Every finding on record at Olympia Transitional Care and Rehabilitation

Based on observation, interviews and record reviews, the facility failed comprehensively assess residents bladder status and ensure they received appropriate treatment and services to restore or maintain continence to the extent possible for 4 of 4 residents (1, 3, 4, & 5) reviewed for bladder incontinence. This failure placed residents at an increased risk of urinary tract infections, discomfort, loss of dignity, and decreased quality of life.Findings included.<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease. The comprehensive Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment, was always incontinent of urine, is not on a toileting program, and required supervision with toileting.The care plan, dated 06/17/2026, documented staff will use supervision and a front wheeled walker to assist the resident to the toilet. Resident 1 required the use of a disposable brief and staff will check and change the brief. On 08/03/2026 at 12:00 pm, Resident 1 said a staff member told them to use their brief instead of walking them to the bathroom causing them to be incontinent. Resident 1 said additional staff members did not bring the resident to the bathroom to maintain continence during their stay at the facility. Resident 1 said it is their preference to use the bathroom instead of being incontinent. Resident 1 said no one ever spoke with them about their preference or the incident.Hospital Progress notes, dated 06/14/2026, documented Resident 1 required the use of an indwelling catheter (a tube that goes up the bladder to drain urine) during their hospitalization.Hospital Progress notes, dated 06/16/2026, documented Resident 1 required continuous bladder irrigation due to hematuria (blood in the urine) during their hospitalization.Clinical Admission, dated 06/17/2026, documented Resident 1 was always incontinent of urine requiring a check and change schedule while using an adult brief.Physician orders, dated 06/17/2026, showed Resident 1 was administered Flomax (a medication used for urinary retention) 0.4 mg one time daily.Progress notes, dated 06/18/2026, documented a renal ultrasound showed a hematoma or a mass in the bladder. A cystoscopy (a procedure using a scope to look inside the bladder) was planned for a later date.The Bowel and Bladder Evaluation, dated 06/23/2026, documented Resident 1 was always incontinent of bladder, alert and disoriented, had a debilitating disease, and shows willingness. The evaluation documented Resident 1 was an unlikely candidate for a bladder program.Progress notes, dated 06/23/2026, documented Resident 1 saw urology with a cystoscopy scheduled on 07/09/2026 due to hematuria. Progress notes, dated 06/28/2026, documented the resident was found on the floor after a fall. The resident reported he was trying to find the toilet.Bladder Continence, dated 06/22/2026 to 07/02/2026, documented 1 episode of continent bladder. The remainder of the days the resident was incontinent 2-3 times a day.Progress notes, dated 06/18/2026, 06/19/2026, 06/20/2026, 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026, 06/29/2026, 07/01/2026, and 07/02/2026, documented Resident 1 was continent of bladder.Comment or Concern Form, dated 07/01/2026, documented Resident 1's FM said Staff G, nursing assistant, was unwilling to assist the resident to the bathroom because he did not know the resident's transfer status telling the resident to go in [their] brief and did not take the resident to the bathroom.On 08/13/2026 at 2:15 pm, Staff F, nursing assistant (NA), said he would take a resident to the bathroom if that is their preference even if they have episodes of incontinence.At 2:22 pm, Staff C, registered nurse (RN), said residents should be taken to the bathroom if it is their preference even if they have episodes of incontinence. At 3:36 pm, Staff B, RN and Director of Nursing, said the bladder evaluation did not address issues such as the type of bladder incontinence experienced by Resident 1, medication used for urinary retention, a history of hematuria, prior catheter use, a scheduled cystoscopy, or the resident's personal toileting preference. Staff B said the evaluation was not comprehensive. Staff B said residents toileting preferences should be honored. <Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus The quarterly MDS, dated [DATE], documented Resident 3 had no cognitive impairment, always incontinent of urine, is not on a toileting program, and was dependent on staff with toileting.On 08/13/2026 at 2:10 pm, Resident 3 was observed laying in bed. The resident appeared to require assistance from staff with mobility.The care plan, dated 06/04/2026, documented Resident 3 required the use of a disposable brief and staff will check and change the brief upon waking, before and after meals, at bedtime, and as needed. The Bowel and Bladder Evaluation, dated 08/03/2026, documented Resident 3 was incontinent of bladder, alert and oriented, had a history of a debilitating disease, and shows willingness. The assessment documented Resident 3 was a possible candidate for bladder re-training.At 2:15 pm, Staff F, nursing assistant, Resident 3 was incontinent, not on a toileting program and they did not assist the resident to maintain continence. At 3:36 pm, Staff B, said Resident 3 did not have a comprehensive bladder evaluation showing data such as the type of incontinence the resident experienced and was not on a toileting program as recommended by the evaluation. <Resident 4>Resident 4 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus. The comprehensive MDS, dated [DATE], documented Resident 4 had moderate cognitive impairment, frequently incontinent of urine, is not on a toileting program, and was dependent on staff with toileting.The care plan, dated 06/22/2026, documented Resident 4 required the use of a disposable brief. Staff will check and change the brief or offer toileting assistance upon waking, before and after meals, at bedtime, and as needed. At 2:09 pm, Resident 4 was observed sleeping in bed. Resident 4 required assistance from staff with toileting and mobility.Bladder Continence, dated 07/12/2026 to 08/10/2026, documented five episodes of continent bladder and remainder episodes were of incontinent bladder.The Bowel and Bladder Evaluation, dated 06/18/2026, documented Resident 4 was continent of bladder, alert and oriented, had surgery, infection or short-term trauma, and shows willingness. The assessment documented Resident 4 was a good candidate for bladder re-training.At 2:15 pm, Staff F, said Resident 4 was not on a toileting program. At 3:36 pm, Staff B, said Resident 4's assessment was not comprehensive and should have a toileting progress addressed. <Resident 5>Resident 5 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease. The quarterly MDS, dated [DATE], documented Resident 5 had no cognitive impairment, occasionally incontinent of urine, is not on a toileting program, and required partial/moderate assistance from staff with toileting.The care plan, dated 04/24/2026, documented Resident 5 is frequently incontinent of bladder and required the use of a disposable brief. Staff will offer assistance or check and change the resident's brief upon waking, before and after meals, at bedtime, and as needed. The resident visited urology and refused treatment for overactive bladder.The Bowel and Bladder Evaluation, dated 07/30/2026, documented Resident 5 was continent of bladder. Bladder Continence, dated 07/12/2026 to 08/10/2026, documented 59 episodes of continent bladder and 30 episodes of incontinent bladder.At 2:15 pm, Staff F, said Resident 5 was not on a toileting program. At 3:36 pm, Staff B, said Resident 5's assessment was not comprehensive and was not on a toileting program. Reference WAC 388-97-1060(3)(c)

Based on interview and record review, the facility failed to thoroughly investigate and resolve grievances for 1 of 3 residents (1) reviewed for grievances. This failure resulted in continued dissatisfaction among residents regarding how their grievances are being addressed and had the potential to impact residents quality of life. Findings included .Grievances policy, dated 11/21/2024, documented the facility will evaluate and investigate concerns and take immediate action to resolve concern. The facility will respond to the individual expressing concerns within three working days and describe actions taken towards resolution. Resident 1 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease. The comprehensive Minimum Data Set (MDS), dated [DATE], documented Resident 1 had moderate cognitive impairment and required supervision with toileting.The care plan, dated 06/17/2026, documented staff will use supervision and a front wheeled walker to assist the resident to the toilet. Resident 1 required the use of a disposable brief and staff will check and change the brief. On 07/21/2026 at 11:13 am, Resident 1's family member (FM) 1 said she reported concerns to nursing staff about the resident's lack of access to a call light and leaving the resident in dirty clothes. FM 1 said there was also an observed incident when Staff G, nursing assistant (NA), was asked to assist Resident 1 to the bathroom. Staff G stated he did not know Resident 1's mobility status then told the resident to just go in [their] brief and walked away. FM 1 voiced her concern to Staff G but he just made a face and walked away. Staff G did not return to assist Resident 1. FM 1 said Staff G lacked empathy and compassion in caring for Resident 1. Due to the concerns, they transferred Resident 1 to a new facility.On 08/03/2026 at 12:00 pm, FM 1 said she reported her concerns to Staff A, Administrator, on 07/01/2026, but was unaware if they ever acted on the concerns. FM 1 said she did not know if the facility filed a grievance and they did not follow up with her after she met with Staff A. Resident 1 said a staff member told them to use their brief instead of walking them to the bathroom. Resident 1 said it is their preference to use the bathroom instead of being incontinent. Resident 1 said no one ever spoke with them about their preference or about the incident.Comment or Concern Form, dated 07/01/2026, documented Resident 1's FM reported several issues including unchanged clothing, poor call light response time, and an unclean room. A concern was voiced related to Staff G and was described as extremely rude with a bad attitude. Staff G was unwilling to assist the resident to the bathroom because he did not know the resident's transfer status and told the resident to go in [their] brief. The document showed Resident 1 was observed calm and dressed in clean clothing and no signs of psychosocial harm noted. The resident was not interviewed. A call light audit was conducted, and 2 residents were found without a call light. No action was noted. Staff G was educated in customer service and how to access the resident's care plan. No interviews with staff or residents were conducted. The resolution dated was noted as 07/10/2026 but did not indicate the FM or resident was contacted regarding the findings of the grievance.On 08/13/2026 at 4:02 pm, Staff A said he was certain he educated Staff G on the facility standards of assisting a resident to go to the bathroom per their request. Staff A said this education is not documented. Staff A said he could not show he had interviewed staff or residents regarding the concerns in the grievance. Staff A said he thought they resolved the grievance. Refer to WAC 388-97-0460(2)

Based on observation, interview and record review, the facility failed to ensure allegations of injuries of unknown origin were thoroughly investigated for 1 of 3 residents (2), reviewed for injuries of unknown origin. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life.Findings included.Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, All alleged incidents of.injuries of unknown source (IUS).must be thoroughly investigated. A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events.Resident 2 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (a neurological condition which effects movement, muscle control, and posture). The quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 2 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs).The care plan, dated 07/01/2026, documented Resident 2 had bruising noted to the left knee and staff will used bilateral knee pads to decrease the risk of injury during self-mobilization in their wheelchair.On 07/21/2026 at 10:56 am, Resident 2's family member (FM) 1 said an IUS to the resident's left knee was found on 07/01/2026. Resident 2's knee appeared bruised and swollen. Resident 2 is dependent on staff for all care. It was unknown how the IUS occurred, and they still do not know how it happened. FM 1 said the facility did not act promptly to investigate the injury. On 07/21/2026 at 2:33 pm, Resident 2 was observed to spin their wheelchair in circles in the day room. No knee pads were placed on the resident. Skin Issues, dated 06/30/2026, documented Resident 2 had no skin issues. Incident report, dated 07/01/2026, documented Resident 2 was noted to have left knee swelling with a yellow-green bruise present. The skin over the swelling was described as stretched and shiny. No pain was noted at the time of the incident. The resident was unable to explain how the injury occurred. Resident 1 was dependent on staff for all ADLs but will sit in the day room and spin their wheelchair in circles. It was determined Resident 2 likely hit their knee while sitting their room or the day room while spinning in their wheelchair. Bilateral knee pads will be applied to prevent further injury. The investigation lacked interviews with other residents who may have witnessed an incident or staff who cared for the resident. On 08/13/2026 at 2:40 pm, Staff E, nursing assistant, said she was unsure how Resident 2 injured their knee. Staff E said she did not think the resident's knee was hit during a transfer or while spinning in their wheelchair. At 3:36 pm, Staff B, registered nurse and Director of Nursing, said she thought Resident 2 hit her knee while spinning in their room. She did not think this could have happened in the day room. Staff B said no other residents were interviewed. Staff B said she did interview staff but did not have evidence this took place. At 4:02 pm, Staff A, Administrator, said he did not see any resident or staff interviews included in the investigation. Reference WAC 388-97-0640 (6)(a)

Based on observation, interview and record review, the facility failed to provide adequate fluids, within reach of the residents, to maintain hydration for 1 of 4 hallways (Dementia Unit) reviewed for hydration. This failure placed residents at risk for dehydration, medical complications and a diminished quality of life.The findings included. Review of the facility procedure, titled Hydration Rounds Procedure updated 01/21/2026 documented .1. Day shift to collect water pitchers when collecting lunch trays.2. Eve [evening] shift to retrieve clean water pitchers from the kitchen, fill them with ice water, and pass the pitchers out to residents on the hall.On 07/29/2026 at 3:20 PM, observations were made with Staff C, Unit Manager on the dementia unit (a secure dedicated wing providing 24 - hour nursing care, specialized memory loss supervision, and structured cognitive activities for patients with Alzheimer's or other Dementias) showed 11 residents did not have a water pitcher or any fluids available to drink at their bedside. During an interview on 07/29/2026 at 3:30 PM, Staff C was asked how residents are to have water if the water pitchers were removed at lunch (12:00 PM) and were not returned for several hours by the next shift. Staff C acknowledged the facility has a process for staff to pick up dirty water pitchers with the lunch trays and evening shift staff are to return clean water pitchers to resident rooms. Staff C stated she was unsure why water pitchers were not replaced and acknowledged 11 residents did not have water available in their rooms at that time.During an interview on 07/29/2026 at 4:30 PM, Staff A, Administrator, acknowledged the facility had completed corrective actions related to hydration in the dementia unit. He stated his expectation would be for residents to always have access to water or fluids at their bedside. Reference WAC 388-97-1060(3)(i)

Based on interviews and record review the facility failed to honor a resident's choice for a room change for 1 of 1 sampled resident (Resident 80) reviewed for resident rights. The facility's failure placed theses residents at risk of not exercising their resident rights, loss of autonomy, and a diminished quality of life.Findings included. Resident 80 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, MDS-an assessment tool, dated 02/24/2026, documented Resident 80 was cognitively intact. On 04/22/2026 at 8:56 AM, Resident 80 stated, They wanted me to move into this room. They did not give me a choice. I told them I liked the old room better. A review of Resident 80's census in the electronic health records (EHR) showed Resident 80's location on 08/28/2025 was room [ROOM NUMBER]-2 and on 11/03/2025 Resident 80's location was 314-2. A review of Resident 80's EHR showed a nursing progress note, dated 09/29/2025 at 11:18 AM by Staff P, Licensed Practical Nurse Supervisor, that said Resident 80 liked their room and would prefer not to move. Staff P educated Resident 80 on the risks for potential falls or other incidents if they shared the bathroom with 3 other residents. Resident 80 stated, I don't care and clarified, I didn't fall, I sat on the ground. A review of the EHR showed a follow up note with a date of service of 12/12/2025 by Staff S, Medical Director, that stated, prefers current room, declined room change for bathroom access. On 04/23/2026 12:32 PM, Staff C, Social Services Director, was asked if Resident 80 agreed to the room change and she stated, I do not have that documentation. When asked if Resident 80 was notified of the room change Staff C stated, no, it is not scanned in. I don't have that documentation. On 04/24/2026 at 11:27 AM, Staff B, Director of Nursing Services, was asked if Resident 80 agreed to the room change and she said initially Resident 80 wanted to stay in their old room. We don't have documentation that Resident 80 agreed to the change. Staff B said she did not have documentation that Resident 80 was notified of a room change or that Resident 80 was given a choice. Staff B said, If Resident 80 did not want to move they could have stayed on the 400 hall. Reference WAC 388-97-0900(1)-(4)

Based on interview and record review, the facility failed to ensure transfer and discharge notifications to the Office of the State Long-Term Care Ombudsman (patient advocate for all residents in the nursing home) were accurate and/or contained the required copy of the notice for the transfer/discharge provided to residents/representatives, and/or that the facility maintained documentation of the transfer with the required information to be communicated to the receiving health care institution/provider for 5 of 5 residents (Residents 9, 8, 4, 84 & 86) reviewed for hospitalization and discharge. This failure placed residents at risk of lack of advocacy and a diminished quality of life. Findings included . The facility's monthly notifications to the Office of the State Long-Term Care Ombudsman were reviewed for [DATE], February 2026, and [DATE]. All months reviewed showed the resident return columns (expected or not expected) did not match the discharged to columns (acute care, psychiatric care, home, adult family home, assisted living, or expired). Most residents with resident return expected, had a discharge location that was not a hospitalization. Most residents with resident return not expected, had a hospitalization location (acute care or psychiatric care). Additionally, there was not additional information sent with the list, which meant there was no documentation that the facility was providing the required copy of the residents' transfer notice for transfers or discharges to the State Long-Term Care Ombudsman for any of the residents. Resident 9Resident 9 was admitted to the facility on [DATE].The electronic health record (EHR) showed Resident 9 was hospitalized from [DATE] to [DATE] and returned to the facility. The facility's notification to the Office of the State Long-Term Care Ombudsman for [DATE] transfers and discharges, showed Resident 9 was listed as resident return not expected with no indication of where Resident 9 went afterwards. Resident 9's transfer notice was not sent with the notification to the ombudsman. Resident 8Resident 8 was admitted to the facility on [DATE].The EHR showed Resident 8 was hospitalized from [DATE] to [DATE] and returned to the facility. The facility's notification to the Office of the State Long-Term Care Ombudsman for February 2026 transfers and discharges, showed Resident 8 was listed as resident return not expected and discharged to acute care (indicating they were hospitalized and not planned to return to the facility). Resident 8's transfer notice was not sent with the notification to the ombudsman. Resident 4Resident 4 was admitted to the facility on [DATE].The EHR showed Resident 4 was hospitalized from [DATE] to [DATE] and returned to the facility. The facility's notification to the Office of the State Long-Term Care Ombudsman for February 2026 transfers and discharges, showed Resident 4 was listed as resident return not expected and discharged to acute care. Resident 4's transfer notice was not sent with the notification to the ombudsman. The EHR also showed Resident 4 did not have an eInteract transfer form (electronic form that has key details on the resident that is pertinent to the receiving healthcare provider/institution to provide care) filled out for the [DATE] hospitalization. Resident 84Resident 84 was admitted to the facility on [DATE]. The EHR showed Resident 84 was hospitalized on [DATE] and did not return to the facility. Resident 84's transfer notice was not sent with the notification to the ombudsman. Resident 86Resident 86 was admitted to the facility on [DATE].The EHR showed Resident 86 was discharged on [DATE] and left the facility against medical advice (AMA). The facility's notification to the Office of the State Long-Term Care Ombudsman for [DATE] transfers and discharges, showed Resident 86 was listed as resident return expected and was discharged to home. Resident 86's transfer notice was not sent with the notification to the ombudsman. During an interview on [DATE] at 11:33 AM, Staff C, Social Services Director, said that social services was responsible for ombudsman notification. Staff C provided the facility's monthly notifications to the Office of the State Long-Term Care Ombudsman for [DATE], February 2026, and [DATE]. Staff C confirmed only this list was sent to the ombudsman, no other documentation. During an interview on [DATE] at 12:22 PM, Staff B, Director of Nursing Services, was asked to look over the three months of the facility's notifications to the Office of the State Long-Term Care Ombudsman. Staff B acknowledged the form was confusing and reversed from what it should have been and said the anticipated discharge did not match what was happening. When asked if they could tell who was hospitalized and returned to the facility, Staff B said they could only tell who was hospitalized but could not tell who had returned. When asked if Resident 9 was expected to have returned from the hospital based on their chart, Staff B said Resident 9 was expected to return to the facility and the list for the ombudsman had said Resident 9 was not expected to return. During an interview on [DATE] at 1:12 PM, Staff B was asked about Resident 4's [DATE] hospitalization. When asked if there was documentation of the required information to be provided to the hospital or for documentation the hospital was called with report on Resident 4, Staff B confirmed there was not an eInteract transfer form. Staff B said they expected the eInteract transfer form to be filled out so the hospital knew about the resident, or at least a phone report. Staff B reviewed progress notes and confirmed there was none to document report had been called. During an interview on [DATE] at 12:30 PM, Staff B when asked if it met expectations Resident 86 was not indicated to the Office of the State Long-Term Care Ombudsman as an AMA discharge, said no. Reference WAC 388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5)

