/ 4 hours off without redness . A 09/27/18 OT treatment note stated, .orthotic device palm guard with finger separator with difficultly of fitting due to complexity of contracture: L wrist flexed 2-5 digits with tips into palm, 3rd is the worsest (sic) with very limited ROM . In an interview on 10/10/18 at 12:59 p.m when asked if the contracture to Resident #64's right hand was worse Staff S stated, Yes. When asked why he recommended a grip splint back on 02/05/18 Staff S stated, (Resident #64) was high risk for contracture and (alteration in) skin integrity .it (the splint) was to decrease the risk. When the resident's splint was put on hold for a potential wrist fracture and then two days later it was determined there was not a wrist fracture, was the splint re-implemented or assessed to see if the resident could tolerate it? I don't think so. When asked if the hand roll RA staff were using was a palm protector/guard or a splint Staff S stated, no .(Resident #64) is a special case, anything you put in her hand she grasps onto and cannot release. When asked if putting a hand roll in the resident's hand causing it to grasp, resulting in her hand remaining in a flexed position, increased the risk for progression of contracture Staff S did not respond. When asked if a hand roll was the best preventative measure for this resident Staff S stated, No. OT's 09/27/18 assessment of the right upper extremity ROM revealed .decreased AROM of the 3rd and 5th digits of the R hand .with flexion -10 to -20 degrees, decreased AROM to R shoulder/elbow . The long term goals for the Left hand were identified as .will safely wear a resting hand splint on right hand for up to 8 hours . In an interview on 10/10/18 at 12:59 p.m. when asked why there was no documentation of a contracture or increased tone to the right hand on the 01/17/18 OT evaluation Staff S stated, The right hand was OK .I would have documented that (tone or contracture) if it were there. So the right hand has declined ROM too. Yes The facility's failure to implement preventative measures the resident was assessed to require resulted in the resident experiencing a decline in ROM to bilateral hands. RESIDENT #6 According to the 07/15/18 Quarterly MDS Resident #6 required extensive assistance with most Activities of Daily Living (ADL), had functional limitations in ROM to both lower extremities, received a AROM RNP on three of seven days in the assessment period, and was cognitively intact, with clear comprehension. On 10/03/18 at 2:28 p.m. Resident #6 expressed I can't lift my shoulders all the way up .I have a exercise program (RNP) but sometimes I don't get two of the days (that were scheduled) because they (RA) get pulled (to work on the floor.) A Limited physical mobility care plan, initiated 10/13/14, directed staff to provide .AROM to all extremities with red theraband 3 sets of 10, 5-6 days per week. Review of the RNP flowsheets for a three week period from 08/28/18 to 9/17/18 revealed Resident #6 was provided her RNP on 8 occasions. However the RNP should have been provided a minimum of 15 times. In an interview on 10/12/18 at 6:57 a.m. when asked if the facility was consistently providing Resident #6's RNP at the frequency she was assessed to require Staff G stated, No. REFERENCE: WAC 388-97-1060(3)(d)

Based on observation, interview and record review, the facility failed to implement measures to prevent development of avoidable pressure ulcers, timely identify, assess, monitor, obtain treatment orders and implement interventions to prevent/heal pressure ulcers, for two (#s 64 & 45) of five residents reviewed for pressure ulcers. These failures placed resident #45 at risk for unidentified wound decline, and resulted in harm to Resident #64, who developed an avoidable pressure ulcer, with full thickness skin loss. Findings include: Refer to CFR: 483.25(c)(1)-(3), F-688, Increase/Decrease ROM/Mobility RESIDENT #64 Resident #64 admitted to the facility on [DATE]. According to the 09/24/18 Quarterly Minimum Data Set (MDS, an assessment tool) the resident had [DIAGNOSES REDACTED]. The resident was also assessed to have severe cognitive impairment and was only sometimes understood. On 10/03/18 at 9:13 a.m. Resident #64 was observed with bilateral hands clenched/flexed, contracted, with a hand roll in the right hand and no device in the left hand. Similar observations were made on: 10/04/18 at 9:32 a.m. a hand roll was observed in the left hand and no device in the right hand; and 10/05/18 at 10:03 a.m. the resident was observed with hand rolls in both hands. No palm guard or grip splint was noted in place to protect the resident from pressure. Record review revealed a 10/05/18 1:13 p.m. progress note that stated, Pressure ulcer noted to the left middle finger (practitioner) and family notified. No assessment was present of the wound characteristics, stage, size or location on the middle finger. A 10/10/18 wound consult assessed the resident to have a .pressure ulcer located on the left hand-3rd digit. The wound measures 0.4 cm (centimeters) x 0.4 cm .there is no tunneling or undermining noted .there is a small (1-33%) amount of necrotic (dead) tissue within the wound bed including eschar .The wound is currently classified as unstageable .the finger damage would seem to be related to the use of a device which was the wrong size given her contractures . Record review revealed Resident #64 was treated by Occupational Therapy (OT) in January/February (YEAR). A 01/30/18 OT treatment note indicated the resident required a .Left hand grip splint .for skin integrity 2/2 (secondary to) flexion tone to left hand with fingers into palm . According to the 02/05/18 OT discharge summary, OT recommended a Restorative Nursing Program (RNP) to include ROM to to all extremities and a left hand grip splint with a prognosis (maintaining current level of function and skin integrity) of Good with consistent staff follow through. Further review of the resident's OT records found the restorative program was insufficient, it was not implemented as the resident was assessed to require for hand positioning; and the required device to maintain skin integrity was not used, (palm guard instead of grip splint) and was not the correct size as per the wound consult note. In an interview on 10/10/18 at 12:59 p.m. when asked if the hand roll RA staff were using was a palm protector/guard or splint Staff S (Director of Rehab and treating OT) stated, no. When asked if a hand roll was the best preventative measure for this resident Staff S stated, No. Failure of the facility to consistently provide RNP services and OT treatment to apply the appropriate devices (grip splint) as the resident was assessed to require, resulted in progression of Resident #64's left hand contracture and subsequently a full thickness pressure ulcer to the tip of her left middle finger. RESIDENT #45 Resident #45 admitted to the facility on [DATE]. According to the 06/30/18 admission and 09/13/18 Quarterly Minimum Data Sets (MDS, an assessment tool), the resident required extensive assistance with ADLs, was understood with clear comprehension, and was at risk for pressure ulcers. A 06/25/18 Potential for pressure ulcer care plan had a listed goal of Will have intact skin .through next review. Staff were directed to Notify Nurse immediately of any new areas of skin breakdown .Administer treatments as ordered and monitor effectiveness .Inform resident/family/caregivers of any new area of skin breakdown . In an interview on 10/03/18 at 1:14 p.m. Resident #45 stated. I have a sore on my foot wanna look at it, (resident removed left shoe and sock) revealing an undated dressing to the top of the left foot, with rolled edges and a dime sized brown stain. When asked how long the dressing had been there Resident #45 responded, About two weeks I think .I guess a should have said something to (the nurse), she probably forgot about it, I will tell her now. Record review revealed no indication that the resident had a wound to her left foot. Review of the (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARs) revealed no order for a treatment to the left foot. Review of the progress notes for (MONTH) and (MONTH) (YEAR) revealed no documentation that a wound had been identified, a treatment was placed, or that the Physician had been notified. On 10/03/18 1:32 p.m. Staff B (Director of Nursing) explained that it was the expectation when a new wound is identified that the nurse measure and assess the wound, notify the physician and obtain a treatment order, transcribe the order to the TAR, provide the treatment, date the dressing, and place the resident on alert. On 10/03/18 at 1:34 p.m. Staff B observed Resident #45's left foot and acknowledged there was an undated dressing with rolled edges and A scant amount of dry 'brownish' drainage. When asked if there was any indication or documentation in the resident's record that staff had identified a wound to the resident's left foot Staff B stated, no and acknowledged that there were no measurements , assessment, Physician order [REDACTED]. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review it was determined the facility failed to ensure, for one (Resident #1) of three sampled residents reviewed for tube feeding, physician's orders [REDACTED]. This failure caused Resident #1 to experience a critical change in condition requiring hospitalization and surgical remedy. Findings included: Refer to CFR 483.20(k)(3)(i), F-281, Services meet Standards According to the 01/22/17 Minimum Data Set (MDS) assessment, Resident #1 admitted to the facility on [DATE] for rehabilitation after surgical repair of a [MEDICAL CONDITION] and with a [DIAGNOSES REDACTED].#1 as cognitively impaired and requiring extensive assistance of one to two staff for activities of daily living. According to the facility's 11/11/16 Enteral tube feeding policy, staff were to Verify the practitioner's order for enteral feeding . Review the patient's medical record to make sure that tube placement was confirmed before beginning the feeding . Assess for GI (gastrointestinal) intolerance to tube feedings every 4 hours by assessing abdominal distention, monitoring complaints of abdominal pain . monitoring gastric residual . According to the facility's 01/22/17 Occurrence report, the resident was noted as a new tube feeder via PEG (grastrostomy) placed in hospital 01/13/17 for nutritional support in light of new/sudden onset dysphagia (trouble swallowing) and NPO (nothing by mouth) status. On 01/21/17 rsd noted with faulty PEG tubing/site; MD in house and notified of leakage with order received to replace PEG in house and verify placement. Upon return of x-ray LN (Licensed Nurse) noted that tube projects in the left mid abdomen in it's expected location on review; LN proceeded to call and leave message with MD (Medical Doctor) urgent line and fax x-ray results to MD and then resume TF (tube feeding) per prior orders . The 01/22/17 Schryver Medical radiology report of the 01/21/17 abdominal x-ray included, PEG tube is in the left mid abdomen. Following contrast injection there is opacification of the stomach, but what appears to be extra gastric contrast concerning for extravasation . This meant the contrast, used by the radiologist to check the position of the feeding tube, was escaping into the abdominal cavity not just the stomach. The physician did not receive the x-ray results until 01/22/17 at which time Staff E, physician, notified the facility and requested Resident #1 to be assessed. The facility determined on the evening of 01/22/17 Resident #1 was, noted with rigid abdomen and pain with palpation . Not only did staff implement the tube feeding at 80 cubic centimeters per hour for 11 hours on the night of 01/21/17, they failed to implement policies to assess a resident every four hours after initiation of a tube feeding and continued to administer medications. Record review did not reveal the original physician's orders [REDACTED]. Interview with Staff A, Administrator, Staff B, Registered Nurse and incident investigator, Staff C, Registered Staff Nurse, and Staff E, Resident #1's physician, on 01/26/17 at 5:00 p.m., revealed the facility identified potential problems with Resident #1's PEG tube requiring physician notification and eventual replacement. These staff agreed Staff D, the night shift Licensed Practical Nurse, notified the physician via phone and fax of the radiology results after the PEG was replaced but did not wait for a response from the physician before implementing the infusion of the liquid nutrition which ran all night. The facility did not transcribe physician's orders [REDACTED]. [REDACTED].#1 for condition after implementation of the tube feeding. Resident #1 was in critical condition at discharge to a local hospital for surgical repair for these errors.