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice by ensuring nursing staff followed physicians orders, had accurate documentation, and/or by ensuring medications were observed to be taken by residents for 6 of 19 sampled residents (Resident 4, 2, 7, 3, 54 & 65) reviewed for nursing care. These failures placed residents at risk for medication errors, delay in treatment, and adverse outcomes.Findings included .Resident 4 Resident 4 was admitted to the facility on [DATE]. A provider order, dated 04/13/2026, directed licensed nurses to provide diabetic nail care every seven days and as needed. Resident 4's diabetes care plan, initiated 09/25/2025, also showed weekly nail care would be provided by the licensed nurse. On 04/21/2026 at 9:17 AM and 04/23/2026 at 11:13 AM, the toenails to the second, third and fourth digits of Resident 4's left foot were thick, yellow, untrimmed and were curved around the end of the toes to the plantar aspect (underside). The April 2026 Medication Administration Record (MAR) showed on 04/02/2026, 04/14/2026, 04/21/2026 nurses documented the resident's diabetic nail care was not provided, and the diabetic nail care scheduled for 04/09/2026 was left blank. Review of the electronic health record (EHR) showed there was no further documentation to indicate why facility nurses were not providing Resident 4's diabetic nail care as ordered. On 04/24/2026 at 7:49 AM, Staff J, MDS Coordinator, acknowledged facility nurses had documented they did not perform Resident 4's diabetic nail care as ordered and indicated it was because they were unable to. Staff J said Resident 4's toenail care needed to be provided by a podiatrist. On 04/24/2026 at 7:51 AM, when asked if nurses should notify the physician if treatment orders were unable to be carried out, Staff B, Director of Nursing Services (DNS), said yes. When asked if there was any documentation to show the physician was notified of nursing's inability to provide Resident 4's weekly diabetic nail care Staff B stated, No. Resident 2 Resident 2 was admitted to the facility on [DATE] with an order for licensed nurses to perform diabetic nail care weekly. A diabetes care plan, initiated 11/06/2024, directed licensed nurses to provide weekly diabetic foot and nail care. On 04/20/2026 at 1:58 PM, 04/22/2026 at 9:36 AM and 04/23/2026 at 1:12 PM, the fingernails on both of Resident 2's hands were greater than a centimeter long. When asked if this was his preference, Resident 2 said no and explained that facility staff had offered to trim his nails a couple of times, but he asked them to come back later. On 04/23/2026 at 3:47 PM, Staff J, MDS Coordinator, confirmed Resident 2's fingernails were long and untrimmed. Review of the April 2026 MAR showed facility nurses signed they completed Resident 2's diabetic nail care as ordered on 04/03/2026, 04/10/2026 and 04/17/2026. On 04/23/2026 at 3:52 PM, Staff B, DNS, said facility nurses erroneously signed for a task they did not complete. Resident 7 Resident 7 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, a wound infection, received opioid and antianxiety medication during the assessment period and was on Hospice services. Review of the EHR showed Resident 7 had the following orders:a) Morphine 20 milligrams (mg) every hour as needed for pain or shortness of breath (SOB), dated 04/18/2026.b) Lorazepam 0.5 mg one tablet every two hours as needed for anxiety or SOB, dated 04/01/2026.The orders did not indicate which medication, the lorazepam or the morphine, should be administered first if the resident had SOB. On 04/23/2026 at 1:25 PM, when asked if Residet 7's was experiencing SOB, which medication a nurse should administer first, the lorazepam or the morphine, or if it was a matter of nurse preference, Staff B, DNS, said the orders were unclear and needed to be clarified. Review of the EHR showed Resident 7 had the following as needed pain medication orders:a) Oxycodone 10 mg every four hours, as needed for pain 5-6/10.b) Morphine 20 mg every hour as needed for pain or SOB.The orders did not indicate what pain medication should be administered for a pain level of 1-4/10 or for a pain level of 7-10/10. On 04/23/2026 at 12:54 PM, when asked which as needed pain medication nurses should administer to Resident 7 for pain levels of 1-4/10 or 7-10/10, Staff B, DNS, stated, I see what you're saying, the orders need to be clarified. Resident 3 Resident 3 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus (a chronic metabolic disorder characterized by high levels of blood glucose resulting from deficiencies in insulin secretion, insulin action, or both). The admission MDS, dated [DATE], documented Resident 3 was moderately cognitively impaired and received insulin injections 6 out of 7 days. Resident 3 had an order, dated 04/06/2026, for Insulin Lispro Inject as per sliding scale:if 70 - 120 = 0 unit;121 - 150 = 2 units;151 - 200 = 4 units;201 - 250 = 6 units;251 - 300 = 8 units;301 - 350 = 10 units;351 - 450 = 15 units if over 450 call MD, subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus A Review of Resident 3's April 2026 MAR showed a blank on 04/18/2026 at 2000. On 04/23/2026 at 3:07 PM, Staff P, Licensed Practical Nurse(LPN)/Supervisor, said while looking at the April 2026 MAR, it did not look like Resident 3's blood sugar was checked as it was supposed to have been and they did not see a progress note. Staff P said her expectation was for the blood sugar to have been checked like the order instructed. On 04/24/2026 at 11:27 AM, Staff B, DNS, said they saw the blank on the April 18th MAR. Staff B said Resident 3's blood sugar should have been taken to see if they required insulin. Resident 54 Resident 54 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 54 was cognitively intact. On 04/22/2026 at 12:16 PM, a medication pass (when a licensed nurse administers medication) for Resident 54 was observed. Staff Q, LPN, poured Tylenol and Pregabalin (for chronic pain) into a medication cup. Staff Q left the medications at Resident 54's bedside and walked out of the room. On 04/22/2026 at 12:24 PM, Staff Q said they should not leave medications at the bedside. Staff Q said Resident 54 would not take their medications if they were standing there. On 04/22/2026 at 1:21 PM, Staff Q was asked if Resident 54 took their medications and Staff Q stated let's go check. Staff Q walked into Resident 54's room and asked them if they took the medications and Resident 54 stated yes. On 04/22/2026 at 1:24 PM, Staff B, DNS, said medications could not be left at the bedside unless a self-medication assessment was completed. Staff B said Staff Q had come to her, told her she left medications at Resident 54's bedside, and Staff B said she completed a self-medication assessment after the fact. Staff B said the observed medications should not have been left at the bedside because Resident 54 had not been assessed for safety at the time. Resident 65 Resident 65 was re-admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 65 was cognitively intact. Resident 65 had an order, dated 04/17/2026, for oxygen (O2) to be administered via nasal canula at 2 liters per minute (LPM) to keep their oxygen saturation (measure of how full your blood is with oxygen) greater than 90%. On 04/20/2026 at 2:30 PM, Resident 65 was observed receiving oxygen via nasal canula at 4 LPMs. On 04/21/2026 at 12:35 PM, Resident 65 was observed receiving oxygen via nasal canula at 3 LPMs. On 04/22/2026 at 9:34 AM, Resident 65 was observed receiving oxygen via nasal canula at 3 LPMs. On 04/22/2026 at 11:56 PM, Staff Q, LPN, went into Resident 65's room and confirmed they were receiving oxygen at 3 LPM. Staff Q reviewed the orders and confirmed the order for Resident 65's oxygen was for 2 LPM. Staff Q said that Resident 65's oxygen levels had been dropping recently while he had a urinary tract infection, and he had required a higher dose of the oxygen to be delivered. On 04/23/2026 at 11:13 AM, Staff R, LPN/Supervisor, said her expectation of staff if a resident was requiring an increase of oxygen delivery was for staff to call the provider. Staff R was told of Resident 85's oxygen order was for 2 LPM and of the observations of the oxygen being delivered at 3 and 4 LPM. Staff R was then asked if Resident 85 required an increase in oxygen should staff have called the provider and had the order adjusted, Staff R said yes, sometimes staff would forget to put a new order in and she expected staff to communicate so she could assist with putting the order in. Reference WAC 388-97- 1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review, the facility failed to ensure pharmacy recommendations were either addressed or implemented for 3 of 5 sampled residents (Residents 3, 6 & 14) reviewed for unnecessary medications. These failures placed residents at risk for medication errors, adverse side effects, and a decreased quality of life.Findings included.Resident 3 Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's orders, showed PreserVision 2 capsules one time a day for supplement, dated 02/16/2026. Review of Resident 3's pharmacy Consultation Report, dated 03/02/2026, showed the pharmacist documented Resident 3's PreserVision Capsule should not be crushed when administered via feeding tube. The pharmacist recommended discussing with the provider the need for alternative therapy. On 04/23/2026 at 3:07 PM, Staff P, Licensed Practical Nurse/ Supervisor, while looking at the pharmacy consultation, said this may have been an oversite, they should have discussed it with the doctor and possibly switched to a liquid multivitamin. On 04/24/2026 at 11:27 AM, Staff B, Director of Nursing Services (DNS), said Resident 3's PreserVision was not addressed and her expectation was for pharmacy recommendations to be addressed. Resident 6 Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's pharmacy Consultation Report, dated 03/03/2026, showed the pharmacist had recommended Resident 6's topical diclofenac (a mild to moderate pain and inflammation reliever) order be updated to include the quantity in grams and the location it was being applied for joint pain. Review on 04/22/2026 of Resident 6's diclofenac order, showed it had not been updated since it was ordered on 11/07/2025 and did not have grams or location added. Resident 14 Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's pharmacy Consultation Report, dated 03/03/2026, showed the pharmacist had recommended Resident 14's as needed oxycodone (pain medication) order be updated to include a pain scale of moderate to severe pain of 5-10/10 (on a 0-10 pain scale with 0 being no pain and 10 being the worst pain). Review on 04/21/2026 of Resident 14's oxycodone order, showed it had not been updated since it was ordered on 11/05/2025 and did not have a pain scale added. During an interview on 04/24/2026 at 11:05 AM, Staff B, DNS, said their expectation regarding pharmacy recommendations, was for the provider to accept or decline and sign at the bottom of the form, or for nursing to address themselves if applicable. Regarding Resident 6, Staff B reviewed the EHR and said the recommendation needed a response from the provider, the order was not updated to include grams or a location, and they did not see the order updated per the pharmacist recommendation. Regarding Resident 14, Staff B said the pharmacy recommendation would have been nursing's responsibility, the order was not updated, and their expectation was for the pain scale to have been updated per the pharmacy recommendation. Reference WAC 388-97-1300 (1)(c)(iv),(4)(c)

Based on interview and record review, the facility failed to follow medication parameters (provider instructions of when to hold or give a medication) and/or ensure nonpharmacological (non-medication) interventions were in place/documented on/observed for 3 of 6 residents (Resident 85, 6, and 7) reviewed for unnecessary medications. These failures resulted in residents receiving unnecessary medications and placed them at risk of hypotension (low blood pressure), falls, injuries and other medical complications. Findings included .Resident 85 Resident 85 was admitted to the facility on [DATE]. Resident 85 had a diagnosis of hypertension (high blood pressure). The Medicare 5-Day Minimum Data Set (MDS, an assessment tool), dated 11/18/2025, documented that Resident 85 was moderately cognitively impaired. Resident 85 had the following provider orders with hold parameters:1) Amlodipine Besylate, one time a day related to hypertension. Hold for SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110. Order dated 12/08/2025. 2) Chlorthalidone (a diuretic, medication that helps remove excess fluid on the body and lower blood pressure), one time a day related to hypertension. Hold for SBP less than 110. Order dated 11/12/2025.3) Lisinopril, one time a day for hypertension. Hold for SBP less than 110. Order dated 11/12/2025 and discontinued 01/05/2026. Review of the Medication Administration Record (MAR) from 01/01/2026 through 01/20/2026 showed the medication Amlodipine was documented as given 8 times outside of the ordered blood pressure (BP) hold parameters. 01/01/2026- BP 98/58 dose was administered01/02/2026- BP 98/58 dose was administered01/04/2026- BP 92/59 dose was administered01/05/2026- BP 100/60 dose was administered01/06/2026- BP 100/60 dose was administered01/11/2026- BP 100/60 dose was administered01/17/2026- BP 100/60 dose was administered Review of the MAR from 01/01/2026 through 01/20/2026 showed the medication Chlorthalidone was documented as given 8 times outside of the ordered blood pressure (BP) hold parameters.01/01/2026- BP 98/58 dose was administered01/02/2026- BP 98/58 dose was administered01/04/2026- BP 92/59 dose was administered01/05/2026- BP 100/60 dose was administered01/06/2026- BP 100/60 dose was administered01/11/2026- BP 100/60 dose was administered01/17/2026- BP 100/60 dose was administered01/18/2026- BP 98/58 dose was administered Review of the MAR from 01/01/2026 through 01/20/2026 showed the medication Lisinopril was documented as given 4 times outside of the ordered blood pressure (BP) hold parameters before being discontinued.01/01/2026- BP 98/58 dose was administered01/02/2026- BP 98/58 dose was administered01/04/2026- BP 92/59 dose was administered01/05/2026- BP 100/60 dose was administered On 04/23/2026 at 12:24 PM, Staff B, Director of Nursing Services (DNS), reviewed the January 2026 MAR and acknowledged the documentation that the Amlodipine, Chlorthalidone, and Lisinopril had been administered outside of parameters. Staff B said the medications should have been held, and she did not see any progress notes regarding the administrations. Resident 6 Resident 6 was admitted to the facility on [DATE] and had a diagnosis of hypertension. The Quarterly MDS, dated [DATE], documented Resident 6 was cognitively intact. Resident 6 had the following provider order, dated 11/07/2025: Metoprolol Tartrate, give two times a day related to hypertension. Hold for systolic BP less than 110. Review of Resident 6's MAR from 04/01/2026 through 04/22/2026 showed there was no area to document Resident 6's blood pressure on the MAR. Review of Resident 6's vital signs record from 04/01/2026 through 04/22/2026 showed that the blood pressure had not been documented as being taken on the following days: 04/03/2026, 04/04/2026, 04/05/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/15/2026, 04/17/2026, 04/18/2026, 04/19/2026, and 04/20/2026. Additionally, on the dates it was obtained, there was only one BP recorded (resident 6 was scheduled to receive the medication two times daily). On 04/23/2026 at 12:00 PM, Staff B confirmed Resident 6 had Metoprolol orders with parameters to hold the medication if SBP was less than 110. When asked if she would expect the blood pressures to be documented on the MAR, Staff B confirmed Resident 6 did not have BPs associated with any of their orders and said her expectation was that BPs would have been associated with the Metoprolol order. When asked if BPs should be taken twice daily when the medication was to be given twice daily with parameters in place, Staff B said, yes. Regarding the dates the BP was not taken at all, Staff B said this did not meet her expectations. Staff B confirmed that on 04/14/2026, the medication was given two times that day with one BP recorded of 109/76, outside of the ordered parameters and said it should not have been given. Further record review showed Resident 6 had the following two active oxycodone orders: 1) Oxycodone 5 milligrams, give 1 tablet every 6 hours as needed for moderate pain (5-6). (The order indicated medication was to be given if pain number was 5 or 6, based on a pain scale used to evaluate pain with 0 being no pain and 10 being the worst pain.) Order dated 04/10/2026.2) Oxycodone 5 milligrams, give 2 tablets every 6 hours as needed for severe pain 7-10 (the order indicated the medication was to be given if pain number was 7, 8, 9, or 10) Order dated 04/10/2026. Review of the MAR from 04/01/2026 though 04/22/2026 showed the first oxycodone order for 1 tablet, for 5-6 pain had been given outside of parameters on the following dates:04/11/2026- given with pain score 304/15/2026- given with pain score of 404/16/2026- given with pain score of 304/16/2026- given with pain score of 4 (second administration that day) Review of the same MAR showed the second oxycodone order for 2 tablets, for pain 7-10 had been given outside of parameters on the following dates:04/18/2026- given with pain score of 404/22/2026- given with pain score of 3 On 04/23/2026 at 12:00 PM, Staff B confirmed the doses were given outside of ordered parameters and said this did not meet her expectations. Resident 7 Resident 7 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, received routine and PRN (as needed) pain medication including opioids (a class of drugs that manage moderate to severe pain) during the assessment period. Record review showed Resident 7 had the following, PRN pain medication orders:a) Morphine 5 milligrams (mg) every two hours PRN for pain or shortness of breath (SOB), order date was from 04/01/2026 - 04/18/2026.b) Morphine 20 mg every hour, PRN for pain or SOB, dated 04/18/2026.c) Oxycodone 5 mg give two tablets (10mg) every four hours PRN for pain 5-6 on a scale to 10, order date was from 03/30/2026 - 04/18/2026.d) Monitor level of pain using 0-10 scale (0=NO PAIN, 1-3= MILD PAIN, 4-5= Moderate pain, 6-9= Severe pain, 10= Excruciating pain) every shift, dated 03/30/2026. Review of the PRN pain medication orders showed for pain 5-6 on a scale to 10, staff were to administer oxycodone 10 mg every four hours PRN. The PRN pain medication orders did not indicate what pain medication (morphine or oxycodone) should be administered for a pain level of 1-4 /10 or 7-10/10 Review of the April 2026 MAR, showed facility nurses administered oxycodone 10 mg to Resident 7 outside of the of the physician ordered parameters:a) On 04/01/2026 at 4:43 AM for a pain level of 7/10.b) On 04/14/2026 at 12:58 PM for a pain level of 0/10. On 04/23/2026 at 3:58 PM, when asked if Resident 7 was administered their PRN pain medication in accordance with the provider order Staff B, DNS stated, No. When asked which PRN pain medication should be administered for a pain level of 1-4/10, or a pain level of 7-10/10 Staff B stated, I see what you are saying. Staff B then said the orders needed to be clarified. An order, dated 03/30/2026, directed nurses to attempt non-pharmacological interventions prior to administration of PRN pain medication(s), which included 0= back rub, 2= Redirect, 3=Reposition, 4= Offer Snacks/Fluids, 5= Provide a quiet environment, 6= Encourage to express Feelings, 7= Take to Activities, 8= Provide Reassurance every shift. Review of the April 2026 MAR showed facility nurses were provided with a place to document the non-pharmacological interventions that were attempted, twice a day. Once on day shift and once on night shift. The nurses recorded the numbers associated with the intervention(s) they attempted and initialed. There was no documentation of the times the nurses attempted the interventions and whether the non-pharmacological interventions were effective or ineffective. The incomplete documentation detracted from the ability to determine if the PRN doses of pain medication were warranted or unnecessary. During an interview on 04/23/2026 at 3:58 PM, when asked how one could tell if the pain non-pharmacological interventions that were attempted were effective or not; and whether the time they were attempted correlated with the administration of PRN pain medication (i.e. were non-pharmacological interventions attempted prior to each dose of PRN pain medication, and were PRN pain medications only administered after non-pharmacological interventions were attempted and were ineffective), Staff B, DNS, acknowledged one could not determine by looking at nurse documentation on the MAR what time pain non-pharmacological interventions were attempted, whether they were effective, whether they correlated (time wise) with the administration of PRN pain medication, and ultimately whether the PRN pain medications that were administered were necessary. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record, the facility failed to obtain consent from residents and/or resident representatives prior to implementing medical devices that potentially restrained movement and/or before administering psychotropic (mind altering) medication for 3 of 6 residents (Resident 7, 4 & 14) reviewed for right to be informed about treatment decisions. The failure to explain the risks and benefits associated with proposed medical devices and psychotropic medications in advance, detracted from the ability to make informed decisions about the proposed medical care/treatment, and prevented residents/resident representatives from exercising their right to decline the proposed care before it was implemented.Findings included .Resident 7 Resident 7 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/05/2026, showed the resident was moderately cognitively impaired, had a diagnosis of depression and received antidepressant and antianxiety medication during the assessment period. Record review showed Resident 7 had a 04/01/2026 order for lorazepam (an antianxiety medication) 0.5 milligrams (mg) every two hours as needed for anxiety or shortness of breath. The April 2026 Medication Administration Record (MAR) showed Resident 7 was administered lorazepam on 04/02/2026 at 8:01 PM. Review of the electronic health record (EHR) showed there was no documentation to show staff informed Resident 7 and/or their representative of the risks and benefits associated with lorazepam and obtained their consent prior to administering the medication. On 04/23/2026 at 12:54 PM, when asked if there was documentation to show staff educated Resident 7 and/or their representative about the risks and benefits associated with lorazepam therapy and had obtained consent for its use, Staff B, Director of Nursing Services (DNS), stated, No. Resident 4 Resident 4 was admitted to the facility on [DATE]. Review of the 5-day MDS, dated [DATE], showed the resident had moderate cognitive impairment, had fallen in the past month prior to admission/re-entry, and no bed rails or trunk or limb restraints were in use. On 04/21/2026 at 9:29 AM, Resident 4 was lying in bed on a perimeter (mattress with raised foam edges help prevent falls by creating a soft barrier around the bed) alternating low air loss mattress. Their bed had grab/mobility bars attached to the right and left side (bilateral). On 04/22/2026 at 2:55 PM, Resident 4 was working on a puzzle in the main dining room in their electric tilt-in-space wheelchair with a seatbelt fastened around their waist. Resident 4 said they had been using a seatbelt when in their wheelchair since the facility provided it quite some time ago. Review of the EHR showed a restraint safety device evaluation and consent form had been completed for a left side mobility bar on Resident 4's bed to aide with bed mobility, completed 04/05/2026. No device evaluation or consent was found for Resident 4's perimeter mattress, tilting wheelchair or seatbelt. On 04/23/2026 at 12:46 PM, when asked if there was documentation of device evaluations and resident consent for the use of the tilt-in-space wheelchair, seatbelt and the perimeter mattress, prior to the evaluations and consents staff completed on 04/22/2026, Staff B, DNS, stated, No. Resident 14 Resident 14 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 14 was severely cognitively impaired. Review of Resident 14's orders showed an order from 04/20/2026 for hydroxyzine (an antihistamine at times used to manage anxiety and related behavioral health symptoms without risks of addiction) every twelve hours as needed for agitation/anxiety for fourteen days. Review of Resident 14's April MAR, showed the first dose was given on 04/20/2026. Review of Resident 14's consent for hydroxyzine, showed consent was not signed until 04/21/2026, by Resident 14's power of attorney (decision maker). During an interview on 04/23/2026 at 12:21 PM, Staff B, DNS, was unable to find documentation from the nurse that consent was obtained prior to the hydroxyzine medication being given to Resident 14. Staff B acknowledged consent should have been done before the first dose was given. Reference WAC 388-97-0300(3)(a), 0260, 1020(4)(a-b)

Based on interview and record review, the facility failed to ensure 2 of 5 residents (Residents 7 and 14) reviewed for unnecessary medications, were free of chemical restraints. The failure to ensure residents receiving psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had identified target behaviors that were monitored and documented when observed, non-drug interventions were attempted prior to administration of as needed (PRN) psychotropic medications, and PRN psychotropic medication orders did not exceed 14 days, unless a clinical rationale was documented in the residents record by the provider. These failures placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects such as sedation, a decline in physical function, and other potential negative health outcomes. Findings included . Resident 7Resident 7 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS, an assessment tool), dated 04/05/2026, showed the resident was moderately cognitively impaired, had a diagnosis of depression and received antidepressant, antianxiety and sedative hypnotic medications during the assessment period. Record review on 04/23/2026, showed Resident 7 had a 04/01/2026 order for lorazepam (an antianxiety medication) 0.5 milligrams (mg) every two hours, as needed (PRN), for anxiety or shortness of breath that had been in place for 23 days. The PRN lorazepam order had been input without a stop date. Review of the electronic health record showed no documentation was present from Resident 7's provider indicating why it was necessary to extend Resident 7's PRN lorazepam order beyong 14 days On 04/23/2026 at 12:54 PM, when asked if the provider documented a resident specific clinical rationale indicating why Resident 7's PRN lorazepam needed to be extended beyond 14 days Staff B, Director of Nursing Service (DNS) stated, No. Review of Resident 7's comprehensive care plan, initiated on 03/30/2026, revealed Resident 7's use of PRN lorazepam, the goal of treatment and the specific behaviors the medication was initiated to target were not addressed. Review of the April 2026 Medication Administration Record (MAR), on 04/23/2026 at 9:14 PM, showed non-pharmacological interventions (NPIs) to be attempted prior to administration of PRN pain medications, sedative hypnotic medication and antidepressant medication had been identified and were in place. There were no NPIs identified for staff to attempt, prior to the administration of Resident 7's PRN lorazepam for anxiety. Nor was there direction to attempt any. The April 2026 MAR showed between 04/01/2026 - 04/21/2026, facility nurse administered the PRN lorazepam to Resident 7 eight times without attempting NPIs prior to administration. During an interview on 04/23/2026 at 12:54 AM, when asked if they could provide documentation to show facility nurses attempted NPIs prior to the administration of Resident 7's PRN lorazepam, Staff B, DNS, stated, No. Resident 14 Resident 14 was admitted to the facility on [DATE] with diagnosis that included Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life), unspecified dementia (cognitive decline) with other behavioral disturbance, and vascular dementia (decline in thinking skills caused by reduced blood flow to the brain) with psychotic disturbance (losing touch with reality). The Quarterly MDS, dated [DATE], documented Resident 14 was severely cognitively impaired. Resident 14 had a provider order, dated 08/19/2025, for the medication Divalproex (Depakote, anticonvulsant [anti-seizure] medication at times used as a mood stabilizer) to be given three times daily related to dementia with other behavior disturbance. Review of the April 2026 Treatment Administration Record (TAR) for Resident 14 showed that there was a behavior monitor in place for the anticonvulsant medication that listed target behaviors for the medication as follows: A. Labile [unstable] mood B. unprompted outbursts and C. agitation. The order indicated these were to be documented on every shift. The order also listed nonpharmacological (non-medication) interventions to include 1. Assist (Resident 14) back to [their] room [ROOM NUMBER]. Allow [Resident 14] to express [their] feelings 3. Assist with problem solving. Further review of the TAR showed there was no area for staff to document the target behaviors or nonpharmacological interventions. On 04/23/2026 at 12:15 PM, Staff B, DNS, was asked if resident 14 had behavior monitoring and nonpharmacological interventions in place for the Depakote, Staff B looked in the electronic health record and said, yes. When asked where the behaviors and nonpharmacological interventions were to be documented Staff B said usually there was an area for the supplementary documentation, but she did not see that it was there for Resident 14's Depakote. Reference WAC 388-97-1060(3)(k)(i), 0620(1)(a)