Based on interview and record review the facility failed to ensure care and services were provided for two (#1 & 2) of four sample residents reviewed. Failure to ensure Resident (#1), who was dependent upon staff for liquid nutrition, received required tube feedings and blood sugar checks caused the resident to experience low blood sugars resulting in decreased level of consciousness, which constituted harm and placed the resident at risk for coma and death. Failure to ensure Resident # 2 received the assistance he was assessed to require for meals caused him distress and placed him at risk for low blood sugars. Findings include: RESIDENT #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 12/05/12 at 9:55 a.m. revealed the resident sitting in his wheelchair in his room. The resident was unable to answer questions as English was not his primary language. Review of November 2012 Physician order [REDACTED]. There was an additionally PO which directed staff to "notify MD if (bs-blood sugars) less than 70 or greater than 350". Review of November 2012 Medication Administration Records (MARs) revealed the resident required three times a day bss and had a bs of 396 on 11/08/12. There was no evidence the physician was notified. Similar findings were identified when facility staff failed to notify the physician of bss outside parameters on 11/09/12 (bs was 69), 11/11/12 (bs was 353) and 11/19/12 (bs was 380). Further review of 11/12 MARs revealed staff documented the resident refused blood sugars on 11/11/12, 11/19/12, 11/20/12, 11/23/12 and 11/ 25/12. There was no noon bs or evidence of refusal documented for 11/26/12. There was no indication facility staff notified the physician of these refusals or attempted to determine the cause of these refusals. The facility failed to keep the physician fully informed of the resident's condition. Staff G documented on 11/23/12, "After report I checked on (Resident #1) His tube feeding was not connected and he was only rousable with vigorous tactile stimulation. I checked his blood sugar and it was 33." Record review revealed Staff G, "administered orange juice via his (feeding tube) and started his tube feeding. I re-checked his bs and it was 95. He was then alert and oriented to self." There was no evidence facility staff considered the emergence of the resident's condition given his history of unstable blood sugars. Facility staff failed to consider the clinical repercussions of the administration of 25 units of insulin at 10:00 a.m. in the absence of tube feeding for nine hours, more than twice the amount of time the physician intended. On 11/30/12, the resident was identified with a bs of 39 and sent to the emergency room for treatment. RESIDENT #2 According to the 9/21/12 MDS, Resident #2 had multiple complex medical [DIAGNOSES REDACTED]. According to incident documents, Resident #2 stated at 10:00 p.m. on 11/22/12 (Thanksgiving) that he didn't get fed his dinner until after 10:00 p.m. (dinner was scheduled to be served at 5:30 p.m.). According to facility investigation documents, the resident stated, "I woke up and saw my tray and started yelling for someone to come feed me. I didn't know what time it was." According to this document the resident last received incontinent care at 5:00 p.m. The summary of Investigation Outcome indicated, "Resident was sleeping in bed with his tray at the bedside. It is unclear whether she (staff E) attempted to wake him up and feed him or not. I interviewed the CNA assigned to (the resident) (who) stated she was not told that Resident had not been fed and she did not see the tray as it was placed on the bedside table where it was not visible." Observation on 12/05/12 at 10:05 a.m. revealed the resident lying in bed, a bedside stand and two overbed tables next to the bed, clearly visible from just inside the door. There was no evidence facility staff considered the resident received no incontinent care from 5:00 p.m. to 10:00 p.m. when he notified staff he was not fed. There was no evidence facility staff determined how the resident, upon waking, could see his tray, but the CNA responsible for the resident's care didn't see the tray from the time it was delivered at approximately 5:30 p.m. and the end of shift at 10:00 p.m. In an interview on 12/05/12 at 10:40 a.m., when asked how the CNA responsible for providing incontinent, oral and p.m. care for this resident didn't see the tray, Staff B stated, "I hadn't considered that." The facility's failure to provide nutrition, either through tube feeding or provision of assistance, caused Resident #1 to experience harm and placed Resident #2 at risk for harm. Failure to ensure staff received training they were determined to require placed additional residents at risk for suffering a similar negative outcome.

Based on interviews and record reviews, the facility failed to ensure three of five residents (#1, #4, #6) received physical therapy (PT) according to their evaluations and care plans. This failure contributed to one resident having severe pain and placed her at risk of decline. The failure placed two additional residents at risk of physical decline and injury. Findings include: RESIDENT #1 In interview on 12/19/11 at approximately 11:50 a.m. Staff C reported that during PTt with Staff D, Staff C observed Staff D had Resident #1 use a "platform" four wheel walker (FWW) (a FWW with a device to place the right arm on an upright handle of the walker). According to Staff C, the platform walkers were utilized for residents with a paralyzed arm, to rest the arm on the platform. Staff C explained Resident #1's care plan (CP) did not include using the device, and Resident #1 complained about severe pain with the device, as Resident #1 had a [MEDICAL CONDITION] shoulder and arm. At approximately 12 noon, Staff F explained that when residents have pain, PTs and PTAs were to respect the residents, and it was desirable not to push them to the point where they were unable to do therapy. Staff E explained that frequently after Staff D worked with residents the PT and PTAs "put out fires" to encourage residents to work with PTAs again, and Staff E felt Staff D did not respect the residents and pushed them hard. At approximately 1:55 p.m., Resident #1 explained when Staff D had Resident #1 use the walker with a raised arm lift on one side, it was the side of Resident #1's fractured shoulder and arm. According to Resident #1, it hurt so bad, she couldn't stand it, and she cried. Resident #1 said when she cried, Staff D put the resident's arm down. Review of Resident #1's evaluation and CP for PT revealed the CP included use of a wheeled walker for maneuvering around obstacles, and needed stand by assist. The CP did not include use of a platform walker. Staff D's 12/7/11 progress notes did not reflect use of a platform walker with Resident #1, and the documentation did not indicate Resident #1 complained of pain during the PT session. Review of Staff E's 12/8/11 progress notes revealed Resident #1 complained of increased soreness "after ambulation yesterday", and pain treatment was applied to the resident's right neck and shoulder. On 12/9/11, Staff E again applied pain treatment, and Resident #1 reported the pain was less. RESIDENT #6 Staff C reported that she observed Staff D have Resident #6 use a "cart" by pushing it, instead of pulling it as it was meant to be used, and the resident almost fell . Staff C said no resident's CP included using that cart in PT. In interview at approximately 12 noon, Staff E explained that the cart Staff D used during a PT session with Resident #6, was extremely dangerous, especially for residents using assistive devices, such as Resident #6 who used a walker. According to Staff E, carts such as the one Staff D used to work with Resident #6 were never used and were never included in any resident's CP. Staff E said she reported Staff D's improper use of the cart during Resident #6's PT session directly to Staff B. According to Staff E, Staff D did not document what was done during PT sessions, or resident's responses to PT. Review of Resident #6's PT CP did not include use of a cart, and there was no documentation in progress notes that a cart had ever been used. RESIDENT #4 At approximately 1:25 p.m., Resident #4 explained that Staff D "did things the other PTAs did not do." According to Resident #4, Staff D did not use the resistance bands to do strengthening excercises, but rather, Staff D used her hands for resistance. In interview at approximately 4:00 p.m. Staff F explained the bands were used for resistance and strengthening, as the bands offered objective units of measurements. Each band had a color, representing a certain resistance, so that the resident's improvement status was able to be assessed. Staff F said hands were not used for resistance and strengthening excercises, as there was no way to measure the resident's strength status. Review of Resident #4's assessment and CP indicated specific strengths that the resident currently functioned at, and the specific strengths that were the goals for PT. According to Staff F, resident pt evaluations and CPs were done by Staff F, PT. Staff F explained that PTAs were expected to document what residents did during PT and how the residents responded, such as if there was any pain, or what strength status the resident reached during the session. In interview on 12/19/11 at approximately 11:15 a.m., Staff A said eight residents complained about Staff D, and requested to work with another physical therapist assistant (PTA). Staff A explained residents requested to not work with Staff D for pt due to personality conflicts. Staff A further said, sometimes physical therapists (PTs) do things that cause pain to residents. At approximately 11:20 a.m. Staff B said he knew Resident #1 did not want to work with Staff D, however, Staff B did not know why. Staff A and Staff B both explained there were no documents regarding these resident's complaints.

Based on observation, interview and record review the facility failed to ensure two of thirteen sampled Residents (#13 & 5) reviewed for medication administration were free of significant medication errors. This failure resulted in significant change in condition which caused the residents to be sent to the hospital. Findings include: Refer to CFR 483.20(k)(3)(i), F-281 RESIDENT #13 According to Resident #13's 10/28/11 discharge Minimum Data Set assessment (MDS), the resident's [DIAGNOSES REDACTED]. The resident's care plan included checking the blood pressure (BP) every shift (every eight hours), encourage fluids, and call the physician if the BP (systolic-top number) was less than eighty. In an interview on 11/01/11 at approximately 2:15 p.m., Staff M explained that on 10/28/11 during the morning medication pass, (approximately 9:00 a.m.), Staff M trained a new Staff member to pass medications. Staff M said that during the 10/28/11 medication pass, the new Staff administered Resident #14's medications to Resident #13. Staff M said she had her back turned while the new Staff administered the medications. In an interview on 11/06/11 at 3:00 p.m., Staff C stated it was the facility expectation that the orientee be supervised at all times. Staff C confirmed the orientee was not supervised. Review of medication administration records (MAR) and physician orders [REDACTED]. Each of these medications were contraindicated for Resident #13 whose [DIAGNOSES REDACTED]. In an interview on 11/01/11 at approximately 1:10 p.m., Staff H explained that Resident #13's BP continued to drop to extremely low levels (top number seventy), and the resident was transferred to the hospital via a 911 call. In an interview on 11/06/11 at approximately 3:00 p.m., Staff C explained the new Staff did not follow standards of practice and did not follow the facility policy and procedure for administering medications to the "Right Resident". This failure resulted in a significant medication error which caused a precipitous drop in Resident #13's blood pressure. RESIDENT #5 According to Minimum Data Set assessments ((MDS) dated [DATE], 10/18/11, and 9/02/11, Resident #5 had [DIAGNOSES REDACTED]. Physician order [REDACTED]. In an interview on 11/01/11 at approximately 12:35 p.m., Staff H explained that on 10/13/11 while Staff K cared for residents on the night shift (between 10:00 p.m. and 6:00 a.m.), Resident #5 reported feeling pain in the abdomen. According to Staff H, Resident #5's blood pressure (BP) was found to be 200/100, and that was unusually high for the resident. Staff H said Staff K administered three doses of [MEDICATION NAME] to Resident #5, then three doses an hour later, and the resident's BP did not change. Staff H explained that Staff K gave Resident #5 a seventh dose of [MEDICATION NAME] at 2:30 a.m., and at 3:00 a.m. sent the resident to the emergency room (ER) with a BP of 262/130. Staff H said Staff K treated the resident's abdominal pain with [MEDICATION NAME], the medication used for the chest pain, and there was no evidence the physician was notified according to the PO. Staff K administered four doses of [MEDICATION NAME] without a physician's orders [REDACTED]. According to Staff H, on 10/19/11 during the night shift, Resident #5 had another crisis with elevated BPs. Staff H explained that Staff K administered three doses of [MEDICATION NAME], waited thirty minutes and gave another three doses, then notified the physician. Staff H said the physician ordered another three doses to be given, and Resident #5's BP remained elevated. When Staff K called the physician again, the direction was to not give Resident #5 anymore [MEDICATION NAME], however, according to Staff H, Staff K gave the resident three more doses, against physician orders, before sending Resident #5 to the hospital. Review of the 10/19/11 progress note revealed at 10:30 p.m., Resident #5's BP was 198/102, and Staff K gave the resident three doses of [MEDICATION NAME]. At 11:30 p.m. Resident #5 had a BP of 250/110 and Staff K noted three doses of [MEDICATION NAME] were given, and then the physician was called. Staff K noted three more doses of [MEDICATION NAME] were given, and the resident's BP was 215/90. At 5:00 a.m. the resident's BP was 240/100, and again at 5:45 a.m., when the resident's BP was 225/100 after three more doses of [MEDICATION NAME] were given. Staff K administered six doses of [MEDICATION NAME] without physician's orders [REDACTED]. In interview on 11/01/11 the resident's physician (MD) said the standard use of [MEDICATION NAME] was to give up to three doses specifically for chest pain, not for controlling BPs. The MD explained that Staff K was never directed to administer nine doses of [MEDICATION NAME] to Resident #5. On two separate occasions, 10/13/11 and 10/19/11, Staff K failed to administer the medication according to the physician orders, failed to administer the medication as indicated and at the correct frequency which contributed to the resident being sent to the emergency room twice, constituting significant medication errors. .