Based on observation, record review, and interview the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 4 of 19 sample residents (Resident 4, 2, 7, & 40) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.Findings included .Resident 4Resident 4 was re-admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS, an assessment tool), dated 04/15/2026, showed the resident received intravenous (IV) medication(s) via a central line (a type of IV access that reaches a large central vein in the body) during the assessment period. Review of the hospital transfer paperwork, dated 04/13/2026, showed Resident 4 re-admitted with a central line to the right upper chest and orders for IV vancomycin (antibiotic) every other afternoon for bacteremia (bacteria in the blood). Review of the comprehensive care plan, initiated 09/25/2025, showed no care plan had been developed or implemented that addressed Resident 4's central line or IV antibiotic therapy. During an interview on 04/24/2026 at 7:49 AM, Staff B, Director of Nursing Services (DNS), confirmed there was no care plan in place that addressed Resident 4's central line access and/or IV antibiotic therapy. Staff B said Resident 4's comprehensive care plan needed to be revised to accurately reflect his current care needs. On 04/21/2026 at 9:29 AM, Resident 4 was observed lying in bed on a perimeter alternating low air loss mattress. The resident's bed had mobility bars affixed to both the right and left side. On 04/22/2026 at 2:55 PM, Resident 4 was sitting in an electric tilt-in-space wheelchair, in the main dining room with a seatbelt fastened around his waist.Review of the comprehensive care plan, initiated 09/25/2025, showed Resident 4's use of a tilt-in-space wheelchair, seatbelt and perimeter mattress had not been care planned. During an interview on 04/23/2026 at 2:46 PM, Staff B, DNS, confirmed Resident 4's use of a tilt-in-space wheelchair, seat belt and perimeter mattress were not care planned, and said the plan of care needed to be updated/revised. An activity of daily living (ADL) care plan, initiated 09/24/2025, documented that Resident 4 may use a left sided mobility bar. On 04/23/2026 at 3:18 PM, Staff J, MDS Coordinator, observed Resident 4's bed and confirmed there were both right and left side mobility bars were in place. During an interview on 04/23/2026 at 12:46 PM, Staff B, DNS, said Resident 4's ADL care plan was inaccurate and needed to be updated. Resident 2Resident 2 was admitted to the facility on [DATE]. On 04/20/2026 at 1:58 PM, Resident 2 was observed lying in bed in a hospital gown. Resident 2 explained that they wanted to be up and dressed by noon daily, but indicated their wishes were not always followed and/or honored.An ADL care plan, initiated 10/24/2024, documented Resident 2 preferred to get up after breakfast. The care plan did not include the resident's desire to be up and dressed before noon.On 04/23/2026 at 3:47 PM, Staff B, DNS, confirmed she was aware Resident 2 liked to be up and dressed before noon. When asked if being up and dressed by noon was care planned, Staff B, DNS, said no, and indicated the care plan needed to be updated to reflect Resident 2's current care preferences. Resident 7Resident 7 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident had moderate cognitive impairment, a wound infection, received opioid and antianxiety medication during the assessment period and was on Hospice services. Record review showed Resident 7 had a 04/01/2026 order for lorazepam (an antianxiety medication) every two hours, as needed, for anxiety or shortness of breath. Review of Resident 7's comprehensive care plan, initiated 09/25/2025, showed there was no care plan in place that addressed the resident's use of lorazepam, or that identified the target behavior(s) the medication was initiated to treat, and the goals of the anxiolytic therapy. During an interview on 04/23/2026 at 12:54 PM, Staff B, DNS, acknowledged Resident 4's comprehensive care plan was incomplete and should have addressed/included the residents use of an antianxiety medication(s), the goal of the medication therapy, and identified the specific target behaviors the lorazepam was initiated to target.Resident 40Resident 40 was admitted to the facility on [DATE]. A Methicillin-Resistant Staphylococcus Aureus (MRSA, a multi drug resistant organism) care plan, initiated 03/07/2026, documented Resident 40 had a MRSA infection and directed staff to follow enhanced barrier precautions. The care plan did not identify the source (urine, blood, wound etc.) or the location of the infection (left foot, nares, etc.).On 04/23/2026 at 4:12 PM, Staff B, DNS, said resident care plans were plans that should be personalized and resident specific. When asked if the source and location of a resident's MRSA infection should be care planned, Staff B, DNS said yes. When asked if it was for Resident 40, Staff B said no.Reference WAC 388-97-1020(2)(c)(d)

Based on interview and record review, the facility failed to provide bowel care in accordance with provider orders and the facility's bowel protocol for 2 of 7 residents (Resident 3 & 7) reviewed for bowel management. This failure placed residents at risk for abdominal pain/discomfort, decreased appetite and other potential health complications.Findings included. Per the facility policy, titled Bowel Protocol, Revised 03/2026:1. Administer Miralax 17gm dissolved in 8 oz fluid as needed if no bowel movement after 3 days2. If the resident does not have a bowel movement after Miralax is given, administer Dulcolax 10mg suppository rectally as needed if Miralax is ineffective and /or no bowel movement after four days3. If Miralax and Dulcolax are ineffective, the provider must be notified for further intervention.4. Document all efforts and interventions, including successful BM or on-going efforts to achieve the goal of a healthy bowel elimination5. With residents who have specialized bowel protocol to meet their individual needs, discuss their normal bowel movements and what is a normal pattern for the resident. Discuss the risk versus benefits to resident and/or resident representatives on not following the facility bowel protocol. Preferences will be care planned to resident's individualized needs/preferences. Resident 3 Resident 3 was admitted to the facility on [DATE]. The admission Minimum Data Set, (MDS-an assessment tool), dated 02/19/2026, documented Resident 3 was moderately cognitively impaired and required set up assistance with oral hygiene and was dependent to substantial assistance with activities of daily living. A review of Resident 3's bowel record showed no bowel movement (BM) documented from 04/08/2026 – 04/11/2026 (4 days). A review of Resident 3's April 2026 Medication Administrator Record (MAR) showed no bowel protocol medications were given. On 04/23/2026 at 3:07 PM, Staff P, Licensed Practical Nurse Supervisor, said there was no documented BM and they should have offered Miralax. Staff P said her expectation was for Miralax to at least to have been offered to Resident 3. On 04/24/2026 at 11:27 AM, Staff B, Director of Nursing Services said she does not see a progress note or any documentation that Miralax was given to Resident 3. Staff B said her expectation was for Resident 3 to have received the first step of the bowel protocol on the 11th. Resident 7 Resident 7 was admitted to the facility on [DATE] with the following as needed bowel management orders:a) Miralax every 72 hours, as needed, administer if no BM after three days.b) Dulcolax suppository, insert rectally if no BM after four days. The March and April 2026 bowel records showed Resident 7 had no BM from 03/27/2026 - 03/30/2026 (4 days) and from 04/02/2026 - 04/09/2026 (8 days). Review of the March and April 2026 MARs showed Resident 7 was not administered any as needed bowel medications. On 04/24/2026 at 12:58 PM, when asked if facility nurses administered Resident 7 as needed Miralax after three days without a BM or an as needed Dulcolax suppository after four days without a BM as ordered Staff B, DNS, stated, No. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident 40) reviewed for pressure ulcers (PU - injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time), was provided care and services consistent with professional standards of practice, to promote healing and prevent new pu formation. The failure to consistently implement preventative offloading measures residents were assessed to require placed residents at risk for further skin breakdown, prolonged wound healing and development of new avoidable PUs. Findings included . Resident 40 Resident 40 was admitted to the facility on [DATE]. Review of the admission minimum data set (MDS, an assessment tool), dated 03/11/2026, showed the resident was cognitively intact, and admitted with a surgical wound and pressure injury to their feet. Review of the 03/07/2026 transfer paperwork showed Resident 40 had a surgical wound to the right heel after an incision and drainage was performed due to osteomyelitis (bone infection) and abscess formation. The 03/07/2026 nursing admission assessment showed Resident 40 had a small non-blanchable area of purple/reddish discoloration to the left heel which was assessed as to be a deep tissue injury (DTI, unstageable PU). An actual skin impairment care plan, initiated 03/07/2026, documented the resident had a right heel surgical wound that was being treated with negative pressure therapy. Staff were directed to float Resident 40's heels. An actual PU and potential for development of further PU care plan, initiated 03/07/2026, showed the resident admitted with a PU to the left heel and directed staff to encourage turning and repositioning, replace the resident's heel lift boots with a wedge cushion to float bilateral (both) heels, assess the PU weekly to include measurements, wound base characteristics, drainage type/amount and a peri wound description and to notify the nurse immediately if any new areas of skin breakdown such as persistent redness, blisters or areas of discoloration were observed. Review of the electronic health record showed Resident 40 had the following wound care orders:a) Cleanse left heel surgical wound with wound cleanser, pat dry, apply skin prep to the peri wound, and then apply negative pressure wound therapy at 125 mmHg [vacuum suction measurement] suction, twice a week on Mondays and Thursday, dated 03/19/2026.b) Cleanse left heel DTI with normal saline, pat dry, and paint the area with betadine every evening.c) Alternating low air loss mattress to Resident 40's bed form offloading and pressure redistribution. Review of the weekly skin notes showed on 03/12/2026 Resident 40 had an unstageable PU (DTI) to his left heel. The area was purplish/red in color, non-blanchable and measured 0.5 cm [centimeters] x 0.7 cm. Further review showed Resident 40's left heel PU, remained virtually unchanged through 04/09/2026, when it was measured at 0.5 cm x 0.5 cm. The 04/16/2026 wound note documented Resident 40's left heel PU had deteriorated due to a marked increase in size. The purple, non-blanchable DTI now measured 5.5 cm x 6 cm but remained intact. On 04/17/2026 an order was given to cleanse the left heel with wound cleanser, pat dry, apply betadine gauze and cover with a foam dressing daily. Review of the April 2026 Treatment Administration Record (TAR) showed there was a 03/12/2026 order that read Right heel surgical wound, left heel DTI, right great toe callus, BUE [bilateral upper extremities] scattered bruises Monitor for s/sx [signs or symptoms] of infection such as purulent discharge, increase pain, redness or odor and dressing placement daily until resolved. The order did not indicate what type of dressing should be applied to which skin issue. The 04/17/2026 order to apply betadine gauze and a foam dressing daily to Resident 40's left heel, was not on the TAR. On 04/21/2026 at 9:54 AM, Resident 40 was observed lying in bed on an alternating low air loss (LAL) mattress, firmness was set to 5 green bars. Resident 40 had no footwear or socks on, and both heels were resting directly on the mattress surface. A wound vacuum was in place to the right heel, and the left heel was open to air. On 04/22/2026 at 2:27 PM, Resident 40 was observed lying in bed on an alternating low air loss (LAL) mattress, firmness was set to 5 green bars. The wound vac was no longer present in the room. Resident 40 reported they just returned from their wound appointment and no longer had the wound vacuum. Observation of Resident 40 showed he had no footwear or socks on, the right heel was dressed and wrapped with kerlix gauze, and the left heel was open to air. Both heels were resting directly on the mattress surface. No heel lift boots, wedge, or pillows to float Resident 40's heels were observed in the room. On 04/23/2026 at 2:54 PM, Resident 40 was observed lying in bed on an alternating low air loss (LAL) mattress, firmness was set to 5 green bars. The resident had no footwear in place and feet were bare. A dressing was noted to the resident's right posterior heel. Unable to clearly observe the dressing as the right heel was resting on the mattress. No dressing was in place to the left heel. Resident 40 reported facility staff had just finished performing the dressing to the right heel. The 04/23/2026 wound note measured the left heel PU at 6 cm x 4 cm x 0.3 cm depth, and documented the area was deteriorating with increased size and area of involvement when compared to prior assessments, The note concluded Wound characteristics show progression with increased area of involvement. The wound note did indicate why there was now a depth measurement included and did not document that the wound had opened. On 04/23/2026 at 3:48 PM, Staff J, MDS Coordinator, accompanied writer to Resident 40's room and confirmed there was not a wedge or pillows in the room to float Resident 40's heels. On 04/24/2026 at 7:27 AM, Resident 40 was lying in bed on an alternating low air loss (LAL) mattress with two pillows positioned under his lower legs to offload the heels. However, someone had placed a blue folded blanket under the resident's heels, which they were resting on. On 04/24/2026 at 12:06 PM, Staff G, Nurse Supervisor, said Resident 40 now had a clear fluid filled blister on the left heel where the previous deep purple non-blanchable area was located. Staff G indicated the depth measurement was the approximate depth of the fluid filled blister and said a new order to paint the area with betadine and cover with a foam dressing had been obtained, and staff were to continue to offload the resident's heels when in bed. On 04/24/2026 at 12:53 PM, Staff B, Director of Nursing Services, confirmed that Resident 40's 04/17/2026 to apply betadine gauze and cover with a foam dressing was not transcribed to the TAR. Staff B also said it was the expectation that staff provide care in accordance with the resident's care plan, if the resident's heels were care planned to be offloaded utilizing a foam wedge, then that's what staff were expected to do. Reference WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to ensure diabetic nail care was provided for 1 of 2 residents (Resident 4) reviewed for foot care. The failure to refer residents to a qualified specialist when staff were unable to meet a resident's diabetic foot/nail care needs, placed the resident at risk for ingrown toenails, foot ulcers, infection, pain/discomfort, and other medical complications associated with inadequate of diabetic foot care.Findings included .Resident 4 was admitted to the facility on [DATE]. A provider order, dated 04/13/2026, directed licensed nurses to provide diabetic nail care every seven days and as needed. Resident 4's diabetes care plan, initiated 09/25/2025, also showed weekly nail care would be provided by the licensed nurse. Observations on 04/21/2026 at 9:17 AM and 04/23/2026 at 11:13 AM, showed Resident 4 had a right above knee amputation and the fifth digit (pinky toe) on the right foot had been amputated. Resident 4 indicated the amputations were due to complications associated with diabetes. Resident 4's remaining four toes on the left foot showed the first, second, third and fourth digits had thick yellow brittle untrimmed toenails that curved around the end of the toes to the plantar aspect (underside) of the toes. The April 2026 Medication Administration Record (MAR) showed on 04/02/2026, 04/14/2026, 04/21/2026 nurses documented the resident's diabetic nail care was not provided, and the diabetic nail care scheduled for 04/09/2026 was left blank. The electronic health record (EHR) showed there was no documentation to indicate why facility nurses were not providing Resident 4's diabetic nail care as ordered, or that staff had notified the provider. On 04/24/2026 at 7:49 AM, Staff J, Minimum Data Set Coordinator, confirmed facility nurses documented they did not perform Resident 4's diabetic nail care as ordered in the month of April 2026 and indicated it was because the resident's toenails were too long thick and brittle for facility nurses to safely cut. Staff J said Resident 4 needed to be referred to podiatry for diabetic toenail care. Review of podiatry documents provided by Staff B, Director of Nursing Services, showed the podiatrist was last at the facility on 03/05/2026 and Resident 4 was not seen. On 04/23/2026 at 4:09 PM, Staff B explained that the facility could not find a podiatrist to service the facility for several months and were making resident podiatry appointments for individual residents on an as needed basis but recently did contract with a podiatrist who was in the facility last on 03/05/2026. Staff B said Resident 4 was hospitalized and re-admitted to the facility on [DATE] (the day before the podiatrist visited) and was not seen. On 04/24/2026 at 9:23 AM, Staff B said given Resident 4's diabetes, history of amputations, and documentation that the resident's ordered diabetic foot/nail care was not/could not be completed, that she would have expected to have been notified and a podiatry referral/appointment to already have been made, but acknowledged those things did not occur. Reference WAC 388-97-1060(3)(j)(viii)

Based on observations, interviews and record review, the facility failed to provide adequate and ordered fluids, within reach of the resident and at mealtimes, to maintain hydration for 1 of 1 sampled resident (Resident 60) when reviewed for hydration. This failure placed residents at risk for dehydration, medical complications and a diminished quality of life.Findings included. Resident 60 was admitted to the facility on [DATE] with unspecified dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities). The Significant Change Minimum Data Set (MDS, an assessment tool), dated 03/30/2026, documented Resident 60 was severely cognitive impaired and depended on staff for care. On 03/14/2026, Resident 60 was ordered to have a fortified diet (foods enhanced with additional vitamins, minerals, or other nutrients to improve overall nutritional intake and prevent deficiencies), with regular texture and thin liquids. Resident 60's at risk for potential fluid deficit care plan, dated 02/05/2026, documented Resident 60 recently had intravenous hydration and needed encouragement to drink fluids. On 04/20/2026 at 11:40 AM, Resident 60's lunch meal tray was delivered to the table. Observation of tray included tomato soup, corn bread, rice and chicken, and pudding bowl. No whole milk on the meal tray. On 04/21/2026 at 9:03 PM, Resident 60's Power of Attorney (POA, a legal document that allows you to appoint someone to make healthcare decisions on your behalf if you become unable to do so yourself) said they were concerned about Resident 60's fluid intake, that Resident 60 had not been receiving enough fluids to stay hydrated and that Resident 60 had a history of urinary tract infections related to this. Resident 60's POA pointed to the clear water mug with a straw in it, sitting in the corner of the room on the nightstand, one fourth full, and said it was out of reach of Resident 60. Resident 60's POA said the water cup had been sitting there like that since Sunday (for three days). On 04/21/2026 at 12:29 PM, observation of the clear water mug sitting on the corner nightstand had been filled. Resident 60's wheelchair had been parked between Resident 60's bed and the nightstand, still out of reach and with an obstacle between Resident 60 and the water cup. On 04/22/2026 at 9:16 AM, a clear water mug sitting on nightstand was observed. Resident 60 was unable to reach the cup on the nightstand. The water mug was full with water and had a straw in it and it was sitting in same position as the previous day. On 04/22/2026 at 11:40 AM, Resident 60's lunch meal tray was delivered to the table. Observation of the tray included a slice of pepperoni pizza, a bread stick, a green salad, cup of marinara, chicken noodle soup and the drink was coffee. No whole milk was observed on the meal tray. On 04/23/2026 at 8:13 AM, An observation of the clear water mug showed it was sitting on the corner of the nightstand. Resident 60's wheelchair had been parked between Resident 60's bed and the nightstand, still out of reach and with an obstacle between Resident 60 and the water cup. On 04/23/2026 at 8:23 AM, Staff E, Certified Nursing Assistant, said they would fill all the water cups every hour to two hours and as needed. Staff E said water cups should have been placed where residents could see it and within reach of the resident. On 04/23/2026 at 8:36 AM, Staff F, Licensed Practical Nurse (LPN), said water cups were filled as needed and at least once a shift form the aides. Staff F said a water mug should be placed at the resident's bedside, within reach of the resident, not on the nightstand. Staff F was asked to observe Resident 60's water cup. Staff F confirmed Resident 60's clear water mug was sitting on the nightstand, not within reach of the resident. When observations were explained about the wheelchair having been parked between Resident 60 and the nightstand, Staff F said even without the wheelchair being parked between them and the nightstand, Resident 60 could not reach the water mug. When asked if that was an acceptable place for the water mug, Staff F stated, no, I will move it. On 04/23/2026 at 9:20 AM, Staff G, LPN/Supervisor, said fluids were offered between meals, at snack time and as needed, which was the same as filling the water cups. When observations of the clear water mug, sitting on the nightstand for the past 4 days, was out of reach of the Resident 60 were explained, Staff G said that it was not acceptable and it needed to be within reach of the resident. On 04/23/2026 at 10:31 AM, Staff B, Director of Nursing Services, with Staff I, Regional Clinical Resource, and Staff J, MDS Coordinator, present, said water cups should have been filled when empty or when a resident asked and should be placed within reach of the resident. When observations of clear water mug sitting on nightstand for the past 4 days was out of reach of the Resident 60 were explained, Staff B said that was not their expectation from staff. Staff I and Staff J nodded in agreement. On 04/23/2026 at 3:08 PM, Staff H, Dietary Supervisor, said with the fortified diet residents should have received whole milk with their meals. Staff H said the fortified diet food was prepared in the kitchen, but the drinks, including whole milk, were placed on the resident's meal tray by nursing staff, from the drink carts delivered to the units prior to the meal. When asked if staff should have placed whole milk on the resident's trays who have a fortified diet type, Staff H said yes. On 04/24/2026 at 10:25 AM, A full clear water mug with a straw in it was observed sitting on the bedside table, up against wall, next to the nightstand, with the resident's wheelchair parked between them and the bedside table. The water mug was not within reach and was blocked by Residents 60's wheelchair. Reference WAC 388-97 -1060 (3)(h)(i)