Based on observation, interview and record review the facility failed to ensure sufficient supervision of a Nurse-in-training. Failure to ensure the orientee administered the correct medication to the correct resident resulted in one resident (#13) recieving incorrect administration of multiple contraindicated medications. This failure caused a precipitous drop in blood pressure, which required hospitalization and posed a risk for death. Additionally, the facility failed to ensure professional nursing standards were met, including ensuring: two residents (#s 1 & 2), received the right doses of their medications; physician's orders [REDACTED].#5) with a chest pain protocol; POs were accurate for five (#s 3, 4, 6, 9 and 10) of five newly admitted residents; three of three nursing staff (Staff D, E and F) followed POs and/or manufacturer recommendations for three (#s 11, 12 and 6) of three residents reviewed during medication pass; and accurate documentation of injection sites for two (#s 11 & 9) of three residents reviewed with injections. These failures placed residents at risk for [MEDICAL CONDITION] upset, a potential for alteration in the desired therapeutic effects related to receiving dosages of medications that were not ordered, and tissue irritation due to lack of injection site rotations. Findings include: RESIDENT #13 Refer to CFR 483.25 F333-Significant medication error. On 11/01/11 at 1:10 p.m., Staff H said that Resident #13 received Resident #14's medications during the morning medication pass on 10/28/11. According to Staff H, Resident #13 was emergently transported to the hospital via a 911 call for an extremely low BP, after receiving Resident #14's medications. In an interview on 11/01/11 at 2:15 p.m., Staff M explained that on 10/28/11, she was training a new Staff member to administer medications. Staff M said her back was turned and the new Staff administered medications. Staff M identified that the new Staff administered Resident #14's medications to Resident #13. On 11/06/11 at approximately 3:00 p.m., Staff C said the expectations for training staff was to stay with the orientee, especially on the first day, and this was the orientee's (new Staff) first day. According to Staff C, the orientee did not identify the "right" resident before administering the medications. Facility Procedure for Medication Administration indicated, "...The licensed nurse (LN) will check the following to administer medication: "...Right medication...Right dose...Right Resident..." RESIDENT #s 1 AND 2 In interview on 11/01/11 at approximately 12:30 p.m., Staff H said that in August 2011, Staff K administered incorrect doses of medications to Resident #s 1 and 2. According to Staff K, another licensed nurse (LN) discovered the medication errors during the narcotic count at the beginning of the next shift. Review of Resident #1's August 2011 narcotic log revealed Staff K administered twice the ordered dose of the [MEDICATION NAME] on 8/08/11 at 2350 (11:50 p.m.) and on 8/09/11 at 0400 (4:00 a.m.). The PO was to administer one tablet, however, on both occasions, Resident #1 was given two tablets. According to Resident #2's August 2011 narcotic log, the PO was to give one half to one milliliters of [MEDICATION NAME], every hour as needed. On 8/08/11, Resident #2 received two milliliters at midnight. FACILITY REFERENCE SOURCES According to the 2010 Nursing Drug Handbook, 30th anniversary edition by Lippincott, indications and dosages for the use of [MEDICATION NAME] tablets was to dissolve under the tongue as soon as chest pain occurred. Repeat every five minutes, if needed for fifteen minutes, for a maximum amount of three doses within a fifteen minute period. Omniview.omnicare web drug info stated: "...If chest pain is not gone after fifteen minutes and three doses of [MEDICATION NAME], call 911. Do not use more than three doses during an attack unless directed by the doctor...". RESIDENT #5 Refer to CFR 483.25 F 309-Care and Services/Highest Practicable. Resident #5's POs included [MEDICATION NAME] 0.4mg (milligram) tablet under the tongue (SL). "Give 1 tablet SL every five minutes x3 as needed for chest pain. Contact MD if no relief." The resident's POs also included medications for pain management and blood pressure control. On 10/13/11, Staff K treated Resident #5's complaints of abdominal pain with [MEDICATION NAME] (ordered for chest pain), and gave a total of seven doses before calling 911. The physician was not called after the first three doses, or the second three doses. On 10/19/11, Staff K administered three doses of [MEDICATION NAME] at 11:00 p.m. and again at 11:30 p.m.. Staff K called the physician at 2:00 a.m. and was directed not to give [MEDICATION NAME]. At 5:00 a.m. Staff K administered three additional doses of [MEDICATION NAME] to Resident #5, contrary to POs. In interview on 11/01/11 at 3:45 p.m., Staff L, the resident's physician explained that Staff K was directed to give pain medication to Resident #5 to bring the blood pressure down. Staff L said Staff K was informed that [MEDICATION NAME] was not to be used to control blood pressure. FACILITY POLICY According to the flexible Medication Pass Policy, "To assist with providing an environment that allows for individual differences in schedules a Flexible Medication Pass policy is established...the following will be the flexible medication pass times: PM- Med(ications) to be administered between 1430 and 2030, HS meds to be administered between 2030 and 2230." According to the facility policy on Subcutaneous injections staff were instructed to "document medication administration on the MAR (Medication Administration Record)". MEDICATION PASS OBSERVATIONS RESIDENT #11 Observation of medication pass on 11/02/11 at 3:25 p.m. revealed Staff D prepare and administer multiple medications, including [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] for people on [MEDICAL TREATMENT]), [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication) and [MEDICATION NAME] ( a narcotic pain reliever). Review of POs directed staff to administer the [MEDICATION NAME] "daily with meals". In an interview on 11/03/11 at 1:05 p.m., Staff C stated the dinner meal for Resident #11 was served, "between 5:50 and 6:00 p.m." According to Drugs.com the medication should be taken with meals and should, "Avoid taking any other medicines within one hour before or three hours after you take [MEDICATION NAME]. (This medication) can bind to other medications and make them less effective." Facility practice of administering medications in conjunction with the [MEDICATION NAME] had the potential to detract from the effectiveness of the other medications. Further observation revealed Staff D administered [MEDICATION NAME] at 3:40 p.m. to Resident #11. Staff D indicated at that time she had performed the sliding scale blood sugar check prior to the administration of the medications administered at 3:25 p.m. and that the resident required no sliding scale insulin coverage. According to POs, staff were to check blood sugars, "before meals and at bedtime." According to administrative staff this blood sugar should have been checked within a half hour of the evening meal, not two hours prior to the evening meal. Failure to perform blood sugar checks when ordered by the physician placed the resident at risk for not receiving needed insulin coverage at the time it was intended. According to POs, staff were to administer this insulin "every evening". In an interview on 11/03/11 at 1:01 p.m. Staff C confirmed the physician's intent was to have this insulin administered, "around 6:00 or 7:00 p.m.". Staff C further indicated facility time codes for medication administration (evening medications administered in a six hour window) did not reflect the intended times for insulin administration and should be clarified. Administration of insulin three hours before the physician ordered time placed the resident at risk for unstable blood sugars. Additionally, review of the 11/11 MAR indicated insulin injection site as "AB" but according to facility injection site documentation protocol "AB" is not a site used for injections. When asked on 11/02/11 at 4:25 p.m., facility administrative staff was unable to indicate where "AB" was on the body. Staff failure to accurately document injection sites prevented staff from rotating injection sites. RESIDENT #12 Observation of medication pass on 11/02/11 at 3:45 p.m. revealed Staff E prepare and administer medications including [MEDICATION NAME] (a medication used to treat muscle spasm) without food. According to the Nursing 2010 Drug Handbook directions for administration of this medication included, "Give with food or meals to prevent GI distress" and patient teaching included, "instruct patient to take oral form (of medication) with milk or meals." Similar findings were identified for Resident #6 when Staff F was observed to administer the medication [MEDICATION NAME], which is recommended to be given with food to decrease [MEDICAL CONDITION] distress. FOLLOWING PHYSICIAN ORDERS RESIDENT #3 Record review revealed Resident #3 received a PO on 10/12/11 for [MEDICATION NAME] (an antipsychotic medication) 0.25 mgs every evening. Review of 10/11 MARs revealed staff transcribed the order to read, "[MEDICATION NAME] 0.5 mgs". In an interview on 11/02/11 at 1:25 p.m. Staff G confirmed the order was transcribed incorrectly, which resulted in the resident receiving double the intended dose for more than two weeks. Administration of double the intended dose of an antipsychotic medication placed the resident at risk for increased sedation and falls. RESIDENT #4 Resident #4 was admitted to the facility on [DATE] with multiple complex medical diagnoses, according to the admission Minimum Data Set. According to Telephone Orders (TO) dated 10/27/11 staff were to administer Vitamin D 2000 IUs. Another TO dated 10/28/11 discontinued this order, however, review of 11/11 MARs revealed staff continued to administer this medication on 11/01 and 11/02/11 without a PO. Failure to ensure medications were accurately transcribed according to POs placed the resident at risk for adverse side effects related to higher than intended dose. RESIDENT #6 Resident #6 was admitted to the facility on [DATE] with POs from hospice, including "polyethylene [MEDICATION NAME] 3350 17 GM (grams)...17 GMS much too large- if needed give sparingly". Review of the 11/11 MAR indicated much too large." In an interview on 11/02/11 at 2:37 p.m., Staff C confirmed the order should have been clarified. Additionally, the 11/01/11 admission orders but was transcribed as one tablet only. Staff C confirmed this order was transcribed incorrectly which placed the resident at risk for not receiving the intended dose. Similar findings were identified for Resident #10 whose inhaler medication was transcribed from POs to the 11/11 MAR indicated [REDACTED]." Failure to rinse the mouth after use of this medication placed the resident at risk for oral yeast infections. Additionally, Resident #10 had an allergy of [MEDICATION NAME] listed on his record. A TO, dated 11/01/11, instructed staff to administer this medication. There was no documentation to support staff clarified the order or discontinued the [MEDICATION NAME] as an allergy. In an interview on 11/02/11 at 4:25 p.m. administrative staff confirmed the order should have been clarified. RESIDENT # 9 Resident #9 was admitted to the facility on [DATE] with a PO for as needed (prn) Tylenol. Review of facility admission orders [REDACTED]. Review of 11/11 MARs revealed duplicate prn Tylenol orders. In an interview on 11/02/11 Staff B stated she expected staff to clarify the orders to avoid duplicity. Failure to clarify the PO placed the resident at risk for complications due to higher than intended doses of the medication. Additionally, Resident #9 received subcutaneous injections three times a day for which staff failed to document an injection site which detracted from staff's ability to rotate sites. .