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 5 residents (Residents 9, 96, & 3) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.Findings included .Review of the facility policy titled, Antibiotic Stewardship, last revision/review date of 4/2025, documented Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. Under the section Leadership it was documented the team would Assess residents for any infection using McGeer's criteria and Require antibiotic orders to include the indication, dose, and duration.Review of the facility provided documentation of McGreer's criteria for urinary tract infection (UTI) showed UTI included only symptomatic UTIs. Surveillance for asymptomatic bacteriuria (defined as the presence of a positive urine culture in the absence of new signs and symptoms of urinary tract infection) was not recommended, as this represented baseline status for many residents. Resident 9Resident 9 was admitted to the facility on [DATE] with a diagnosis of chronic cystitis (long term inflammation of the bladder). Review of the electronic health record (EHR) showed Resident 9 had been on Cephalexin since 01/21/2026 for chronic cystitis. Review of the March 2026 Infection Prevention and Control Surveillance Log showed the signs and symptoms listed for Resident 9 were LOC (Level of consciousness, log did not indicate what the symptoms related to LOC were) and the current antibiotic order did not indicate an end date.On 04/23/2026 at 1:30 PM, Staff D, Infection Preventionist (IP), said that Resident 9 met criteria for the prescribed antibiotic when it started in January 2026 but no longer met criteria. Staff D said she had not had a conversation with the provider about the long-term antibiotic use and said she should have. Staff D acknowledged the antibiotic did not have an end date and said it should have. Resident 96Resident 96 was admitted to the facility on [DATE]. Review of the February 2026 Infection Prevention and Control Surveillance Log showed Resident 96 had listed urinary symptoms of agitation and confusion with listed treatment of Nitrofurantoin (antibiotic). Review of the March 2026 Infection Prevention and Control Surveillance Log showed Resident 96 had listed urinary symptoms of agitation, restlessness, and aggression with listed treatment of Bactrim (antibiotic). On 04/24/2026 at 11:49 AM, Staff D, IP, said that Resident 96 did not meet criteria for the prescribed February and March antibiotics and she was unable to find documentation in the EHR that she had discussed the lack of meeting criteria with the provider and it should have been discussed. Resident 3Resident 3 was admitted to the facility on [DATE] with an indwelling urinary catheter (a tube that enters the bladder and drains the urine out).Review of the February 2026 Infection Prevention and Control Surveillance Log showed Resident 3 had urinary symptoms of pain, burning, and LOC (log did not indicate what the symptoms of LOC were) and was prescribed two antibiotics, amoxicillin and Cefdinir. Review of the EHR showed that Resident 3 remained on the antibiotic Cefdinir since that time and this antibiotic did not have an end date. Further review of Resident 3's EHR showed an order, dated 02/13/2026, for Nitrofurantoin (antibiotic) for UTI, which was not found on the February 2026 Infection Prevention and Control Surveillance Log. Additionally Resident 3 had an order, dated 03/25/2026, for Gentamicin Sulfate (antibiotic) every Monday and Friday related to UTI, and the antibiotic did not have an end date and was not on the March Infection Prevention and Control Surveillance Log.Further review showed Resident 3 had another antibiotic order, dated 03/10/2026, for Ceftriaxone, for infection. This order did not indicate what type of infection the antibiotic was prescribed for, however the March 2026 Infection Prevention and Control Surveillance Log indicated catheter with symptoms of pain, hematuria (blood in the urine) and LOC (log did not indicate what symptoms of LOC were). On 04/24/2026 at 11:49 AM, Staff D, IP, said that Resident 3 was currently on the antibiotic Cefdinir and had been on that antibiotic since admission. When asked if Resident 3 met criteria for this antibiotic Staff D said no, she had called the provider the day before, and Resident 3 had been on antibiotics for too long, way too long. When asked if there was an end date for the current Cefdinir antibiotic, Staff D said, no and there should be. When asked if she had documentation that the Cefdinir had been reassessed since February, Staff D said not until yesterday, she had not realized it was to be a long-term antibiotic. When asked how often long-term antibiotics were reevaluated for ongoing needs, Staff D said she had no specific review plan up to that point, going forward there would be a new process and reassessments. Regarding the February Nitrofurantoin antibiotic not being on the line listing, Staff D said she missed it altogether. Regarding the Gentamicin Sulfate antibiotic not having an end date and not being on the surveillance log, she said she would expect there to be an end date and it should have been on the March log. Regarding the order for the Ceftriaxone for infection and asked if this was a complete order, Staff D said, no and it did not meet her expectations. No associated WAC

Based on observation, interview and record review, the facility failed to monitor the functioning of window alarms to prevent elopement for 1 of 20 residents (Resident 1) in a secure dementia unit. This failure placed residents at risk for elopement from the facility, injury and a diminished quality of life. Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (loss of memory, function, and overall thinking to the point where it disrupts daily living) with behavior disturbance and sensorineural hearing loss (permanent hearing loss). The Minimum Data Set (MDS), an assessment tool, dated 02/15/2026 showed Resident 1 was cognitively impaired, had shown behavior symptoms, wandering behaviors and required staff supervision for ambulation and most activities of daily living.Review of Resident 1's elopement/wandering evaluation, dated 02/09/2026, documented the resident was disoriented, ambulated independently or with supervision and had a score of 21 (High risk 10-55).Review of Resident 1's care plan, dated 02/10/2026, showed the resident was at risk for elopement, wandered, had a history of attempts to leave the previous facility unattended, had impaired safety awareness and wandered aimlessly. An intervention of a wander guard (electronic wander management system designed to protect residents with cognitive impairment from wandering away from a facility) was implemented on 02/10/2026.Review of a physician's order, dated 02/09/2026, showed Resident 1 may reside in the secured dementia unit.Review of Resident 1's progress note, dated 02/14/2026 at 11:52 PM, documented the left window screen on Resident 1's window was observed on the ground outside, indicating the resident likely exited through the window, ambulated around the exterior of the building, then rang the doorbell at the front entrance and reported this information to the staff.Review of a facility investigation summary for an incident, dated 02/14/2026, showed Resident 1 left the facility unattended on 02/14/2026 between the hours of 9:45 pm and 10:30 pm. The resident returned unharmed and was dressed appropriately. It was identified Resident 1 had left the facility through an alarmed window that failed to alarm when the resident opened the window. On investigation the alarm on Resident 1's window malfunctioned. Resident 1 was placed on 15-minute safety checks throughout the night. The alarm system was replaced the following morning.On 03/17/2026 at 3:10 PM, Resident 1 was observed seated on a chair in the dining room working on a puzzle. The resident had a wander guard on the lower extremity. Observation of the resident's room showed a functioning window alarm on the left side of the window and the window screen intact.During an interview with Staff A - Administrator on 03/18/2026 at 9:45 AM, he acknowledged on 02/14/2026 at 10:30 PM, Resident 1 had rang the facility doorbell and asked to return to his room. He stated the window screen had been found outside and it appeared the resident had exited the facility through the window. Staff A stated the window alarm was found intact with workable batteries but did not alarm. He stated the facility checked all resident window alarms and found no other issues. Staff A was asked how often the window alarms were checked. He stated maintenance was checking the window alarms approximately quarterly but could not provide documentation of checking the function of the window alarms. During an interview with Staff B, Plant Operations Manager on 03/18/2026 at 1:00 PM, he stated he made rounds weekly and glanced at the window alarms for any flashing red light which may indicate it needed attention. He stated he checked for window alarm function and changed the batteries on all window alarms every three months. He acknowledged he did not have documentation of maintenance or checks for the window alarms for the secure dementia unit.Reference WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to ensure laboratory tests were completed as ordered for 1 of 3 residents (Resident 4) reviewed for quality of care. This failure placed the resident at risk of medical complications from lack of monitoring of medical conditions.Findings included.Review of the facility policy, titled Laboratory Testing, undated showed It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, PA [Physicians Assistant], NP [Nurse Practitioner] or clinical nurse specialist and to promptly notify the ordering entity of test results.Lab results and pending or missing lab results will be part of a change of shift report.Pending or missing lab results will be followed-up during daily clinical meeting.Resident 4 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease and Hyperparathyroidism (occurs when 1 or more of the 4 parathyroid glands in the neck produce excessive parathyroid hormone [PTH], leading to high calcium levels [hypercalcemia]. Review of the admission Minimum Data Set (MDS), an assessment tool, dated 10/25/2025 showed the resident had cognitive impairment and required assistance for activities of daily living.Review of Resident 4's laboratory results dated [DATE] showed a high calcium level of 12.2 (8.6 - 10.2 normal range).Review of a physician's order, dated 11/14/2025, showed an order to obtain PTH, vitamin D and ionized calcium one time only for hyperparathyroidism.Review of Resident 4's laboratory results, dated 11/14/2025, showed a PTH and ionized calcium were not performed/ no specimen was received.Review of a provider note, dated 11/22/2025, showed .calcium 12.2 on 11/7/25. PTH and ionized calcium was not performed, reordered today.Review of a physician's order, dated 11/28/2025, showed an order to obtain PTH and ionized calcium one time only for hyperparathyroidism.Review of Resident 4's laboratory results, dated 11/29/2025, showed PTH and ionized calcium not performed, no specimen received.Review of a physician's order, dated 12/01/2025, showed an order to obtain a CBC (complete blood count) and CMP (comprehensive metabolic panel).Review of a progress note, dated 12/02/2025 at 11:17 PM, showed the nurse received call from the lab related to a critical lab value for calcium. Resident transferred to the hospital for evaluation and treatment.Review of Resident 4's hospital record showed the resident was admitted to the hospital on [DATE]. Hospital records showed .Blood work.Calcium was elevated at 17.Pt [patient] was admitted .for acute pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lungs), aspiration pneumonia (infection caused by inhaling something other than air in the lungs) and hypercalcemia (abnormally high calcium levels in the blood, primarily caused by hyperparathyroidism or malignancy).During an interview with Staff A, Administrator on 01/30 /2026 at 11:45 PM, he acknowledged Resident 4 had physician orders for labs on 11/14/2025 and 11/29/2025 for PTH and calcium ionized levels. He acknowledged the lab indicated the specimens for calcium and PTH were not obtained on those dates. Staff A acknowledged the lab notified the facility Resident 4 had a high calcium level on 12/02/2025 and the resident was sent to the hospital for evaluation and treatment. Staff A stated it was a nursing responsibility to ensure labs were collected, sent and results were received as ordered.Reference WAC 388-97-1620 (2)(b)(i)(ii)

Based on interview and record review, the facility failed to provide the Ombudsman with transfer notification for 3 of 3 sampled residents (Resident 64, 71 & 16) reviewed for hospitalization. The failure to ensure required notifications were completed, prevented the Office of the State Long-Term Care Ombudsman (an advocacy group for individuals residing in nursing homes) the opportunity to educate residents and advocate for them regarding the discharge process. Findings included . Resident 64 was admitted to the facility on [DATE]. Resident 64 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 71 was admitted to the facility on [DATE]. Resident 71 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 16 was admitted to the facility on [DATE]. Resident 16 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. On 03/31/2025 at 9:40 AM, documentation of the Ombudsman notification was requested from Staff D, Social Services Director, for Resident 64, 71 & 16. At 10:45 AM, Staff D, SSD, said they send the Ombudsman notification of resident transfers and discharges by fax to the Ombudsman at the beginning of the next month. At 11:22 AM, Staff D, SSD, was reminded of the requested Ombudsman notification. On 04/01/2025 at 1:55 PM, at the time of the survey exit conference, documentation of Ombudsman notification still had not been provided. Reference WAC 388-97-0120 (2)(a-d) .

Based on observations, interviews, and record review the facility failed to ensure residents were free from avoidable accidents for 1 of 3 residents (Resident 1) reviewed for Activities of Daily Living (ADLs-such as bed mobility, toileting, eating, and transferring) and accidents. This failure placed residents at risk for injury and diminished quality of care. Resident 1 experienced harm when facility staff did not follow resident's individualized care plan (CP) and use two people for bed mobility during incontinence care, resulting in a fall from the bed and a broken leg. Findings included POLICY Review of the facility's Policy/Procedure - Activities of Daily Living policy, revised 07/2015, showed nursing assistants would provide assistance with ADLs based on the resident's individualized care plan and in accordance with professional standards of quality and clinical practices. <Resident 1> Review of the 12/21/2023 quarterly Minimum Data Set (MDS-assessment tool) showed Resident 1 had no cognition problems, no behaviors, and no rejection of care. Resident 1's diagnoses included chronic heart and lung disease, Post Traumatic Stress Disorder (PTSD-a mental health condition triggered by a terrifying or traumatic event), depression, obesity, and no fractures. Resident 1 was incontinent and dependent on staff assistance for toileting hygiene and rolling side to side in bed. Resident 1 received scheduled and PRN (as needed) pain medication for almost constant severe pain (that affected their sleep and daily activities) and no recent history of falls. Review of the ADL CP, dated 07/20/2023, directed staff to check and change Resident 1 when waking up, before and after meals, and at their request. Resident 1 was dependent on staff to use the bed pan when requested, required two-person assistance for bed mobility, and used the trapeze to help turn and reposition. Review of a Nurse Progress Note (NPN), dated 01/07/2024 at 7:12 PM, showed the on-call Registered Nurse (RN) was contacted regarding Resident 1's bed width and the difficulty staff had positioning Resident 1 in bed, [Resident 1] appears to be on the edge of the bed and CNAs [Certified Nursing Accidents] are afraid of [Resident 1] rolling out of bed. A request was made about obtaining a larger bed for resident and staff safety. Review of a NPN, dated 01/08/2024 at 10:33 AM, showed the Interdisciplinary Team (IDT) determined Resident 1's bed was appropriate, and staff would be educated on proper techniques for turning and repositioning. The NPN did not show rationale for the determination of correct bed size. Review of the 01/09/2024 Kardex (simplified care directive for care staff) showed Resident 1 required care-in-pairs (two people for all personal cares), two people for bed mobility, and wore disposable briefs for incontinence. Review of a NPN, dated 01/09/2024 at 6:21 AM, showed Resident 1 rolled out of bed during resident care at 5:02 AM and was assisted to the floor by the CNA. When paramedics arrived and attempted to roll Resident 1 onto their back, the resident hollered out in pain and was transferred to the Emergency Department (ED). Review of the facility Fall Incident Report (IR), dated 01/09/2024 at 5:02 AM, showed Resident 1 was on an air mattress and Staff D, CNA, attempted to turn Resident 1 on their side, without another staff member's assistance, by pushing Resident 1 away them and Resident 1 rolled off the opposite side of the bed. Review of a Fall Committee IDT progress note, dated 01/15/2024 at 1:16 PM, showed during the provision of incontinence care, Resident 1 slid off the side of the bed, right leg first. Post fall interventions included education to staff on the standards of nursing practice for bed mobility Review of a NPN, dated 01/27/2024 at 6:18 PM, showed Resident 1 readmitted to the facility with diagnoses of a right leg fracture. Once Resident 1 was transferred from the stretcher to the bed, they required five staff to roll them and provide personal cares. Resident 1 was very anxious and scared of falling out of bed. In an interview on 04/29/2024 at 12:30 PM, Resident 1 stated they broke their leg in January during a fall from the bed because the CNA did not use two people to change their disposable brief. Resident 1 stated the bed they had at that time was too narrow for their body and did not have siderails to help roll, facility staff were made aware, but a wider bed was not provided until after they broke their leg. Resident 1 stated Staff D (who was of smaller stature) was on the left side of the bed and pushed on the resident's left hip to help them roll to the right side. As the resident began to roll over, the resident realized there was not another CNA on the right side of the bed, Resident 1 said they felt the air mattress sink on the right edge, and they then fell off the right side of the bed. Resident 1 stated they felt excruciating pain in their right leg and hip. Resident 1 stated Staff D could not assist them to help break the fall because they were on the left side of the bed and because, I am a big [person]. Resident 1 stated they were taken to the hospital and found they had a right leg fracture. Resident 1 stated this incident had caused them considerable pain whenever they roll in bed, delayed their recovery and discharge, and made their overall quality of life worse. Resident 1 stated the orthopedic (bone) specialist was not able to operate on the leg and may never be able to fix it; and either way they had lost the use of their leg and feared they might never walk again. In an interview on 04/29/2024 at 4:45 PM, Staff C, Director of Nursing, stated Staff D did not follow the care plan for cares-in-pairs and two-person bed mobility while they attempted to provide incontinence care but should have. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide a complete discharge summary to the resident and their primary care physician and failed to implement a process to reconcile pre-discharge medications with the resident's post-discharge medications for 2 of 6 sampled residents (#1 & 2) reviewed for community discharge. This failure placed residents at risk of unmet care needs, medical complications, and a diminished quality of life. This caused harm to Resident #1. Findings include 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 11/18/18, documented Resident #1 was discharged from the facility to the community on 11/28/18 and return to the facility was not anticipated. Review of the medical record showed on 11/21/18 Resident #1's Montreal Cognitive Assessment (MoCA) (used to determine whether a person has abnormal cognitive function) was 22/30 indicating abnormal cognitive function. The resident's medical record documented on 12/06/18, Received email from (Resident#1's state case manager) that (Resident #1) has not been seen by a PCP (primary care physician), has not been able to administer his own meds, and has not been called by home health services. (Staff D, Social Service Assistant) called (home health agency) to check on referral. Left Voicemail. (Staff D) called CM (case manager) .and is waiting for a call back. (Staff D) spoke with nursing to find out how (Resident#1's) self-administration program went. The record did not document confirmation of arranged home health services, outcome of self-administration program, reconciliation of medications, contact information for facility practitioner, and did not identify the recipients of the discharge summary. A provider note, dated 12/14/18 at 11:15 AM, showed Resident #1 was taken to the medical clinic by a temporary caregiver to establish care. (Resident #1) was brought today by a temporary caregiver who is only taking him to doctor visits. (Resident #1) currently does not have any caregiver support from anyone who helps him administer his medications. He does not know how to draw up and inject the Humalog sliding scale (system of administering insulin based on blood sugar levels). He also does not know how to use his [MEDICATION NAME] inhaler (medication used to control symptoms of [MEDICAL CONDITION] by relaxing the airway and keeping it open). The note showed Resident #1 had 3 [MEDICATION NAME] inhalers with different brand names the resident stated he was using each daily, and a [MEDICATION NAME] inhaler (medication used to treat airflow obstruction in patients with [MEDICAL CONDITION]) which the resident said he was not using. (Resident #1) is currently on 2Liters per minute of oxygen by nasal cannula and has not been able to change the canisters. He does not know how to change them. Resident #1's temporary caregiver noticed that (Resident #1) forgets phone conversations or falls asleep during calls and does not remember later. This is a discrepancy from Resident #1's reported cognitive status at discharge. The note documented, Upon detailed review of (Resident #1)'s medication list, he was discharged from the skilled nursing facility with [MEDICATION NAME] (an anti-psychotic medication used to treat [MEDICAL CONDITIONS] 1, and resistant depression in adults) 5mg BID (twice daily) under the name (Resident #3) (same last name as Resident #1). The temporary caregiver reports a lot of memory issues since discharge in contrast to the reported discharge cognitive status. The nurse manger provided (Resident #1) with education and information on how to replace oxygen tanks at home. On 1/16/19 at 9:30 AM, Resident #1's Community Medical Provider (Provider A) said Resident #1 was referred to the clinic for establishing medical care. Provider A stated, The facility had not provided any current medical record for Resident #1. Provider A stated, The only document I have received was an emergency room encounter summary from (MONTH) (YEAR). Provider A said Resident #1 was confused and disheveled during the office visit on 12/14/18. Resident #1 was unable to explain what or how many medications he has been taking. Provider A said she was very concerned Resident #1 had been taking an anti-psychotic medication that was intended for a different resident. Resident #1 was displaying signs of adverse medication side effects during the visit. Provider A said Resident #1 displayed signs of confusion, sedation, and was unable to provide his own care. Provider A said Resident #1 has missed appointments, and her staff had been unable to reach Resident #1 by phone. At 2:40 PM, Resident #1 said when he was discharged from the facility, a staff member handed him a bunch of medications and some papers and rushed him out the door. The resident stated, It was a rush job. It was a last minute fly by. Resident #1 stated, I can't give myself insulin. I can't take my blood sugar. I don't even know what medications I'm supposed to be taking. Resident #1 said for a few weeks after leaving the facility, my mind was so foggy I do not remember what was going on. The resident stated, I stopped taking the medication ([MEDICATION NAME]) so I am starting to be able to think again. 2) Resident #2 was admitted to the facility on [DATE] with multiple diagnoses. The MDS, dated [DATE], documented Resident #2 was discharged from the facility to the community on 12/10/18 and return to the facility was not anticipated. On 01/16/19 at 10:00 AM, Resident #2's caregiver showed this surveyor two (2) large opaque plastic trash can liners which contained multiple medication bottles and multiple medication blister cards which the resident had been instructed to put aside by her state case manager. The Bag #1 contained approximately 40 blister medication cards. There were multiple duplicate medications and administration instructions that were no longer correct and/or medications no longer prescribed. Bag #2 contained multiple over the counter and prescription medications, approximately 50 in total. Bag #2 contained unlabeled loose pills (approximately 20 orange capsules, 7 white oblong tablets, 6 round green tablets, 12 medium size white round tablets, 30 small size white round tablets, 1 red and yellow capsule, multiple small size white round 1/2 tablets) and the contents of several open capsules. Bag #2 contained the following expired medications. Medication Name: Discard by: Quantity: [MEDICATION NAME] 08/01/17 6 tablets [MEDICATION NAME] 03/03/18 22 tablets [MEDICATION NAME] 02/17/18 42 tablets [MEDICATION NAME] 03/06/18 4 tablets tamsulosin 02/20/18 42 tablets Xarelto 03/06/18 7 tablets Xarelto 02/10/18 8 tablets [MEDICATION NAME] 02/17/18 34 tablets [MEDICATION NAME] 02/23/18 18 capsules [MEDICATION NAME] 02/23/18 48 capsules [MEDICATION NAME] 03/07/18 16 tablets [MEDICATION NAME] 01/27/18 22 tablets A review of the medical record documented on 12/10/18, at 10:38 AM, Resident #2 discharged from the facility and moved into an apartment with her husband. The resident was informed to please call the facility at the phone number below and speak with (admissions or social services) if you have any problems within the next 30 days. Medical records showed on 12/29/18 the resident's husband called the facility (as instructed) with questions regarding medications. Staff E, Registered Nurse (RN), documented, Unable to provide any more information, education or medical advice as resident is (discharged ) and now under (physician) care. On 01/16/19 at 11:30 AM, Resident #2 stated, I was handed some paperwork and pushed out the door. The resident said she was not given any instructions on what to do with all the medications. The resident said they had tried to call the facility, but the facility had not returned any of their calls. Resident #2 said she had not received a copy of her discharge summary, and her medications were not gone through with her at or prior to discharge. On 01/24/19 at 11:45 AM, Staff H, Licensed Practical Nurse (LPN), indicated she was one of the three resident care managers, and all three care managers had been recently hired. Staff H indicated the discharge process was not clear to them when Resident #1 and Resident #2 were discharged to the community. Staff H was unable to provide documentation of discharge instructions, medication reconciliation, and self-medication administration assessment for Resident #1 and Resident #2. Staff H said the current process for discharging a resident to the community involved coordination with the interdisciplinary team, medication reconciliation, and a review of the discharge care plan with the resident at the time of discharge. At 12:30 PM, Staff B, RN and Director of Nursing Services, said the facility was notified of a possible medication error on 12/18/19 involving Resident #1 discharging home with one of Resident #3's medication blister cards. Staff B stated, As a result of our investigation, we identified an education need surrounding medication reconciliation at discharge. We provided immediate training to all nursing staff on the discharge process and flagged all residents with the same or similar names. We have been auditing all discharges to ensure all of the discharge steps and required notifications were provided at the time of discharge. The changes and clarifications to the discharge policy were fully implemented on 01/10/19. The facility failed to implement a process to reconcile all pre-discharge medications with the resident's post-discharge medications resulting in Resident #1 discharging home with another resident's anti-psychotic medication. Resident #1 experienced adverse consequences of taking the incorrect medication. Resident #2 was discharged to her apartment with multiple expired medications, discontinued medications, and medications with conflicting administration instructions on the label. Reference WAC 388-97-0080(7)(b)