Based on interview and record reviews it was determined that the facility failed to ensure two of thirteen residents (#s 5 & 7) reviewed for medication services received care and services consistent with their needs. This failure contributed to two hospitalization s related to excessively high blood pressure and abdominal pain for Resident #5 and placed Resident #7 at risk of severe pain and sleep deprivation. Findings include: RESIDENT #5 According to Minimum Data Set assessments ((MDS) dated [DATE], 10/18/11, and 9/02/11, Resident #5 had [DIAGNOSES REDACTED]. The resident's health conditions included frequent, severe pain, making it hard to sleep. Physician order [REDACTED]. medications for pain management and to treat high blood pressure. Review of Resident #5's vital signs flowsheets for dates between 9/23/11 and 10/11/11, revealed the resident's systolic (top number) blood pressure (SBP) range was 110-180, and the diastolic (bottom blood pressure number) (DBP) range was 60-83. Resident #5's SBP between 10/14/11 and 10/18/11 ranged from 111-197 and the DBP ranged from 66-81. In an interview on 11/01/11 at approximately 12:35 p.m., Staff H explained that on 10/13/11 while Staff K cared for residents on the night shift (between 10:00 p.m. and 6:00 a.m.), Resident #5 reported feeling pain in the abdomen. According to Staff H, Resident #5's blood pressure (BP) was found to be 200/100, and that was unusually high for the resident. Staff H said Staff K administered three doses of [MEDICATION NAME] to Resident #5, then three doses an hour later, and the resident's BP did not change. Staff H explained that Staff K gave Resident #5 a seventh dose of [MEDICATION NAME] at 2:30 a.m., and at 3:00 a.m. sent the resident to the emergency room (ER) with a BP of 262/130. Staff H said Staff K treated the resident's abdominal pain with [MEDICATION NAME], the medication used for the chest pain, and there was no evidence the physician was notified. Review of progress note written 10/13/11 revealed that at 2300 (11:00 p.m.) Resident #5 complained of abdominal pain, and the resident's BP was 200/102. Staff K gave the resident three doses of [MEDICATION NAME]. Staff K documented at "...2400 (midnight), the resident stated that she felt bad and c/o (complained of) ABD (abdominal) pain, BP 220/100, Nitro ([MEDICATION NAME]) PRN (as needed) given x3 (three doses), SBP (systolic-the top number) went to 190, by 0230 (2:30 a.m.) resident cried and c/o abd pain BP 260/110 PRN nitro given x1 SBP down to 230..."..."Resident sent to hospital by 0300 (3:00 a.m.), BP R (right) arm 227/103, L (left) arm 239/109." According to Staff H, on 10/19/11 during the night shift, Resident #5 had another crisis with elevated BPs. Staff H explained that Staff K administered three doses of [MEDICATION NAME], waited thirty minutes and gave another three doses, then notified the physician. Staff H said the physician ordered another three doses to be given, and Resident #5's BP remained elevated. When Staff K called the physician again, the direction was to not give Resident #5 anymore [MEDICATION NAME], however, according to Staff H, Staff K gave the resident three more doses, and then sent Resident #5 to the hospital. Review of the 10/19/11 progress note revealed at 10:30 p.m., Resident #5's BP was 198/102, and Staff K gave the resident three doses of [MEDICATION NAME]. According to Staff K's end of shift note, the resident's BP was not reassessed until one half hour later, at 11:00 p.m.., when Resident #5's BP was 210/100. It was unclear from Staff K's note if any interventions were implemented for the 11:00 p.m. elevated BP. At 11:30 p.m. on 10/19/11, Resident #5 had a BP of 250/110 and Staff K noted three doses of [MEDICATION NAME] were given, and then the physician was called. Staff K noted three more doses of [MEDICATION NAME] were given, and the resident's BP was 215/90. The BP was not monitored until 2:00 a.m., two and a half hours later, when Resident #5's BP was 210/85. No treatments were implemented for the resident's abnormal BP, and Resident #5's BP was not monitored during the night. The next BP was taken at 5:00 a.m. when it was found to be 240/100, and again at 5:45 a.m., when the resident's BP was 225/100 after three more doses of [MEDICATION NAME] were given. On 10/19/11 Resident #5 was again sent to the hospital for treatment of [REDACTED].#5's BP, placing the resident at risk of stroke or death due to extremely elevated blood pressures. In interview on 11/01/11 the resident's physician (MD) said the standard use of [MEDICATION NAME] was to give up to three doses specifically for chest pain, not for controlling BPs. The MD explained that Staff K was never directed to administer nine doses of [MEDICATION NAME] to Resident #5. The MD said she was not notified Resident #5 was sent to the hospital on [DATE]. Staff K failed to closely monitor Resident #5's BP, placing the resident at risk of stroke or death, and failed to follow the PO's for treating abdominal pain, leaving the resident to experience prolonged pain. RESIDENT #7 According to Resident #7's 10/12/11 annual MDS, the resident's [DIAGNOSES REDACTED]. This MDS also stated that Resident #7 needed pain management for "severe, horrible pain, almost constantly, making it hard to sleep." Resident #7's October 2011 care plan showed the resident's interventions for sleep disruption due to pain and discomfort caused by spasms included repositioning, allowing the resident to direct her own care, and allowing her to set her own routine. In an interview on 11/04/11 at approximately noon, Resident #7 explained that on October 19, 2011 she did not receive medications that were usually given to her at midnight (MN). She said that one of the medications was to prevent spasms, and the other to prevent severe headaches. Resident #7 said the routine was to receive medications at MN, before staff assisted her with turning/repositioning at 12:30 a.m.. According to Resident #7, she felt pain and discomfort when touched or turned due to spasms, beginning from the bottom of the feet, extending to the top of the legs, and into the abdomen. She said when she was turned side to side, it caused a great deal of pain in her back and she needed the medications at MN to avoid discomfort/pain. According to Resident #7, on 10/19/11 at 12:30 a.m., when the nursing assistant (NAC) entered the resident's room to reposition/turn her, she informed staff that she had not received her midnight medications. At 2:30 a.m. she reminded the NAC again, she had not yet received her medications. Resident #7 said at approximately 3:50 a.m., the licensed nurse (LN) administered the medications, three to four hours later than usual. On 11/01/11 at approximately 1:15 p.m., Staff J explained that on 10/19/11, Resident #7 did not receive medications on time. Staff J said the resident waited from midnight (when the medications were normally administered) until 3:45 a.m. before receiving the medications. According to Staff J, between midnight and 3:30 a.m., Resident #7 reminded staff repeatedly that she had not received the medications. Review of Resident #7's October 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the facility incident documentation, the NAC reminded Staff K on four occasions between 12:20 a.m. and 3:30 a.m. that Resident #7 had not received the medications. Staff K did not follow up with either Resident #7 or the other LN, and placed the resident at risk for inadequate sleep related to pain/discomfort. .