Based on observation, interview and record review, the facility failed to prevent the development of an unstageable pressure ulcer for 1 of 3 sampled residents (#1) reviewed for skin issues. This failure placed residents at risk for development of pressure ulcer and a diminished quality of life. This caused harm to Resident #1. Findings include . The facility's Skin Care Policy and Procedure and Skin Monitoring and Management, revised 06/2016, documented, It is the policy of this facility that: (1) A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and (2) A resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The Skin Monitoring and Management policy documented, Weekly skin check conducted by a licensed nurse. All residents will have a head to toe skin check performed at least weekly by a licensed nurse. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 04/07/18, documented Resident #1 had severe cognitive impairment and required extensive assistance with activities of daily living including bed mobility and transfers. The MDS documented the resident was at risk for pressure ulcers, had no unhealed pressure ulcers on admission, and documented interventions of pressure relieving devices for the chair and bed. The Licensed Nurse (LN) Initial Admission Record, dated 03/31/18 at 5:12 PM, documented Resident #1 had no pressure and circulatory ulcers when he was admitted to the facility. A Weekly Skin Evaluation, dated 04/22/18 at 7:32 AM, documented Resident #1 had no ulcers, wounds and other skin problems. A nursing note, dated 04/25/18 at 1:38 PM, documented Resident #1's skin as, Skin color is normal. The note documented Resident #1's left hand and right lower extremity were swollen and inflamed. The physician (MD) was contacted and orders were given to start Resident #1 on a steroid. A nursing note, dated 04/26/18 at 3:17 PM, documented, Resident is with noted (sic) black eschar to right heel. Eschar measures 4.5 cm (centimeters) x 1.2 cm. Site is without drainage and has no open area. The eschar is thick and dry. The surrounding tissue around eschar is mildly red. Site is tender to the touch. Site cleansed, [MEDICATION NAME] was applied to site and wrapped with kerlix, heel guard is in place. Heel is floated. New orders received for air mattress. Wound team to follow. Family is aware and agrees with plan of care. Positions with pillows for comfort. Placed onto alert monitor. The resident's care plan for impaired skin integrity documented, 4/26/18 unstageable pressure ulcer to right heel. Interventions included use of an air mattress, heel protectors, float heels, treatment of [REDACTED]. A physician order, dated 04/29/18 at 2:00 PM, documented Resident #1 was to wear heel medix blue boots while in bed. A physician order, dated 04/29/18 at 2:00 PM, documented, (Resident #1) to have an air overlay mattress on bed at all times, ensure setting is at medium. Check every shift. A nursing note, dated 04/30/18 at 11:41 AM, documented, Resident was found to have an unstageable pressure ulcer to right outer feel. Had been on a regular mattress, now have low air loss mattress on bed at all times, and bilateral heel medix boots on while in bed. Currently cleaning .cover with heel guard and wrap with kerlix daily. MD and family notified. Order obtained to refer to (wound care service). On 05/01/18 at 11:46 AM, Resident #1 was observed to wince when the dressing was removed from the wound. When asked if his heel hurt, Resident #1 nodded his head and stated, Yes. At 12:10 PM, when asked how the wound progressed to unstageable before it was identified, Anonymous Staff A stated, In my opinion, his feet weren't checked. He can move only minimally and (his feet) just laid on the mattress. I feel bad to see it get to that stage. At 02:06 PM, when asked about Resident #1's heel, the Director of Nursing Services (DNS) stated, He has an unstageable pressure ulcer on his right outer heel. It was found last week sometime. When asked if Resident #1 had the pressure ulcer when he admitted to the facility, the DNS stated, No, he grew it here. It started as a blister. When I heard about it, it was eschar. When asked about other residents with pressure ulcers, the DNS said, Not that we grew. We grew this one. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review the facility failed to consistently identify quality of care deficiencies or develop an action plan to correct known deficiencies requiring quality assessment and assurance interventions. Failure to conduct an effective program that timely identified and developed action plans to respond to quality care deficiencies placed residents at risk for reduced quality of care and quality of life. Findings included . Refer to the following deficiencies: F600, F607, and F610 related to immediate jeopardy of abuse F686 related to the development of a facility acquired pressure ulcer causing harm to the resident F908 related to unsafe functionality of a resident's bed causing harm to the resident F697 related to an ineffective pain management program for a resident F584 related to unsanitary and homelike environment for all residents F947 related to nurse aides not receiving 12 hours of in-service training with one hour of abuse training and dementia training F730 related to nurse aides performance reviews not completed F880 related to lack of following infection control practices during personal care, medication pass, hand hygiene and isolation procedures F677 related to Activities of Daily Living (ADL) effecting 8 dependent residents Appendix Z, Emergency Preparedness Program effective June 9, 2017 with the Final Rule effective November 15, 2017 On 12/13/17 at 3:18 PM, an interview took place with Staff Z, Administrator, (ADM) and Staff N, Department of Nursing, (DON) regarding the facility's Quality Assessment and Assurance/Quality Assurance Process Improvement QAA/QAPI program. Staff Z, ADM stated the facility held QAA committee meetings at least quarterly with all department heads, medical director and pharmacy. The facility staff communicated quality care issues through various avenues to include daily morning stand up meetings, weekly subcommittee meetings, through their charting software program of point click care, interdisciplinary memos, and communication binders. He explained when trends were identified a performance improvement plan was developed, implemented, and a root cause analysis conducted with the use of a fishbone diagram prioritizing concerns with a matrix. Department heads also conducted record audits reporting results to the committee. Throughout the recertification survey process, the identified deficiencies included: <Abuse-Immediate Jeopardy> Facility staff reported a resident created mental anguish and a fearful environment. The facility did not implement their written policies or corrective actions to prevent abuse. Staff Z, ADM, stated he was frustrated this occurred. The plan was for ongoing, constant, and diligent training with reporting and identifying triggers. The incident was not okay. <Pressure Ulcer Development-Harm> On 12/12/17 at 12:32 PM, Staff G, MD stated the resident did have poor bed mobility and positioned on the right side most of the time. Staff G, MD acknowledged no new prevention interventions or individualized interventions to meet Resident #8's care needs were put into place. <Unsafe, Malfunctioning Resident Equipment-Harm> For several months, several facility staff reported a resident's bed was unsafe for the resident, as well as, the staff. The resident told several staff regarding the unsafe condition of his breathing machine with no assistance to have the machine repaired. Staff Z, ADM and Staff N, DON both stated they constantly discussed the residents to best assist each with their care needs. They reported the facility was resident focused with discussion in the QAA meetings. <Pain-Harm> Facility staff stated the resident often reported pain with the resident knowing what therapies/treatments assisted with decreasing his pain. The facility did not acknowledge the resident's requested interventions for an effective pain management in controlling the pain. Staff Z, ADM, stated a twice a week pain clinic visits was offered to the resident with alternative medications and therapies. Facility staff was aware of the problem; did not get addressed by the QAA committee. <Sanitary and Comfortable Homelike Environment-at a Substandard Quality of Care Level> Staff Z, ADM, said he was not aware the showers had black substance on the ceiling, in the grout, on the floor and wall tiles. Stated needed to review the housekeepers' checklist and will be discussed at QAA meeting. He explained the housekeepers' need to pay attention to detail with continual checks, same for the shower chairs and all of the residents' equipment. <Required Nurse Aide in -Service Training> Staff Z, ADM, and Staff N, DON, stated the facility could not recover the computer-tracking database for the nurse aide training to include abuse and dementia. This issue was not brought to the QAA committee. <Nurse Aide Performance Review> Staff Z, ADM, and Staff N, DON, stated they were unaware of the nurse aide performance reviews not being current. They both said this was an issue brought to the next QAA committee. <Infection Prevention & Control> Staff Z, ADM, stated infection control was a monthly discussion at the QAA meeting. He was aware of urinary tract infections were an issue with a performance improvement plan initiated. He stated he was unaware of the infection control issues the surveyors found during this survey. <ADL Care Provided for Dependent Residents> Staff Z, ADM, and Staff N, DON, were aware of one resident having issues with receiving ADL care due to he refuses. They were unaware of as many as eight nor receiving ADL care. <Emergency Preparedness Program > The facility received deficiencies in each of the 27 federal requirements for the emergency preparedness program. Staff Z, ADM, stated with the new requirements, the emergency preparedness program was a continual work in progress. He reported the facility needed to catch up with the new regulations, developing and implementing trainings with status discussions in the QAA meetings.

Based on observation, interview, and record review, the facility failed to develop and implement measures to prevent skin breakdown for 1 of 8 residents (Resident #8) reviewed for pressure ulcers. This failure caused harm to Resident #8 who developed an avoidable Stage 3 pressure ulcer to the right ankle. Findings included . Record review of the facility's policy, Skin Monitoring and Management, revised on 06/2016 showed Stage 3 pressure injury as full thickness loss of skin .Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location . Resident #8 readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 11/25/17 showed the resident had no pressure ulcers, was at risk for developing pressure ulcers, and required an extensive assist of 1 person for bed mobility. Braden score (assessment of skin at risk for breakdown; score greater than 19 indicates low risk) was 13. Review of Resident #8's care plans initiated 12/21/15 showed that she required assistance with bed mobility, to encourage and assist to turn and reposition every 2 hours and as needed. On 11/02/17 the risk for impaired skin integrity care plan was updated to address anticipated decline but no new interventions were added to prevent a break in skin integrity. Observation on 11/30/17 at 11:18 AM showed Resident #8 in bed laying on right side. Observation on 11/30/17 from 1:09 PM until 2:45 PM Resident #8 was in bed laying on right side. Record review showed daily skilled nursing notes from 11/11/17 through 11/26/17 that described skin as color in normal and bed mobility as extensive assist of 1-2 people. An incident report dated 12/02/17 showed an abrasion to the right outer ankle of Resident #8. On 12/4/17 doctor orders were received .to start Vit. C bid (twice daily), place air mattress to bed for pressure relief. Have wound team assess patient On 12/04/17 a nursing note showed that the area on the right ankle was nonblanchable and resident complained of discomfort with shoes and a pad placed over the area. A progress note by Staff G, Medical Director (MD) dated 12/05/17 showed Patient with a new unavoidable ulcer. Appears to be stage 2 .Patient is end of life care with prognosis of less than 6 months. I did refer to hospice and she was denied. She's had significant weight loss with poor nutritional status over the last several months. She has poor bed mobility. Review of the registered dietitian (RD) note dated 12/01/17 showed Resident #8's weight was stable from prior stay and intake was fair on average. The weight record for Resident #8 showed her initial admission weight as 116.9 pounds and her last recorded weight on 11/13/17 as 119.6 pounds. On 12/07/17 at 1:20 PM and 3:15 PM, an air mattress was observed in place and set on 4. The setting number panel correlates with weight and 4 equals 175 pounds. On 12/08/17 at 8:39 AM the air mattress was observed to be set on 4. On 12/08/17 at 9:10 AM Staff H, Resident Care Manager (RCM) stated the doctor orders the setting for the air mattress and acknowledged there was not an order for [REDACTED]. A nursing note dated 12/10/17 showed Right ankle red and surface tissue sloughing off Area surrounding right ankle is sore upon palpation. On /12/11/17 at 11:15 AM Staff K, Certified Nursing Assistant (NAC) stated that Resident #8 likes to lay on right side and the bed was turned today so the other side was against the wall to see she would lay on her other side more. Staff K, NAC added the nurses monitor the air mattress settings and make the adjustments. On 12/11/17 at 1:35 PM observed Staff H, RCM change the dressing to the right outer ankle. Staff H, RCM described the wound as stage 2 and pointed to an area in the lower portion of the wound bed and stated it was slough. According to the MDS, the definition of a stage 2 is Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. Slough is defined as yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. Resident #8 said ouch when the wound was touched to clean. Staff H, RCM stated that the wound had been present about a week. During an interview with Staff N, Director of Nursing (DON) on 12/11/17 at 2:15 PM, she stated that skin breakdown on Resident #8 was unavoidable per doctor's order. Staff N, DON stated that the unavoidable determination was due to weight loss and less than 6 months to live with a hospice referral, but hospice declined the admission as the resident did not meet criteria. Staff N, DON stated that NAC staff has told her Resident #8 declines to be repositioned off right side and was not aware if this was documented or why the resident refuses to turn. Staff N, DON added that they have moved the bed to other side against wall to see if she will lay on her other side. Staff N, DON stated that the wound team comes every Friday, but Resident #8 was not seen on 12/08/17 rounds even though doctor ordered on [DATE], adding she will be seen this week. Staff N, DON acknowledged the care plan did not include interventions to decrease the risk of skin breakdown prior to this aside from the regular pressure reducing all residents sleep on. Staff N, DON stated that the expectation would be to have interventions in place if risk was identified. Staff N, DON acknowledged the RD assessment and weight record did not correlate with the significant weight loss indicated when determining the unavoidable status. During an interview on 12/12/17 Staff W, MDS Coordinator (MDSC) stated that resident status had not changed from the previous to qualify for a significant change MDS. Staff W, MDSC added the weight loss that did occur was related to [MEDICAL CONDITION] and the resident was currently above her baseline admission weight. On 12/12/17 at 9:57 AM Staff N, DON stated that nurses don't always stage wounds correctly so the doctor or wound team does it. Staff N, DON described a stage 2 as the top layer of skin is gone and first layer involved and stage 3 is more involvement. Staff N, DON added that slough or a darkened area would be unstageable the wound bed can't be visualized. On 12/12/17 at 10:24 AM the wound was observed when Staff N, DON assessed the wound. Staff N, DON removed the old dressing and the resident said ouch that hurts as the dressing was adhered to the wound. Staff N, DON described the wound bed as beefy tissue with no slough. Red inflamed and painful to touch. Pointed to a dark area and said that it was not slough but drying up, a scab. Staff N, DON stated scab is considered slough. Staff N, DON added I think it's better, smaller but still red, over 50% is good tissue, don't know what is under the scab, little subcutaneous tissue under it. Staff N, DON estimated the scab about .2cm x .2cm and the whole area .5cm x .3cm. On 12/12/17 at 10:45 AM Staff O, Registered Nurse (RN) verified Resident #8 had not received prn medication prior to dressing change and stated she last received prn in November. On 12/12/17 at 12:32 PM Staff G, MD stated that the pressure ulcer was a stage 2 and was smaller and shallower than last week but didn't measure. Staff G, MD added that a small scab was present at 9 o'clock in the wound bed. Staff G, MD stated that Resident #8 had poor bed mobility and was positioned on the right side most of the time. Staff G, MD acknowledged no new prevention interventions or individualized interventions to meet Resident #8s care needs were put into place. Staff G, MD agreed Resident #8's weight was stable when reviewed the documented weights from admission to the most current.

Based on interview and record review, the facility failed to provide necessary care and services when the facility failed to conduct and document a thorough assessment and use clinical judgment prior to administering medications for 1 of 7 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for adverse side effects from medications including death. This caused harm to Resident #1. An immediate jeopardy was identified and the facility was informed on 10/25/17. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set (MDS), a comprehensive assessment tool, dated 9/26/17, documented Resident #1 did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. The MDS documented the resident was capable of increased independence in some activities of daily living, and had multiple mood and psychiatric disorders including anxiety, [MEDICAL CONDITIONS], and post-traumatic stress disorder. Resident #1's admission order summary report, dated 9/19/17, documented occupational and physical therapy to evaluate and treat as indicated; and medication orders included [MEDICATION NAME] for anxiety, [MEDICATION NAME] for muscle spasms [MEDICATION NAME]-[MEDICATION NAME] for dementia, [MEDICATION NAME] for bi-polar disorder, [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for [MEDICAL CONDITION], trazadone for depression with evidence of sleepiness, and vilazodone for depression. There were no orders for hospice/palliative or comfort care. On 9/20/17, a nursing note documented, Resident was forgetful and confused. Resident was adjusting to the facility routine slowly and walked up and down the hallway all through the shift. On 9/22/17, a social services note documented, Resident appears to be adjusting to the facility. No other concerns. On 9/23/17, a nursing note documented, Resident alert and confused, continues to walk/wander up and down the hallway. Resident does not sit still for any length of time. On 9/26/17, a physician admission note documented the resident was admitted to the secure dementia unit for exit seeking behavior and elopement risk with a goal of long term care in the secure dementia unit. A review of Resident#1's vital sign flow sheet documented the last pulse, blood pressure and respiratory rate was taken on 9/26/17 and were within normal range. On 9/28/17, a nursing note documented, Resident with noted [MEDICAL CONDITION], restless/anxious and pacing in the hallway. On 10/02/17, a nursing note documented, Message sent to Resident Care Manager to contact family and get more information on her job. We are guessing it was on night shift, she does not sleep at all except for a few naps. On 10/4/17, a social services note documented the resident was seen by the dentist on 10/03/17 for a routine exam and would be placed on the hygienist list for cleaning. On 10/5/17, a fall committee note documented, Resident is a continuous wanderer. Will continue to monitor for 3 more weeks. No documentation was in the resident's medical chart regarding a change in condition between 10/5/17 and 10/6/17. On 10/6/17, a nursing note documented, Resident is lethargic, Resident is forgetful/confused. Remained in bed this shift but did receive her shower. On 10/7/17, a nursing note documented, Resident found with light red discoloration on arms. A facility incident report, dated 10/7/17 at 2:14 p.m., documented Resident #1 was found with light red discoloration on arms, hips, and both knees. The resident has been noted to push self-up and down in the armchair and it is felt the bruises are due to bumping on the arms of the chair. (Resident #1) is seen trying to use her arms getting up, and when she is in manic phase she will seat on the chair repeatedly up and down to the chair using her arms, legs, and sliding her buttocks. A physician note, dated 10/9/17 at 4:56 p.m., documented, Patient is relatively new admit on multiple [MEDICAL CONDITION] drugs. Initially on admit she was very restless at night and we scheduled her Klonopin (in addition to trazadone and [MEDICATION NAME]). Now for the last 3 days she has been very somnolent. Plan, wean Klonopin, go down to 0.5mg (from 1mg) at night for 1 week then discontinue. Consider wean of [MEDICATION NAME] next. Patient occasionally cycles into wakeful periods at night but not for the last several days so will reassess if that starts happening again. On 10/10/17, a care conference note documented, Nursing states resident's sleep patterns are off. MD reduced Klonopin to see if that helps. Daughter states she has a history of this. Nursing will refer to therapy for balance concerns. A physician order [REDACTED].>A fall committee note, dated 10/10/17 at 11:31 a.m., documented, No falls since admit, will continue to monitor for 2 more weeks. A nursing noted, dated 10/11/17 at 3:47 a.m., documented, Resident resting in bed through night, attempts to open eyes to verbal stimulus. No signs or symptoms of distress at this time. A nursing note, dated 10/11/17 at 3:48 p.m., documented, New order in place for comfort measures only and hospice referral. New POLST signed and in chart MD aware no medications had been administered for 2 days. The October 2017 Medication Administration Record [REDACTED]. Resident #1's Physician order [REDACTED]. On 10/11/17, an updated POLST documented comfort measures only (Use medication, positioning, wound care and other measures to relieve pain and suffering). On 10/11/17, a hospice referral was ordered by the Medical Director (MD). The October 2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The October 2017 MAR indicated [REDACTED]. The MAR indicated [REDACTED] A nursing note, dated 10/11/17 at 10:46 p.m., documented, Approximately 2035 hrs. Summoned to resident's bedside to find her unresponsive to touch and sternal rub, without respirations and no radial or audible pulses (S1S2); negative corneal reflex (indicative of death). A nursing note, dated 10/12/17 at 4:02 a.m., documented, Resident passed away at 2218 with family at her side. On 10/25/17 at 2:00 p.m., Licensed Nurse (LN) A stated, on 10/11/17 at approximately 3:30 p.m., she was approached by a family member requesting medication for her mother. LN A stated, Resident #1 was not my resident, I did not know what was going on with her. (Resident #1's) nurse was on break so I went and looked at (Resident #1). LN A said Resident #1 was sweaty and was breathing fast. LN A said she contacted the MD and was given a verbal order to enact the Comfort Order Set. LN A stated, I retrieved [MEDICATION NAME] form the e-kit and administered 20mg of [MEDICATION NAME]. LN A said she did not document an assessment and vital signs before or after the administration of [MEDICATION NAME]. LN A stated, As soon as I gave the [MEDICATION NAME] her nurse was back so I left. When asked how LN A determined which order from the order set to administer, LN A stated, I just used my judgment. When asked if LN A was aware of Resident #1's medical history and clinical picture, LN A stated, I had a vague knowledge of the resident's history. The facility's Comfort Order Set documentation included the following 3 orders: [MEDICATION NAME] 2mg/ml take 0.3-0.5ml by mouth every 4 hours as needed (for anxiety or dyspnea) for up to 10 days, [MEDICATION NAME] 20mg/ml take 0.5-1ml by mouth every 1 hours as needed for pain or air hunger for up to 10 days and [MEDICATION NAME] ophthalmic 1% solution 1-2 drops under tongue every 6 hours as needed for controlling respiratory secretions. Resident #1's medical record documented, Resident#1 had not been prescribed any opioid medications during or prior to admission to the facility. The Food and Drug Administration package insert for [MEDICATION NAME] 20mg/ml documented, [MEDICATION NAME] is indicated for the relief of severe acute and severe chronic pain. The usual adult dose is 10-30mg every 4 hours. [MEDICATION NAME] should be given with caution and the initial dose should be reduced in certain patients, such as the elderly. Medication may suppress respiration in the elderly, very ill, and those patients with respiratory problems, therefore lower doses may be required. On 10/25/17 at 2:40 p.m., LN B stated, I was at lunch when Resident #1 received her first 20mg dose of [MEDICATION NAME]. I checked on her and she was resting quietly. At 5:50 p.m., Resident #1's family member came out and stated that Resident #1 needed more medication. I checked on her and she was moving a little bit so I administered 20mg of [MEDICATION NAME]. LN B said Resident #1 was pretty quiet after the second dose of medication. At approximately 8:20 p.m., Resident #1's family member approached again stating her mother needed more medication. I checked on her and she was fidgeting a little so I gave her 20mg of [MEDICATION NAME]. LN B stated, after the third dose of [MEDICATION NAME] Resident #1 was calm and very peaceful. LN B said between 9:30 p.m., and 10:00 p.m., a family member reported to her that Resident #1 had passed away. When asked how LN B determined which medication order to administer from the comfort order set, LN B stated, I just gave her what she had been given before. The family told me she was dying, I assumed she was dying, I just wanted to keep her as comfortable as possible. LN B stated, I'm sure that there is no documentation, I never document, never have. The facility failed to conduct and document a thorough assessment and re-assessment for Resident #1 who experienced a change in medical condition. The facility failed to clarify a medication order set without clear parameters and prioritization for medications. These failures resulted in harm to Resident #1. Reference WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure resident beds were safe and free from hazards for 2 of 4 sampled residents (#1 and #5) reviewed for accident hazards related to exposed electrical wires on their beds which resulted in a staff member being shocked while providing care to Resident #1. In addition, random observations of facility beds were found to have damaged electrical cords. This failure placed all residents, who were provided unsafe beds, at risk for the same and/or similar avoidable accident hazards since the beds were not inspected and maintained for safety. This was determined to be an immediate jeopardy. Findings include: Resident #1 was admitted to the facility in September 2011, with multiple health conditions including severe dementia and inability to make her needs known. The resident was incontinent of urine/bowel, and required extensive assistance for daily living tasks. On 5/8/17 at 3:30 p.m., when asked about the problem with Resident #1's bed and the injury to Nursing Assistant (NA) A on Sunday 5/7/17, the Director of Nursing Services (DNS) said she was not aware of the incident and the NA's injuries. The resident's room/bed were observed. The resident was not interviewable. The bed was observed against the wall and the electrical cord was within the resident's reach. The Director of Maintenance (DM) indicated he had not seen the bed and the cord, and said his assistant had removed the bed from service, had repaired the cord and the bed was placed back into service. He did not know where the bed was located as there were no maintenance reports to show service occurred, and the cord had been thrown away. The documents for the bed inspections, completed by facility nursing staff the evening of 5/8/17, showed the following beds on the dementia unit: Room 506-1 some small exposed areas on the cord. Room 509-1 had some damage. Room 511-2 had a frayed cord and replaced with an orange extension cord-like plug. Room 514-1 had exposed wires. Room 515-1 had exposed wires. Room 500-1 cord frayed. On 5/9/17 at noon, the DM said the beds had been repaired. On 5/23/17 at 8:10 a.m., the DM was asked to provide the maintenance logs to show inspection and service of the beds identified on 5/8/17. He said he was not sure where they were and he would find them. The maintenance work orders provided showed, between December 3, 2016 and May 16, 2017, only 1 bed cord issue, dated 12/21/16, bed cord, damaged at foot in room 202-2, repair requested by son and on 5/1/17 breaker problem. At 9:00 a.m., when asked if his name/initials were on the 5/8/17 bed inspections, the DM said, No, I didn't do them, nursing staff did. When asked about the electrical issues and NA who was shocked by the exposed wires on Resident #1's bed, the DM said, I don't see a problem with what happened .this could happen in any building, it was just an accident. The DM indicated this avoidable accident was being made more of .than it needed to be. On 5/23/17 between 9:15 a.m. and 4:00 p.m., random beds were inspected with the Fire Marshal (FM) and the following issues were identified: Resident #5's (Roommate of Resident #1) bed had a visible damaged electrical cord by the metal frame with exposed wires at intervals along an approximately 10 inch section of cord. The resident was on continuous oxygen. When three staff members wanted to help the resident to bed, the FM immediately asked the DM to replace the cord. When asked about the electrical issues in his room, Resident #6 held up a role of black electrical tape (BET) and said, This is how things are fixed. The (DM) doesn't care. Resident #2 said she saw NA A's injuries right after the accident and said, Her (NA A's) hand was black and swollen! I feel unsafe, it is dangerous here . The room was observed to not have enough outlets for the resident's equipment and she said, That's why I keep my bed unplugged. The resident said her roommate had electrical problems with her bed and the DM did nothing. No documentation was found regarding an electrical problem with her roommate's bed and if it was repaired. The resident said the DM should be doing bed inspections, not staff, what do they know about this .they need to take care of residents. Random observations of beds in the dementia unit found the following: Room 500-1, full bed cord damaged. Approximately 6 inches of BET was removed and showed exposed wires. Room 500-2, BET was removed and showed 2 exposed wire areas. Room 501-2 had a broken prong sticking out from the outlet. The FM asked the DM to removed it immediately. Room 506-1, cord damaged and covered with BET. Room 507-1 had nearly 6-feet of damaged cord that was replaced by the maintenance assistant. Room 509-1, when BET removed, showed exposed wires cut completely through. Room 511-1 showed a two-prong without a ground prong. Room 511-2 showed a replacement cord that looked like an orange extension cord and no ground prong. Room 513-2, when BET removed, showed exposed wires. Room 512-1, no ground prong. At 1:30 p.m., the DM said he had inspected all of the beds. When asked to see the documentation of the beds he inspected and the repairs made, the DM said he did not have any documentation. The DNS said the DM had followed staff for some of the inspections. The facility knew, on 12/21/16, that a resident's son asked for a replacement cord for Room 202-2, and that the beds may need to be inspected. The facility knew on May 7, 2017 at 6:30 a.m., that a staff member suffered an electrical shock trying to protect Resident #1 from grabbing exposed wires on her bed cord. The facility knew on 5/8/17 that several beds, identified by nursing staff, were in need of immediate repair with more than BET. Facility failure to recognize, act upon the immediacy of the electrical bed problems, and prevent avoidable injuries such as sustained by NA A, placed all residents at risk when beds were not inspected frequently, repaired properly and immediately to protect residents, staff and the public from electrical injuries. This failure resulted in immediate jeopardy. Reference (WAC) 388 -97 -1060 (3)(g) Refer to F 456 and F 465.