Based on interviews and record reviews the facility failed to adequately monitor one out of 12 residents (Resident #1) on anticoagulant therapy following medication adjustment. The facility failed to follow facility standards and did not check the resident's blood clotting time for two weeks after adjusting the medication dose. The facility failed to question interaction between anticoagulants and antibiotics despite warnings from the pharmacy. These failures resulted in the resident experiencing bleeding into his chest cavity. Findings include: The Federal Regulation 42 CFR 483.25 which applies to unnecessary drugs advises facilities that use of anticoagulation therapy must be monitored by [MEDICATION NAME] Time (PT)/International Normalization Ratio (INR), with frequency determined by clinical circumstances, duration of use, and stability of monitoring results. Multiple medication interactions significantly increase PT/INR results to levels associated with life-threatening bleeding. Review of Resident #1's hospital discharge summary dated 4/05/11, revealed the resident was admitted to the facility on [DATE] after undergoing surgery for [REDACTED]. Review of the 4/13/11 lab results revealed an abnormal clotting time of 3.0. The physician had ordered that if the INR was greater than 2, certain medication adjustments were to be made. According to the 4/13/11 physician orders [REDACTED]. Review of the April 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 4/18/11 in addition to the antibiotics, Resident #1 was started on Aspirin for its blood thinner properties. On 4/19/11, a third antibiotic was intiated and discontinued two days later, after the resident received two doses. On 5/13/11 during an interview at 1:50 p.m., the Director of Nursing (DNS) said there was no written policy, however, the facility standard for anticoagulation therapy and dose adjustments in response to an INR outside the acceptable range as ordered by the physician, was to reevaluate the clotting time three to four days later. The DNS explained that when a resident was on antibiotic therapy along with blood thinners, the INR should be checked more frequently. The DNS stated that with every medication delivered to the facility, the pharmacy sent a written memo to the facility explaining drug compatibilities and potential side effects. On 5/13/11 at 1:50p.m. Staff A said the written memos usually arrived with the delivered medications, and she was unable to locate any memo from the pharmacy pertaining to Resident #1's anticoagulation therapy in combination with antibiotic therapy . In interview on 5/16/11 at 9:30a.m., the pharmacist said that on 4/19/11, a written memo was sent that warned the facility of the risks for increased bleeding due to interactions between the blood thinner medication and the antibiotics. The pharmacist stated that Resident #1 was on three different antibiotics, and each antibiotic could possibly interact with the anticoagulant, and cause prolonged bleeding that could potentially be unsafe for the resident. Review of the 4/19/11 written correspondence from the pharmacy to the facility revealed two written pharmacy consults, one for each type of antibiotic due to the potential drug interactions with the blood thinner medication. According to the written warnings, the highest risk for drug interactions occurred when the antibiotics were initiated and when they were discontinued. The recommendation was to closely monitor the lab values as the dose of the anticoagulant may need adjustment. According to the 5/13/11 interviews with nursing staff and the 4/23/11 nursing progress notes, Resident #1 was transported to the emergency room at 2:00 a.m. for increased confusion, profuse sweating, complaints of general weakness, and a lowered blood pressure with an increased pulse. Resident #1 was evaluated at the hospital and it was determined that he had an unsafe elevation of his clotting time, his INR was 10.0, and he was bleeding into his chest cavity. The resident spent time in the intensive care unit and remained in the hospital for twenty days. On 5/18/11 at 9:55a.m. the Medical Director (MD), also the prescribing physician said that two weeks between checking the INR was too long. He explained that when residents were first started on blood thinners, and when residents were on blood thinner medication with antibiotics, the INR was ordered twice a week at first, then if the resident was stable, the labs were done weekly. The facility did not adhere to the standards for more frequent INR evaluations, and did not monitor Resident #1 to determine if/what interventions were needed to prevent the subsequent outcome to the resident.

Based on observation, interview and record review the facility failed to ensure two of three residents (#1 and #2) assessed at risk for falls and requiring safety devices, implemented those safety devices. Failure to implement injury prevention devices contributed to Resident #1 to sustaining a closed head injury. Failure to implement alarms or ensure alarms were operational for Resident #2 prevented staff from identifying unsafe transfer behaviors and potentially preventing falls. Findings include: RESIDENT #1 According to the 8/22/10 Minimum Data Set (MDS) Resident #1 had [DIAGNOSES REDACTED]. According to the 8/22/10 Resident Assessment Protocols, the resident was at risk for falls related to the use of psychotropic medications, "required assistance with all mobility," and "(the resident) can be restless in the bed." The facility indicated a care plan would be developed that would include intervention to prevent falls and injury. Review of the resident's care plan revealed the facility would implement " bed alarm, bilateral mats to each side of bed." Staff C said, in an interview on 10/26/10 at 3:15 p.m., "...The bed was in the medium position because (the resident) was eating, feeding himself...The mat wasn't there...(the) mat should have been there because it would have prevented injury." Resident #1 said, in an interview on 10/27/10 at 8:30 a.m. at a local hospital, "I was leaning over to the side (of the bed), just gravity. The more I leaned the harder it was to straighten up. The farther I went the more afraid I was going to fall, so I called for help. No one came. I guess they didn't hear me. I fell over on my head, then everybody came. The worst thing was I noticed, on the way down (to the floor) my cushion (floor mat) was against the wall. For some reason somebody put it there...I felt worried. I was afraid I'd hurt myself..." October 24, 2010 hospital admission documents revealed the resident sustain a closed head injury. Review of the facility's 10/24/10 evidence of investigation revealed the bed was not in the low position and a housekeeping staff member removed the fall mat. RESIDENT #2 According to the 8/05/10 MDS, Resident #2 had [DIAGNOSES REDACTED]. The resident said, in an interview on 10/26/10 at 3:26 p.m., "No one helped me to fall. It was an accident. I'm not hurt." The resident did not recall how the fall occurred. According to a 7/10/10 fall assessment the resident had a "shuffling gait," and "poor (weight) bearing," in addition to the risk factor identified on the MDS. Staff documented on the assessment the resident had three injury falls and four non-injury falls from April of 2009 to August of 2010. Five of the falls occurred between 5/3/10 and 8/10/10. As a result of this assessment staff developed a care plan that included the application of sensor alarms in the resident's bed and wheelchair. Review of the facility's evidence of investigation revealed the resident independently transferred himself from the wheelchair to the bed on 10/25/10 at 4:00 a.m. According to the investigation the sensor alarm did not sound when the resident rose from the wheelchair. According to the Director of Nursing interviewed on 10/26/10 at 3:34 p.m. and again on 10/27/10 at 12:55 p.m. the alarm did not sound because staff failed to ensure the device was properly attached to the power source after the resident was toileted.