Based on observation, interview and record review, the facility failed to ensure residents had functioning beds without exposed electrical wiring for 1 of 3 sampled residents (#1), reviewed for safe patient care equipment. This failure created the potential for injuries to residents and caused harm to a staff member while trying to protect Resident #1 from touching the exposed cord wires. This was determined to be an immediate jeopardy. Findings include: Resident #1 was admitted to the facility in September 2011, with multiple health conditions including severe dementia and inability to make her needs known. The resident was incontinent of urine/bowel, and required extensive assistance for daily living tasks. On 5/8/17 at 3:30 p.m., when asked about the problem with Resident #1's bed and the injury to Nursing Assistant (NA) A on Sunday 5/7/17, the DNS said she was not aware of the incident and the NA's injuries. During an observation of the resident's room/bed, the resident was not interviewable. The bed was observed against the wall and the electrical cord was within the resident's reach. On 5/8/17 at 4:00 p.m., the Administrator (ADM) said he was notified of the electrical problems on Sunday morning around 9:00 a.m. and spoke to Staff C. The ADM said he did not report the event and investigate it because only the staff member had been injured and not the resident. When asked if an assessment was done to show no injury to the resident, the ADM said he could not say. No documentation was found in the record to show an assessment of either Resident #1 or the roommate (Resident #2, who used oxygen) had been done. The ADM said this could occur with any resident's bed, and since the resident was not injured, nothing more was done. The Director of Maintenance (DM), who had not seen the bed or the cord, said his assistant had removed the bed from service, had repaired the cord and the bed was placed back into service. He did not know where the bed was now located. When asked to see the damaged cord, the DM said his assistant had thrown the cord away, and he had not personally seen the damaged cord. When asked to review the maintenance logs/service records for the bed, the DM said there were no records to review. At approximately 4:30 p.m., random beds throughout the facility were observed with the DNS. At this time the DNS reported the issue to the state hotline, started an investigation, and initiated an inspection by nursing staff of all beds in the facility. The documents for the bed investigations, completed the evening of 5/8/17, were reviewed. On 5/9/17 at approximately 11:00 a.m., random identified beds were inspected with the DNS on the dementia unit showed the following: Room 506-1 some small exposed areas on the cord. Room 509-1 had some damage. Room 511-2 had a frayed cord replaced with an orange extension type cord. Room 514-1 had exposed wires. Room 515-1 had exposed wires. Room 500-1 cord frayed. These had been repaired with black electrical tape (BET). At approximately noon on 5/9/17 and 5/23/17, NA A described the electrical event and showed her injuries. NA A said she and another NA went into Resident #1's room at 6:30 a.m. on 5/7/17 to provide care. NA A said she noticed exposed wires on the electrical cord plugged into the wall. The resident's bed was against the wall and the electrical wall outlet was about 4 feet from the floor and the exposed wires were about 1 foot down the cord from the outlet and within easy reach of the resident. NA A said she pulled the bed from the wall to protect the resident while another NA held the resident's hands to keep her from touching the exposed wires. The NA said her body was pushing the bed away and when she moved her hand up to remove the cord, her metal ring touched the exposed wires. She said there was a spark and she was electrocuted and had a blistered thumb, black area on her hand, arm, fingers and thumb with numbness and arm pain to her shoulder. She said all of the electricity to the entire wall, including the resident's roommate (#5) who used continous oxygen, went out and the housekeeper had to restart the electricity at the facility's main electrical breaker panel. NA A's right hand/fingers and thumb were observed to be slightly swollen and she could not touch her fingers together due to the swelling, pain and numbness. She said the emergency room (ER) physician told her she was electrocuted and the swelling and numbness should go away in a few more days. The NA said she believed the resident would have been able to grab the cord and could have been injured if she had not discovered the exposed wires and intervened for the safety of the resident. At approximately 1:30 p.m., Resident #2 said she saw NA A's hand after the incident on Sunday (5/7/17) and described the NA's hand as black, swollen, burned .and the roommate (Resident #5) uses oxygen . On 5/23/17 at 11:00 a.m., NA A said she was still having several medical issues and numbness of her hand. On 5/23/17, the repairs made with BET were inspected with the Fire Marshal. When the BET was removed, the repairs were found to be inadequate to prevent the potential for electrical injury. Failure of the facility to ensure residents' beds were periodically inspected/repaired by qualified staff and documented to be in good repair, placed this resident and all residents at risk for injury and resulted in harm to NA A which was determined to be an immediate jeopardy. Reference (WAC) 388 97-2100 Refer to F 465.

Based on observation, interview and record review, the facility failed to maintain a safe environment for 1 of 3 sampled residents (#1), staff and the public related to lack of maintenance of residents' beds that were found to have damaged electrical cords, and created a risk of electrical injury to Resident #1, and caused an electrical injury to Nursing Assistant (NA) A when she intervened to protect the resident from harm. This resulted in an immediate jeopardy. Findings include: Resident #1 was admitted to the facility in September 2011. She had severe dementia and could not make her needs known. She required extensive assistance from staff for all care and services. On 5/8/17 at 3:30 p.m., when asked about the problem with Resident #1's bed and the injury to Nursing Assistant (NA) A on Sunday 5/7/17, the DNS said she was not aware of the incident or the NA's injuries. The administrator stated he had been informed the morning of the incident and did not report it and investigate the event because the NA was harmed, not the resident. At approximately 4:00 p.m., the Director of Maintenance (DM) said his assistant had removed the bed from service, had repaired the cord and the bed was placed back into service. He did not know where the bed was currently located. When asked to see the damaged cord, the DM said his assistant had thrown the cord away, and he had not personally seen the damaged cord. When asked to review the maintenance logs/service records for the bed, the DM said there were no records to review. The documents for the bed inspections completed by nursing staff the evening of 5/8/17, were reviewed and showed the following: Room 506-1 some small exposed areas on the cord. Room 509-1 had some damage. Room 511-2 had a frayed cord replaced with an orange extension-type cord. Room 514-1 had exposed wires. Room 515-1 had exposed wires. Room 500-1 cord frayed. The beds had been repaired by the DM. On 5/9/17, at approximately noon., NA A described the electrical event and showed her injuries. NA A said she noticed exposed wires on the electrical cord plugged into the wall. The resident's bed was against the wall and the electrical wall outlet was about 4 feet from the floor and the exposed wires were about 1 foot down the cord from the outlet and within easy reach of the resident. The NA A said she pulled the bed from the wall to protect the resident while another NA held the resident's hands to keep her from touching the exposed wires. NA A showed her right hand/fingers and thumb that were still slightly swollen. NA A could not remove her ring due to the swelling and could not touch her fingers together due to the swelling, pain and numbness. NA A said the emergency room (ER) physician told her she was electrocuted and the swelling and numbness should go away in a few more days. NA A said she believed the resident would have been able to grab the cord and could have been injured if she had not discovered the exposed wires and intervened for the safety of the resident. On 5/23/17 at noon, the NA said when she pushed the bed away with her body and started to move her right hand wearing a metal ring, up to unplug the cord from the wall, there was a spark and she was electrocuted. She described her hand as numb and she was experiencing further medical problems. Failure of the facility to ensure residents' beds were inspected regularly and in good repair, and to keep maintenance records to show specific equipment that had been repaired/replaced, resulted in potential injury to residents, the public, and caused a serious electrical burn injury to staff NA A. This was determined to be immediate jeopardy. Reference (WAC) 388-97 -3220 (1)

Based on interview and record review, the facility failed to consult with the physician and notify family members for 1 of 3 sampled residents (#3) reviewed for notification of changes, when the resident incurred a fall that resulted in an 8-hour delay in treatment for [REDACTED]. This failure resulted in harm to Resident #3. Findings include: Resident #3 was admitted to the facility from the hospital on [DATE] with multiple health conditions including a recent stroke, and [MEDICAL CONDITION] (irregular heat beat) for which he was prescribed a daily anticoagulant/blood thinner (Xeralto) medication. The resident had [MEDICAL CONDITION] (partial loss of the ability to produce language, spoken or written). The admission progress note, dated 5/4/17 at 2:46 p.m., showed, .the resident has word salad, [MEDICAL CONDITION], the words come quick but are the incorrect words, unable to ascertain cognitive ability due to [MEDICAL CONDITION] . The progress note, dated 5/6/17 at 11:12 p.m. and 11:19 p.m., showed, Resident found on the floor in prone (face down) position beside his bed. Abrasions to knee, dressing applied. Incontinent .no responsible party contact in chart so at this time, he is his own responsible party. The facility's summary of the incident documented, At noon (5/7/17) family members arrived upset related to not being notified at the time of the fall. They also reported the scan of the resident's head was positive for a brain bleed. The physician progress notes [REDACTED]. Patient found to have a small SAH (subarachnoid hemorrhage, bleeding between the brain and the tissues that cover the brain). Question as to delay in transfer .I was not immediately notified, therefore when secure messaging (electronic) was reviewed the following morning, I made the clinical decision approximately 8 hours after the fall, when I was made aware, to send patient to ER for further evaluation and resident was taking aspirin and daily blood thinning medication. On 5/9/17 at 1:00 p.m., the Director of Nursing Services (DNS) said she was not sure if staff asked the resident if he wanted to go to the ER at the time. There was no family contact in the record at the time and no documentation was found to show the resident was included/asked if he wanted to go to the ER. The DNS said the physician would be contacted by telephone and electronic messages for future notifications. Reference (WAC) 388-97-0320 (1)(a-d), 2(a)(b),(3) Refer to F 309. .

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (#3), reviewed for necessary care and services, received timely care after a fall. This failure resulted in harm to Resident #3 when a delay in physician intervention and treatment for [REDACTED]. Findings include: Resident #3 was admitted to the facility from the hospital on [DATE] with multiple health conditions including diabetes, wounds to right leg/foot, and heart failure. He had a recent stroke with right-sided weakness, [MEDICAL CONDITION] (decline/loss in cognition), and [MEDICAL CONDITION] (irregular heat beat) for which he was prescribed a daily anticoagulant/blood thinner (Xeralto) medication. The resident had [MEDICAL CONDITION] (partial loss of the ability to produce language, spoken or written). He required extensive assistance with daily living tasks and a Hoyer (mechanical) lift for transfers. The progress note, dated 5/6/17 at 11:12 p.m. and 11:19 p.m., showed, Resident found on the floor in prone (face down) position beside his bed. Abrasions to knee, dressing applied. Incontinent. Physician made aware .denies hitting head, fall unwitnessed .no responsible party contact in chart so at this time, he is his own responsible party. Review of the fall injury monitoring form (neurological check sheet), showed the facility monitored the resident every two hours and there was no increase in the normal confusion status. The facility's summary of events for 5/6/17 at 9:50 p.m., documented, .the nursing assistant (NA) entered the room related to the call light being on (resident's roommate called for help) .NA observed patient lying on the floor in the prone (face down) position with a small amount of fluid on the floor .at approximately 11:15-11:30 p.m The night shift nurse performed an assessment and noted a discoloration to the right forehead but did not realize this was a new injury. On 5/7/17 at 6:15 a.m., the progress note showed, Received call from physician to send resident to emergency room (ER) for evaluation and scan of head . The physician progress notes [REDACTED]. Patient found to have a small SAH (subarachnoid hemorrhage, bleeding between the brain and the tissues that cover the brain). Question as to delay in transfer .I was not immediately notified, therefore when secure messaging (electronic) was reviewed the following morning, I made the clinical decision approximately 8 hours after the fall, when I was made aware, to send patient to ER for further evaluation as resident was taking aspirin and daily blood thinning medication. On 5/9/17 at 1:00 p.m., the Director of Nursing Services (DNS) reviewed the record and indicated the facility failed to show timely notification/consultation with the physician had occurred from the time of the incident until the physician checked electronic messaging at 6:15 a.m., the following morning, and resulted in an estimated 8-hour a delay in care and treatment. Reference (WAC) 388-97-1060 (1) .

Based on observation, interview and record review, it was determined the facility failed to ensure the safety of 1 of 3 sampled Residents (#1) reviewed for supervision to prevent accidents. This failure resulted in harm when the resident was turned in bed by one staff member and fell from his bed.sustaining a left hip fracture. Findings include: Resident #1 lived in the facility since 2012. He had multiple health conditions including diabetes, bowel/urine incontinence, dementia/cognitive deficit, seizure disorder and worsening congestive heart failure. The resident used a bariatric (extra large) bed (without rails) for safety when he turned due to his excessive weight. He was transferred to and from bed with the help of two people and a mechanical (Hoyer) lift. The most recent Minimum Data Set (MDS, a comprehensive assessment tool) dated 1/26/17 indicated the resident required extensive assistance of 2 staff members with most daily living tasks, transfers and 2+ staff members for bed mobility. On 2/17/17 review of facility investigation documents (ID) revealed the resident incurred a fall on 2/15/17 at approximately 11:30 p.m. The nursing aide (NA) documented: While providing incontinent care, I was going to the far side of the bed when (Resident #1) rolled out of bed .since I was walking around the bed, I did not witness the fall. The ID indicated the resident was a 2 person for Transfer, Bed Mobility and Hoyer lift. After this fall, the resident was found on the floor on his left side and sustained significant injuries. He was transported to the hospital via 911. On 2/22/17, review of hospital records dated 2/16/17, revealed the resident had an acute left femur .comminuted, (a break or splinter of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma .), displaced (bone snaps into two or more parts and moves so that the two ends are not lined up straight) fracture. Additional [DIAGNOSES REDACTED]. According to the surgeon, surgery would be difficult because of the resident's medical history and potential for bleeding complications. It was decided the resident would not be a good candidate for surgical intervention. The resident was started on narcotics for pain and returned to the facility on [DATE], placed on comfort measures and passed away on 2/20/17. On 2/22/17 at noon, during interview, the Director of Nursing Services (DNS)) stated she thought the resident could be moved in bed with one staff member. Review of the care plan, progress notes and assessments indicated the resident required 2 or more staff members during care and transfers. Failure to ensure two staff members worked with this resident resulted in harm and placed all residents who required the assistance of two or more staff members at risk of accidents.

Based on observation, interview and record review, it was determined the facility failed to ensure pain was identified and managed for 1 of 5 residents (#108) reviewed for dental pain, failed to ensure physician orders [REDACTED].#127) reviewed for wound care, and failed to ensure monitoring after a procedure for 1 of 5 residents (#41) reviewed for dental services. This failure caused harm to Resident #108 and placed residents at risk of experiencing unmanaged pain, a delay in wound healing and potential complications after dental procedures. Findings include: <Resident #108> Resident #108 was admitted to the facility 9/4/15 with multiple medical [DIAGNOSES REDACTED]. The resident was able to answer yes and no questions by nodding up and down and side to side, and spoke individual words. The resident's Minimal Data Set (MDS), an assessment tool, dated 8/16/16, documented the resident had obvious or likely cavities or broken natural teeth. The Pain Risk Evaluation, dated 1/15/17, categorized the resident as high risk for pain. The January 2017 Physician order [REDACTED]. The physician order [REDACTED]. The Medication Administration Record [REDACTED]. Each time, the source of the pain and the effectiveness was not documented. On 1/30/17 at 2:31 a.m., the MAR indicated [REDACTED]. At 2:32 a.m., one minute after administration of the medication, the MAR indicated [REDACTED]. On 1/30/17 at 11:28 a.m., the Director of Nursing services (DNS) stated the expectation for assessing medication effectiveness would be 30 to 45 minutes after medication administration. The DNS indicated one minute was not a correct or acceptable practice. The DNS stated the LNs are to document the source of pain, as well as effectiveness of the pain interventions, in the resident progress note each time. When asked to show these entries in Resident #108's medical record, the DNS was unable to and stated, They are supposed to document it each time but did not. The DNS said all non-pharmacological interventions are individualized to each resident's needs. Resident #108 had listed snack as one of his interventions attempted prior to giving pain medication in the month of January 2017. This was documented in the resident's MAR. The January 2017 Physician order [REDACTED]. The DNS indicated the intervention was incorrect and removed snack as an intervention. On 1/25/17 at 11:17 a.m., Resident #108's family member explained the resident's teeth cause major discomfort for him and have been since his initial injury in 2015. The family member stated, He is in terrible pain from the sharpness when his tongue hits the edges (of his teeth). He needs them all pulled. Resident #108 nodded his head up and down in a yes motion numerous times as the family member spoke. When Resident #108 was asked directly to rate his pain from zero-to-ten, zero being no pain at all and 10 being the worst pain imaginable/excruciating, the resident nodded yes when the word excruciating was used. The resident's family member stated the resident would complain of pain when up in wheel chair for long periods of time due to injuries from the past accident. The resident nodded yes when asked if he had pain when up in a chair for long periods. When asked, Do your teeth hurt when touched, when you try to speak or during oral care?, the resident answered verbally, Yes. On 01/30/17 at 8:59 a.m., Nursing Assistant (NA) R stated Resident #108 did not like oral care or if you touch his face at all. The resident pulls his head away. NA R stated, It's hard to give care. On 1/30/17 at 11:00 a.m., NA S attempted to provide oral care to Resident #108. When NA S placed the wet oral swab in the resident's mouth, the resident started yelling and pulling away. As the swab moved inside the resident's mouth, the resident's face turned red and the resident yelled louder and louder. Licensed Nurse (LN) A asked NA S to stop. NA S stated, I'm sorry- the water isn't cold. He always does this. I think it's the root endings of his teeth causing him pain. He always does this and has pain. When asked, Are you having pain?, Resident #108 yelled out yes! and nodded vigorously. When asked, Is it your mouth and teeth causing the pain?, Resident #108 stated yes. On 01/30/2017 at 11:34:20 a.m., NA S stated, We really do take care of our residents. He just has so much pain from those teeth. I never even thought about that it hurts his mouth when we shave him until I saw you ask him. When asked if the nurses are aware of residents pain, NA S stated, Yes, many times they will hear his screaming out during oral care and they come in. On 1/30/17 at 2:31 p.m., when asked how the resident's pain is assessed, LN H stated, The resident is not verbal and I can't tell exactly where or when he is having pain. I rely on the resident's mother to let me know what he needs and the source. LN H indicated she does not ask the resident specifically. She goes through his mother to assist with the communication barrier. When asked how pain is assessed when the family is not there, LN H stated, Well, the good thing I can say is I haven't given him much pain meds on my shifts. Review of the pain assessments in Resident #108's medical record documented staff usually use the numerical 1-10 pain scale to assess the resident's pain. When asked, the resident was not able to express his pain using the numerical pain scale. The MAR indicated [REDACTED]. Resident #108 expressed pain 16% of the time. The MAR indicated [REDACTED]. The resident was identified as being in pain 80% of the time. The facility staff failed to consistently accommodate the resident's cognitive and communication needs in order to accurately assess and manage the resident's pain. This caused harm to Resident #108. <Resident #127> Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's MDS, dated [DATE], the resident was moderately cognitively impaired and required extensive assistance with activities of daily living (ADLs). Review of Resident #127's Treatment Administration Record (TAR) showed the resident had a diabetic ulcer on her left great toe measuring 9 centimeters (cm) x 7 cm. The TAR included an order to cleanse the toe, pat it dry, apply [MEDICATION NAME] (a wound ointment) to the wound bed and cover with a dry dressing every shift. Resident #127's Physician order [REDACTED]. Floating heels includes placement of a pillow or pad to keep heels from directly touching the bed to reduce the pressure to heels. On 1/23/17 at 4:15 p.m., the resident was observed lying in her bed. Her heels were not floated and there was no dressing on her toe wound. On 1/26/17 at 8:58 a.m., the resident was observed sitting on her bed eating breakfast. The ordered dressing to her wound was not in place. At 10:50 a.m., 11:14 a.m., 1:49 p.m., 3:51 p.m. and 4:49 p.m., the resident was observed lying in her bed with her heels flat on the bed and the wound dressing not in place. On 1/27/17 at 9:00 a.m., the resident was observed sitting on her bed. The wound dressing was not in place. At 11:47 a.m., the resident was observed in bed. Her heels were not floated and her wound dressing was not in place. On 1/27/17 at 11:49 a.m., when asked if any residents on the hall needed their heels to be floated while in bed, NA U was not aware Resident #127 had an order to float her heels. On 1/27/17 at 11:58 a.m., when asked about the treatment for [REDACTED]. At 12:18 p.m., LN A stated Resident #127's wound was a diabetic ulcer she had had since admittance to the facility. LN A stated the treatment for [REDACTED]. LN A said the resident pulled the dressing off at times. The resident's order stated the dressing should be replaced if it came off. The resident's TAR did not indicate any replacement bandages were placed during the month of January. Nursing notes did not indicate the resident had been removing the dressing. When asked about the order to have the resident's heels floated while in bed, LN A said she was unable to locate that intervention on the care plan. LN A stated, She is in bed all the time. That should be on her care plan and being done. <Resident #41> Resident #41 admitted to the facility on [DATE]. The resident's MDS, an assessment tool, dated 1/7/17, indicated the resident had obvious or likely cavity or broken natural teeth and the resident participated in the assessment. On 1/25/17 at 10:55 a.m., Resident #41 reported not having any of her own teeth and not having dentures yet. At 3:25 p.m., Resident #41 was observed to not have any natural teeth. A Social Service note, dated 10/12/16, documented Resident #41 was scheduled for teeth extractions at a dental provider on 10/17/16 at 2:00 p.m. Record review of progress notes from 10/12/16 through 10/25/16 made no mention of the teeth being extracted. There was no documentation of any monitoring for post procedure complications. Common complications after dental procedures include excessive bleeding, infection and/or pain. The October 2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 1/25/17 at 2:38 p.m., the Social Service Director (SSD) confirmed Resident #41 had her teeth extracted 10/17/16. When asked if there should be documentation about the procedure she said, Yes. When the SSD reviewed Resident #41's record, she stated, Nursing missed that. At 3:29 p.m., when asked about monitoring and documentation post teeth extraction, LN A stated, Yes, they weren't doing it and they should have been.

Based on observation, interview and record review, it was determined the facility failed to provide necessary dental services for identified dental problems for 3 of 5 current sampled residents (#108, 131 & 41) reviewed for dental services. This failure caused harm to Resident #108 when he experienced ongoing pain related to dental problems and placed all residents at risk for infection and further complications related to unmet dental needs. Findings include: 1) Resident #108 was admitted to the facility 9/4/15 with multiple medical diagnoses. The resident's Minimal Data Set (MDS), an assessment tool, dated 8/16/16, documented the resident had obvious or likely cavities or broken natural teeth. Resident #108's MDS, dated [DATE], documented the resident responds adequately to simple, direct communication. An Initial Dental Assessment, dated 9/25/15, completed by a dentist, documented, several broken teeth. A Dental Assessment, dated 9/13/16, identified Resident #108's gum tissue was red and irritated. He had bleeding gums upon palpitation and heavy plaque and calculus was identified. The dentist recommended extract all teeth with a referral to an oral surgeon. A Social Services Progress note, dated 9/13/16, documented resident seen by the dentist today. Dentist recommends seeing oral surgeon and extracting all teeth. Dentist will be sending referral to get process moving. An email sent from the Social Services Assistant (SSA) on 12/29/16 at 3:15 p.m. to the dental office manager documented, I was going through my dental notes and came across (the dentist's) 9/13/16 recommendation for extractions and requested a referral form be sent to facility for extractions to be set up outside the facility with an oral surgeon. The email, which requested follow-up, was sent three months and 16 days after the dental exam and need for referral was identified. On 1/25/17 at 11:17 a.m., Resident #108's family member stated the resident's teeth caused major discomfort for him and have been since his initial injury in 2015. The family member stated, He is in terrible pain from the sharpness when his tongue hits the edges (of his teeth). He needs them all pulled. Resident #108 nodded his head up and down in a yes motion numerous times as the family member spoke. When Resident #108 was asked directly to rate his pain from zero-to-ten, zero being no pain at all and ten being the worst pain imaginable/excruciating, the resident nodded when the word excruciating was used. When asked directly, Do your teeth hurt when touched, when you try to speak or during oral care?, the resident answered, Yes. On 1/25/17 at 3:06 p.m., when asked why the facility had not followed up to arrange dental extractions for Resident 108 between 9/13/16 and 12/29/16, the Social Services Director (SSD) stated, You're right, we should have sent a referral. On 1/26/17 at 8:10 a.m., Resident #108 was observed to have several dark, decayed and broken teeth. On 1/30/17 at 11:00 a.m., Nursing Assistant (NA) S attempted to provide oral care to Resident #108. When NA S placed the wet oral swab in the resident's mouth, the resident started yelling and pulling away. As the swab moved inside the resident's mouth, the resident's face turned red and the resident yelled louder and louder. Licensed Nurse (LN) A asked NA S to stop. NA S stated, I'm sorry- the water isn't cold. He always does this. I think it's the root endings of his teeth causing him pain. He always does this and has pain. When asked, Are you having pain? Resident #108 yelled out yes! and nodded vigorously. When asked, Is it your mouth and teeth causing the pain?, Resident #108 stated yes. 2) Resident #131 admitted to the facility on [DATE] with multiple medical diagnoses. Resident #131's Admission Oral Assessment, dated 7/21/16, documented the resident had missing or broken teeth and no artificial teeth present. Resident #131's Activities of Daily Living Care Plan, initiated 7/22/16, documented, (Resident) is edentulous besides a few natural teeth on the bottom. No dentures present. Requires 1 assist with oral care. On 1/24/17 at 8:57 a.m., Resident #131 stated her dentures went missing at her last care facility. The resident stated she would like to get her dentures replaced. Observation of the resident's mouth showed no teeth on top and two teeth on the bottom. On 1/27/17 at 10:27 a.m., Resident #131's family member stated, we would love her to get dentures. I think it would really help her appetite if she could eat regular food. The family member stated she had questioned the facility staff about the possibility of dentures for Resident #131 and never heard anything back. The dental visit summary, dated 10/18/16, documented the resident was edentulous on the top, missing many teeth on the bottom, had red/irritated gums and some bone loss. Hygiene Cleaning was checked under the Doctor Recommends section of the form. A hand written note, Recommend New F/ was documented in the margin next to the doctor recommendations. A social services progress note, dated 1/10/17, documented, Resident does not have dentures and was seen by the dentist on 10/18/16. Dentist recommended hygiene cleaning, will add to list during next hygienist visit. On 1/30/2017 at 11:04 a.m., the SSD stated all residents dental needs are assessed upon admission and quarterly through care conferences. When asked about Resident #131, the SSD stated, I believe the dentist said she was not a candidate for dentures. The SSD then looked at the summary from the dental visit on 10/18/16. The SSD stated the form recommended routine hygiene cleaning. The SSD stated she did not know what the notation Recommend New F/ meant. The SSD stated she would email the dental office to gather more information. At 3:08 p.m., the SSD provided a printed email from the dental office manager, dated 1/30/17, at 3:07 p.m. The email documented, when (the dentist) saw (Resident #131) in October she did not have Medicaid coverage. I just checked and it looks like she got coverage in December. I will send you a Denture Request form for (Resident #131) tomorrow. When asked why she did not follow-up with the dental office sooner, the SSD stated I would have no reason to follow up since the doctor only recommended hygiene cleaning every six months. The SSD stated she did not follow up with the dentist to see what the hand written notation on the Dental Summary meant. At 3:30 p.m., the dental office business manager stated it would be up to the facility to let the dental office know when the resident got her Medicaid approval which would cover denture services. 3) Resident #41 was admitted to the facility 10/6/07. According to the MDS, dated [DATE], the dental section identified the resident as having likely cavity or broken natural teeth. On 1/25/17 at 10:55 a.m., Resident #41 said she had no teeth and didn't have any dentures yet. A review of the Dental care plan identified the intervention to coordinate arrangements for dental care, transportation as needed/ordered. A physician progress notes [REDACTED].#41 had been having a new behavior of screaming out. The plan included having dentistry come back to evaluate the resident, believing she may benefit from having her lower three teeth extracted resulting in improved mouth pain and screaming episodes. A physician progress notes [REDACTED].#41 had very poor dentition with multiple broken off teeth. She had been seen by the dentist and the plan was to get multiple extractions and dentures, which the resident was quite pleased about. On 1/25/17 at 2:38 p.m., the SSD reported Resident #41 was seen 4/12/16, two months after the physician first made note that the resident may be experiencing oral pain, by the dentist that comes to the facility every two months. At that time the dentist made a referral to an oral surgeon. Record review noted Resident #41 had a dental consult on 4/12/16 and a referral was made to the oral surgeon on 4/19/16. A SS progress note, dated 4/20/16, indicated the facility has attempted to contact Resident #41's daughter regarding a referral to the oral surgeon for her teeth extractions. A Care Conference note, dated 7/26/16, indicated Resident #41 was seen on 7/7/16 at the oral surgeon's office for a consult for teeth extractions and the Social Service Assistant (SSA) had called to schedule the procedure and left a message. On 1/25/17 at 3:43 p.m., the SSA stated on 7/7/16 the facility received a form from the oral surgeon that needed to be completed and signed by the physician before services can be provided. The form was completed and faxed back to the oral surgeon on the same day. The oral surgeon's office then calls the facility to schedule an appointment. When asked if there was any communication with the oral surgeon's office and the facility between 7/7/16 and 10/11/16 documented in the resident records, she was unable to locate any. A physician progress notes [REDACTED]. A SS progress note, dated 10/11/16, noted the oral surgeon had been called by the SSA to schedule an appointment for the teeth extractions and a message was left. A follow up note, dated 10/12/16, indicated the oral surgeon had called back and Resident #41 was scheduled to have the procedure the following week on 10/17/16 and no preapproval was needed. The note documented the resident was excited to hear the news and couldn't wait. On 1/25/17 at 2:38 p.m., the SSD said Resident #41 had her teeth extracted at the oral surgeon on 10/17/16. Record review of the SS Dental Binder documented Resident #41 signed an authorization form for dentures on 11/23/16. A SS progress note, dated 12/29/16, indicated the dentist was working on getting dentures at that time. On 1/25/17 at 2:38 p.m., the SSD stated SS coordinated and tracked dental needs of long-term care residents. The SSD stated going through the oral surgeon was a long process. On 1/26/17 at 2:44 p.m., the Director of Nursing Services (DNS) stated her understanding of the 8 month time period between identifying the teeth needed to be extracted to when it was done is that messages were being left and no one was calling back. When asked if these calls should be documented in the medical record, the DNS stated, yes. At 3:02 p.m., the SSA stated she normally waits a month to a month and a half to follow up and stated I probably waited longer than I should have to follow up on her. When asked about getting dentures for Resident #41, the SSA stated it can take up to 3 months and that she would ask the dentist when he came in.

Based on observation, interview and record review, it was determined the facility failed to ensure 4 of 10 sampled Residents (#1, #2, #3 & #4) and 1 of 1 discharged Residents (#11) reviewed for accidents, received adequate supervision and timely assistance, evaluation of previous accident prevention measures and implementation of new interventions to prevent repeated falls that resulted in harm to Residents #1 and #11 and placed all residents at risk from the same/similar deficient practice. Findings include: 1) Resident #1 was admitted [DATE] with multiple medical conditions including respiratory failure and required oxygen; depression, anxiety and decreased mobility. She was assessed at high risk for falls. The resident was alert and oriented and could make her needs known. Review of the record on 5/24/16 revealed the following: The resident fell on [DATE] that resulted in a back fracture and the record indicated: (Resident) has poor safety awareness and requires frequent redirection and reorientation . The documented fall prevention measures on the investigation report, but not included on the Comprehensive Care Plan (CCP), were (Resident) to be with staff member as she allows for closer supervision. The resident incurred another fall on 4/14/16 and was found on the floor of the bathroom. This unwitnessed fall resulted in a right hip fracture. On 5/25/16 at 1:25 p.m., Resident #1's call light was observed flashing above her room door. Staff members were at the nurse's station across the hall from the room; a Licensed Nurse (LN) was at the medication cart in the hallway and several staff members walked by the room without answering the resident's call light. At 1:35 p.m., the surveyor answered the light to see what the resident needed and informed the LN. Due to Resident #1's significant fall/injury history, failure to ensure timely responses to her call light for assistance placed the Resident at risk for repeated falls/injuries. On 6/13/16 at noon, the Resident ' s call light was flashing. She was observed in bed and was able to sit up and place her legs over the bed. She stated she still had significant pain in her right leg since her fall and surgery. According to the Licensed Nurse (LN) 6, the Resident does transfer herself to the bedside commode but knows she (Resident) should ask for help. The bedside commode was at the foot of the bed and not near the resident. The resident said she could not wait for her light to be answered many times and needed to use the commode but it is too far away right now. There was no assessment to indicate if the resident could safely transfer herself although staff knew the resident transferred herself independently without supervision when she could not wait for help. Due to the resident ' s fall history, these issues were brought to the Director of Nursing Services (DNS) attention. 2) discharged Resident #11 was admitted to the facility from the hospital on [DATE] with multiple health conditions including a fall at home in January that resulted in massive bleeding in the brain resulting in blindness, significant cognitive decline, difficulty speaking and generalized muscle weakness. The Resident was prescribed multiple medications including a blood thinner (Coumadin) with increased risk for bleeding. He required extensive assistance for all activities of daily living including transfers, toileting and mobility. On 5/24/16 review of the Physical Therapist's admission evaluation dated 2/19/16, indicated Patient demonstrated high fall risk and impulsive at times .needs time to process commands, needs simple 1 step commands .needs therapy to improve functional ability with reduced risk of falls and return to prior level of function .without skilled therapeutic intervention, the patient is at risk for falls and compromised general health. The admission nursing note (NN) dated 2/19/16 at 8:00 p.m. indicated Resident placed at the nurse's station for frequent checks as he was observed leaning forward in his wheelchair (w/c) .the LN was passing medications and the Nursing Assistant (NA) left the resident to answer a call light and when the NA returned, the resident (fell out of his wheelchair) was found to have hit his head on the floor with a laceration to his left eyebrow. The resident was transported to the emergency room (ER) at 11:30 p.m. for evaluation and sutures to the wound. The late entry NN dated 3/3/16 at 7:47 p.m. indicated Resident found sitting against the wall . The late entry NN dated 3/4/16 at 7:16 p.m. indicated Resident found sitting on his left side against the wall .helped him get up to his wheelchair and placed at the nurse's station until went to bed . The plan was to keep resident in highly visible area when up in wheelchair. The NN dated 3/11/16 at 1:00 p.m. indicated Therapy states that the resident is complaining of left hip pain upon standing and is not able to bear weight on the left lower extremity . The NN dated 3/11/16 at 10:00 p.m. indicated the left hip x-ray showed a left hip fracture with slight displacement and a physician order [REDACTED]. The NN dated 3/12/16 at 11:00 a.m., indicated Up in his chair .states it hurts but not that bad .received new orders to send the resident to the hospital as a direct admit. Review of the resident's comprehensive care plan (CCP) initiated upon return from the hospital following left hip surgery on 3/16/16, indicated the resident was at risk for falls .unaware of safety needs, deconditioning, vision/hearing problem, gait/balance problems with interventions that included: anticipate and meet needs; call light within reach .bed against the wall and in lowest position .bed near nurse's station. The NN dated 4/20/16 at 6:00 p.m. indicated Resident found lying on the floor .back against the bed .resident slid off his wheelchair . Review of the interdisciplinary team (IDT) note dated 5/17/16 at 7:30 a.m., related to a 4/19/16 fall, does not fully understand his deficits and may make impulsive move with limited safety awareness .attempted to get to his bed unassisted and was unable to navigate the transfer and sat on the floor next to the bed . 3) Resident #2 was admitted on [DATE] with multiple health conditions and a primary [DIAGNOSES REDACTED]. Review of the record on 5/25/16 indicated the resident had an assisted fall on 4/30/16. As the nurse guided the resident to the floor, the resident hit her head on the handrail that resulted in a bump to her forehead. Review of documentation reports dated 5/1/16 by the Director of Nursing Services (DNS) and the administrator, revealed the resident had a habit of wandering throughout the unit. The interventions per the 8/27/15 care plan for fall related to gait/balance problems with pronounced forward lean were Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility, maintain a clear pathway, free of obstacles, and provide commode near bed for night time toileting. The records indicated the resident fell on [DATE] while toileting self. The DNS documented the resident was capable of self-transferring and ambulating via front wheeled walker (FWW) although she should have had at least 1 person assist related to poor safety awareness. She required frequent toileting as well as frequent checks for incontinence. The 5/19/16 updated care plan interventions were: check range of motion, neuro checks as ordered, provide activities that promote exercise and strength building where possible, therapy referral, and toileting program through the night. The Resident Care Manager (RCM) was interviewed on 5/24/16 at 3:00 p.m. The resident was placed in a wheelchair due to ineffective gait and a pronounced forward stooping posture. The RCM said the Resident's body is almost parallel to the floor and cannot raise head to see where (she is) going. The resident was put in the wheelchair because of the falls. The facility care team discussed placing the resident in a wheelchair before the fall. The resident would cart the walker, place it down, and walk away and does not wait for assistance. The resident wants to self-toilet and is ok if there is something to hold onto. The resident had two falls in the last month and no falls prior. The last fall was on 5/18/16. Rather than implement fall prevention measures, the resident was placed in a wheelchair. 4) Resident #3 was admitted on to the facility on [DATE] with multiple health conditions including dementia. She required extensive assistance of staff for mobility, transfers and used a wheelchair. Review of the record on 5/25/16 indicated the resident was placed by the nurse's medication cart for closer observation on 4/27/16 at 7:30 p.m. The nurse left the cart and the resident fell out of her wheelchair and was found face down by the nurse's medication cart with the wheelchair on top of her that resulted in a 1cm x 0.2cm bleeding laceration to the back of her head. After the fall, rather than ensuring supervision, the prevention measure implemented by the facility was to not use the resident's standard wheelchair (WC) but to place the resident in a Tilt-in-Space WC (restricting ability of movement). On 5/24/16 during interview with Licensed Nurse (LN) 4 she stated: We try to bridge (position) the resident so she will stay in bed and we put the W/C at the foot of the bed so resident doesn't try to get into it. We leave resident in the hall so resident does not try to get into bed. I would find out why resident was trying to get out of the chair and get whatever resident wants. On 5/24/16 at 3:00 with RCM: One of our interventions is to keep resident close to the nurse's station to prevent resident from falling. Resident was singing right by the nurse's med cart, the nurse was right there when she fell . When asked what they were doing for fall risk prevention, the RCM stated, I know they put the resident in a different wheelchair. Resident was in a standard wheelchair at the time of the incident. I believe resident is in a Tilt-in-Space now. I do not know if she is getting therapy or restorative, I don't know her that well. 5) Resident #4 was admitted [DATE] with multiple health conditions including Alzheimer's. The resident required assistant of one person for transfers, ambulation and mobility. According to the record, the resident fell on [DATE] and fractured her right arm when she attempted to toilet herself. Her shoes were loose and laces were not tied properly. Preventative actions prior to fall were: anticipate and meet needs. Encourage to participate in activities that promote exercise, physical activities for strengthening and improve mobility. Place FWW near the resident when sitting. The care plan focus is At risk for falls related to Deconditioning, Wandering, Gait/balance problems i.e. shuffled short steps initiated on 9/21/15. The expectation was that the resident would be free of falls through the review date of 7/18/16. Interventions listed above with the addition to encourage walker use and place it near resident when sitting. Review of the Comprehensive Care Plan (CCP) revealed no Fall Prevention Devices Revision Date: 6/23/15 in place and No Progress Notes Found. On 5/24/16 at 3:00 p.m., the RCM was interviewed and stated: The resident is in a wheelchair due to broken arm from the fall. Resident cannot use a walker. We had 3 falls (in the unit) that day. Staffing was not any different that day. One of the aides was not down there. I don't know if one of the aides was on break. Resident is usually independent. I heard resident yell .the resident had slipper socks and it looks like crammed foot into a shoe. During observations on 5/24/16 and 5/25/16, the resident was only seen in a wheelchair. Failure to ensure residents were supervised to prevent harm even after placed in areas for close observation and placed in wheelchairs rather than implementing preventive measures, resulted in repeated falls and injuries and placed all residents at risk of harm/accidents.

Based on interview and record review, the facility failed to follow professional standards of practice to include basic first aid treatment for 1 of 1 sampled Residents (#1) who was found outside approximately 1/2 block away from facility property on the ground and with obvious observed injuries. Resident #1 was moved from found location without benefit of emergency medical transport assistance to assess and stabilize the obvious injuries and condition and placed the resident at further risk of harm. This failure was determined to represent an immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. The resident had [DIAGNOSES REDACTED]. He was to receive therapies to improve strength and return home with his wife. According to facility investigation documents (ID), on 3/26/16 at night, the resident was found by staff approximately ½ block away from the facility on the grounds of a nearby medical clinic. He was found down on his right side between a large metal dumpster and trash container fully clothed, lying in a puddle and soaking wet, complaining of pain about 10:40 p.m.possible clavicle fracture. There was no documentation in the nursing notes (NN) to indicate what transpired on the evening of 3/26/16 prior to or after the resident was found outside with significant injuries. According to the hospital records, the resident was outside in the elements for at least 1-2 hours. He was admitted to the hospital with [REDACTED].mild Rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood) most likely due to fall, left clavicle fracture, left rib fractures and compression fracture to back. In addition to fractures, the resident had several abrasions to his right upper arm, right knee and right side of head .he had a low body temperature and was placed in a warming unit. He had mild left atelectasis (collapse or closure of a lung resulting in reduced or absent gas exchange). On 3/29/16 at 2:00 p.m., during interview with the Director of Nursing Services (DNS), she stated there was a question if the resident had been hit by a car and No, the police were not called. The hospital was a couple of blocks away and when asked why staff moved the resident and risked causing more harm without knowing the extent of the resident's injuries, why not stay with the resident and call 911? The DNS said it was pouring down rain and staff wanted to get the resident inside. She said staff retrieved a wheelchair, 2 staff used a gait belt to help him into the wheelchair, brought him inside and got him out of his wet clothes and then 911 arrived. According to the basic first aid: If you suspect a back or neck (spinal) injury, do not move the affected person. Permanent paralysis and other serious complications can result. Get help. Call 911 or emergency medical help. Keep the person still . This was not done. Emergent help was not immediately obtained when the resident was found with obvious injuries. Refer to F 309 and F 323.

Based on interview and record review, it was determined the facility failed to obtain emergent, immediate assistance for 1 of 1 sampled Residents (#1) who was found outside beyond facility property for an unknown length of time. The resident sustained [REDACTED]. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital following treatment for [REDACTED]. He was to receive physical and occupational therapy from facility staff to gain strength to return to his prior level of function and return home with his wife. His prior level of function was to walk his dogs around the neighborhood daily and socialize with neighbors. According to facility investigation documents (ID), on 3/26/16 at night, the resident was found by staff approximately ½ block away from the facility on the grounds of a nearby medical clinic. He was found down on his right side between a large metal dumpster and trash container fully clothed, lying in a puddle and soaking wet from the rain complaining of pain about 10:40 p.m. There was no documentation in the nursing notes (NN) to indicate what transpired on this evening. Review of the ID, the resident was observed by a Nursing Assistant (NA) around 10:15 p.m., Awake, dressed, sitting in his room and said he wanted to stay up and watch TV. On 3/29/16 at 2:00 p.m., during tour of the possible exit route taken by the resident, the Director of Nursing Services (DNS) showed where staff found the resident in the back area of the nearby medical office. She said staff notified her around 11:00 p.m. that the resident was missing and found and that 911 had been called. She said staff members thought the resident might have a broken clavicle and other injuries and because it was pouring down rain, staff retrieved a wheelchair from the facility, and with the help of two staff members, placed the resident in a wheelchair and took him back to his room where he was taken out of wet clothes and 911 was called. This was validated in the investigation documents since nothing was documented in the NN. There were no NN related to this event. Review of the ambulance documents dated 3/26/16 indicated the facility called 911 at 11:11 p.m. The ambulance team arrived at the resident's bedside at 11:25 p.m. and transported him to the ER by 11:36 p.m. According to the ambulance team's documentation, .the resident was not sure how he got outside, stated he was cold. There was a 3 inch bleeding hematoma slightly below the resident's left clavicle; left breast bruised and starting to swell. NA stated she thought the resident was outside since at least 10:00 p.m. because she heard cries for help. However she did not go to investigate because she felt it was unsafe secondary to it being dark outside and it took two staff members to place the resident in a wheelchair to get him back inside. According to the hospital records, the resident was outside in the elements for at least 1-2 hours. He was admitted to the hospital with [REDACTED].mild Rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood) most likely due to fall, left clavicle fracture, left rib fractures and compression fracture to back. In addition to fractures, the resident has several abrasions to his right upper arm, right knee and right side of head .he had a low body temperature and was placed in a warming unit. He has mild left atelectasis (collapse or closure of a lung resulting in reduced or absent gas exchange). On 3/30/16 at 9:30 a.m., during interview with the resident's spouse, she said she had visited with the resident all day on 3/26/16 and had supper with him .about 6:00 o'clock and he seemed fine, I was pleased. He could walk around without difficulty but they (facility) wanted him to use a wheelchair or a walker. I know he used them in therapy but he walked just fine. He never had any problems and walked the dogs every day at home. He was driving, doing everything for himself and on 3/8/16 he saw his cardiologist and he was great. Now, since the fall, he is not well at all .just not doing well. He can't eat, drink or do anything. He is a totally different man. Refer to F 281 and F 323.

Based on observation, interview and record review, it was determined the facility failed to ensure the safety of 1 of 1 sampled Residents (#1) when he exited the facility at night, unobserved and was found beyond facility property with significant injuries. The door Resident #1 was determined to exit through had no working alarm to alert staff. In addition, once the door was locked at night there was no means to re-enter or alert anyone that a person needed assistance. This was determined to be an immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] from the hospital. He was to receive physical and occupational therapy from facility staff to gain strength to return to his prior level of function and return home with his wife. His prior level of function was to walk his dogs around the neighborhood daily and socialize with neighbors. According to facility investigation documents (ID), on 3/26/16 at night, the resident was found by staff approximately ½ block away from the facility on the grounds of a nearby medical clinic. He was found down on his right side between a large metal dumpster and trash container fully clothed, lying in a puddle and soaking wet, complaining of pain about 10:40 p.m. The resident had sustained significant injuries. On 3/29/16 at 2:00 p.m., during tour of the possible exit route taken by the resident, the Director of Nursing Services (DNS) showed the exit door located at the end of the 400 unit hallway and across from the physical therapy gym as the most likely exit. The exit door sign indicated the door was locked at 10:30 p.m. and to use the front entry. After some time of searching, the DNS was able to find the key to demonstrate how the door was locked and used after hours. After the door was locked, it could still be opened from the inside and allowing exit and without alarms sounding. However, once the door was locked and if used as an exit, the door would not allow re-entry to the facility. She said people would need to use the front door. Failure to ensure the exit door was secured in a manner to protect residents, staff and the public resulted in harm to Resident #1 and placed all residents at risk of a similar event. Refer to F 309.

Based on observation, interview and record review, it was determined the facility failed to have sufficient, qualified staff to provide and supervise care for 1 of 4 sampled Residents (#1) Observations, interviews with staff, combined with record reviews, revealed inadequate supervision of residents to ensure the care needs of these residents were met by licensed staff or certified nursing assistants in accordance with established clinical standards and their care plans. Staff did not adequately assess, plan, report or document information needed to formulate effective and timely interventions and evaluate the interventions for effectiveness. This failure resulted in an immediate jeopardy when care to Resident #1 failed to follow accepted standards of practice and placed all residents at risk of similar deficient practices. Findings include: The above information has been detailed in the following citations: 1) Refer to 42CFR483.20(k)(3)(i) F 281 Service Meets Standards for facility failure to follow professional standards of practice to include basic first aid treatment for 1 of 1 sampled Residents (#1) who was found outside approximately 1/2 block away from facility property on the ground and with obvious observed injuries. Resident #1 was moved from found location without benefit of emergency medical transport assistance to assess and stabilize the obvious injuries and condition and placed the resident at further risk of harm. This failure was determined to represent an immediate jeopardy. 2) Refer to 42CFR483.20(m) F 285 for facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR) was accurately completed upon admission and that services were obtained in a timely manner for 1 of 4 sampled residents (#1) reviewed for PASRRs. 3) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility to obtain emergent, immediate assistance for 1 of 1 sampled Residents (#1) who was found outside beyond facility property for an unknown length of time. The resident sustained [REDACTED]. 4) Refer to 42CFR483.75(l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards and practice to ensure complete and accurately documented records for 1 or 4 sampled Residents (#1) reviewed for sufficient, accurate information in the clinical record. This failure resulted in the inability to identify the physical and psychosocial needs and relevant outcomes to Resident #1 who experienced harm that resulted in immediate jeopardy.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to Resident #1 referenced in F 281, F 285, F 309, F 323 and F 514 and impacted care, safety, dignity and quality of life and resulted in an immediate jeopardy. Findings include: The information below is more detailed in the individual citations: 1) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient, qualified staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function related to injuries incurred by Resident #1 and resulted in immediate jeopardy. 2) Refer to 42CFR483.25(h)(2) F 323 Prevention of Accidents for facility failure to ensure the safety of 1 of 1 sampled Residents (#1) when he exited the facility at night, unobserved and was found beyond facility property with significant injuries and resulted in immediate jeopardy.

Based on observation, interview and record review it was determined that even though Resident #1 (of 4 sampled residents for falls), had been properly assessed and had adaptive equipment to meet her needs, she had a significant injury fall as a result of lack of nursing supervision. Facility failed in supervision when Resident #1 had become tired after dinner and had been left in her personal wheelchair from which she landed face forward on the floor, instead of the tilt in space wheel chair that was careplanned. Resident #1 has been a resident since 11/22/14. She is close to discharge to an adult family home and so she has been participating in her activities of daily living (ADLs) as much as possible. Over time at the facility, she has had several infections that slowed her progress toward discharge per nurses ' progress note. But on 4/18/15 she was able to navigate the halls of the facility in her personal wheelchair and even go to the facility beauty parlor for hair care. When Resident #1 was out of bed she was care planned and assessed to be in a tilt in space wheel chair. The tilt in space wheel chair was a protective device ordered for her confusion and lack of safety awareness and to keep her from falling. But on 4/18/15 it was decided to trial her in personal wheel chair and see how she would do according to the Resident Care Manager and Director of Nursing interviews. On the evening of 4/17/15, on evening shift, she was in her tilt in space wheel chair as reflected in the nurses ' notes that she tried to crawl out of it. But on 4/18/15 at 6 pm she was still in her personal wheel chair. There had been no assessment or supervision of her mental condition or personal performance in the wheel chair that evening and she had not been placed in her tilt in space wheel chair per nurses ' note review. And according to the investigation record she fell asleep in her personal wheel chair and fell out of the chair. She sustained a laceration to the forehead that required stitches and skin tear to her hand. According to the emergency room doctor ' s notes she sustained a closed head injury. On 4/ 24/15 while reassessing Resident #1 after this fall for a self-release seatbelt in her wheel chair it was determined that her personal wheel chair did not fit her for positioning purposes as her feet did not reach the floor and a facility wheel chair which was lower to the ground allowed her increased mobility, per review of Physical Therapy notes and interview.

Based on observation, interview and record review, the facility failed to follow and implement interventions consistent with recognized standards of practice as appropriate for 1 of 4 (#105) current sampled residents reviewed for pressure sores. This failure could have contributed to the development of a pressure sore after admission. Findings include: Resident #105 was admitted on [DATE] with [DIAGNOSES REDACTED]. Quarterly Minimum Data Set (MDS) an assessment tool dated 12/16/13 indicated that Resident #105 was assessed to be cognitively intact, at risk for developing pressure ulcer, and required extensive 2 person assist for bed mobility. Resident did not exhibit rejection of care per admission MDS dated [DATE] and most recent MDS dated [DATE]. The following Care Area Assessment (CAA's) that were selected for further assessment and care planning included pressure ulcer and activities of daily living (ADL's)/rehabilitation potential. A Braden scale (an assessment tool used for predicting pressure ulcer) was completed on 09/11/13 with a score of 15 to18 which indicated that resident was at risk for developing pressure ulcers. The resident's hospital record (dated 8/22/13) and prior to facility admission indicated the resident was admitted with Bilateral ischial (hip) wounds described as "cavernouse in size-approximately 10cm with irregular edges and both with approx 8cm undermining L (left) isch (ischial) from 8-12 o'clock and R (right) isch (ischial) from 12 - 4 o'clock. Bone palpated throughout the wounds. Red Base." Observation of the pressure ulcers on right buttocks on 1/27/14 at 1:36 p.m. with Licensed Nurse H revealed the right buttock had an pressure ulcer of 6 x 4 x 2 cm and tunneling 6cm deep. The right hip area was 4.8 x 2.1 x 1 cm deep. The dressing on the coccyx had a green color and lightly sanguinous. The ulcer measured 2.8 x 1.5 x 3.1 cm deep. The left buttock ulcer measured 4 x 2.5 x 0.8 x 5.8cm deep. The resident's left and right heels had darkened to pink areas with some slight brownish skin with dry skin over the rop o dark skin. <DRESSING CHANGE> On observation during dressing change performed by LN H on 01/27/14 at 1:36 p.m., the following three breeches in practice were noted: first when removing dressing on left buttocks, rolling the outside of the dressing onto itself, secondly touching the spout of the spray bottle which contained the Wound Cleanser to the 4X4 sponge which was used to cleanse the inside of the open area on the left buttocks, and finally dragging the moist 4X4 sponge on the skin surface below the open area as the moist 4X4 was placed in the left buttocks open wound which was left in for the wound. 01/28/14 at 11:26 a.m., LN H stated that by removing dressing by curling the outside of dressing over the wound there would be potential to bring bacteria from skin into wound, and the same for the moist 4X4 sponge touching skin prior to inserting it into the wound, and finally with the 4X4 sponge touching the end of the Wound Cleanser spray bottle as all these practices could potentially introduce bacteria into the wound. <REPOSITIONING> The care plan dated 09/11/13 and in room care directive (a facility document that guides provision of resident care) dated 9/13/13 indicated frequent turning, turn reposition every 2 hours and as needed, max remobilization, air mattress, provide Range of Motion (ROM), elevate heels pillow under lower legs, instruct and encourage repositioning self at 15-20 minute intervals. Record review on 01/27/14 at 1:03 p.m. indicated that air mattress was not ordered by physician, additionally the physician ordered to float heels, and encourage supine (a more flat position) positioning while in bed. Multiple observations during survey found the resident in bed in the sitting position with head of bed elevated from 40 to 60 degrees. Heels were flat on bed and Resident #105 stated, "The pillows they {staff} put under my lower legs are so thin and flat that my heels are on the bed anyways, so what's the use." The following dates and times are reflective of observations in which Resident #105 was in a sitting position with head of bed elevated with heels directly on air mattress. On 01/21/14 at 3:00 p.m., 01/22/14 at 1:15 p.m., 01/23/14 at 8:56 a.m., 9:26 a.m., 01/27/14 at 9:18 a.m., 10:40 a.m., 11:53 a.m., 12:15 p.m., 1:30 p.m., 2:38 p.m. and 4:18 p.m., and 01/28/14 at 9:29a.m. Progress notes dated 10/14/13 reads that the "Pt {patient} reviewed during Interdisciplinary Team meeting related to need for a repositioning/turning program. Pt cannot independently reposition self therefore staff needs to reposition Q 2 hr {every 2 hours}and PRN {as needed} to ensure good care." Resident #105's progress notes from 12/10/13 through 01/13/14 indicated that resident refused to be bridged and repositioned on multiple occasions. On 01/28/14 at 3:40 p.m., when asked if staff offered to reposition Resident #105 every 2 hours, LN B stated, "Staff still need to go in and offer to reposition this resident, and the resident can refuse it, it's his choice. They (staff) still need to check under him." 01/27/14 at 2:40 p.m., when asked NA F if s/he repositioned Resident #105 every 2 hours on the night shift (approximately 10 p.m. to 6 a.m. timeframe), NA F stated, "He {Resident #105} usually goes to sleep around 10:30 p.m. and then I go in around 2 a.m. and he is usually snoring on first round, so I empty his catheter and leave." NA F also stated that she usually does two rounds during the night shift, a first round at approximately 2:00 a.m. and a second round at approximately 5:00 a.m., and that Resident #105 is usually awake on second round when she empties his urinary catheter again. The facility failed to assess reasons for care refusals and possibly implement alternate interventions to mitigate the development of pressure ulcers for Resident #105. Refer to F-155. <PRESSURE ULCER ASSESSMENT> During observation of dressing change on 01/27/14 at 1:36 p.m., wound was observed to have full thickness tissue loss with granulation at base of wound that included tunneling at 12 o'clock that was 3.1cm deep. Facility Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer form indicated that the midline coccyx pressure ulcer was a Stage 2. On 01/29/14 when asked how s/he identified the staging of the midline coccyx pressure ulcer for Resident #105, LN H stated, "I would call it {midline coccyx pressure ulcer} more of a Stage III than a Stage II, but I do depend on my RCM {Resident Care Managers} to accurately Stage pressure ulcers, because they {Resident Care Managers} have more experience with than I do." 01/29/14 when asked who filled out the Skin Grid- Pressure/[MEDICAL CONDITION] Ulcer form for Resident #105's midline coccyx pressure ulcer, LN B stated, "I did." Then when asked how she identified Resident #105's as being a Stage II LN B stated, "I have not seen the pressure ulcer myself." S/he then stated that s/he relied on the information that is provided to him/her by the nurse who performed the dressing change. <LABORATORY VALUES> Laboratory values dated 11/12/13 indicated that hemoglobin (10.9 g/dL) and hematocrit (35.4 %) were below normal. physician's orders [REDACTED]. On 01/28/14 at 3:40 p.m., when asked about follow up blood work results for hemoglobin and hematocrit, LN B stated blood work was not completed and no results were available. .

Based on observation, interview, and record review, the facility failed to have a physician's order including medical justification, maintenance and care for use of an indwelling urinary catheter for 2 of 2 (#1 & 2) sampled residents reviewed for urinary care. This failure caused harm to Resident #1 who sustained catheter related complications, including urinary tract infections. Findings include: The Code of Federal Regulations (CFR) 42.483.25(d)(1) identifies that urinary catheters should be reserved for short-term decompression of acute [MEDICAL CONDITION] due to risk of significant complications from the use of indwelling urinary catheters. According to the CFR "The assessment should include consideration of the risks & benefits of an indwelling (suprapubic or urethral) catheter; the potential for removal of the catheter; & consideration of complications resulting from the use of an indwelling catheter, such as symptoms of blockage of the catheter with associated bypassing of urine, expulsion of the catheter." All observations and interviews took place on 6/3/13. <Resident #1> Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 4/26/13, documented the resident required extensive assistance with Activities of Daily Living (ADLs), had a urinary foley catheter (a tube inserted into the urethra to drain urine from the bladder), was always incontinent of stool, received nutrition via a tube placed in her stomach, and was moderately cognitively impaired with long and short term memory deficits. On readmit 3/18/13, the Nursing comprehensive admission data collection and assessment documented the resident had a urinary catheter, but did not document the size of the catheter. Review of the transfers orders from the hospital documented "Foley catheter management per nursing protocol-Permanent." Review of the facility admission orders [REDACTED]. On 4/2/13, according to the facility documentation, Resident #1's catheter was removed and an attempt to reinsert it failed. The PCP ordered the resident to go to an emergency room (ER) to have a urinary catheter inserted. The resident returned later in the evening, and was documented as having a urinary catheter placed by the ER staff. On 4/3/13, the signed physician orders for Resident #1 had no orders for a urinary foley catheter. There was no evidence the nursing staff identified the lack of a current faclity order for continuation of it, and did not seek and order for the urinary catheter. On 4/19/13, another Nursing comprehensive admission data collection and assessment was completed. It documented the resident had a urinary catheter size, and the LN documented the medical justification was [MEDICAL CONDITION], although there was no physician diagnosis. On 4/22/13 according to the nursing progress notes, the LN documented Resident #1's urinary catheter bag contained "green thick looking pus in it " and the physician was going to be faxed. Twenty-four hours later, a fax, dated 4/23/13, at 9:45 pm, was sent to the PCP notifying of the abnormal findings . On 4/24/13, the PCP returned the fax with documented orders for the facility to obtain a urine culture for Resident #1. The urine specimen was obtained at 5:30 on 4/25/13. 4/26/13, the PCP assessed the resident and documented the urinalysis was positive, the culture was pending, and diagnosed Resident #1 "UTI with associated clinical sequelae." The physician ordered an antibiotic, [MEDICATION NAME] 100mg per tube twice daily for 7 days. On 4/29/13, at 7:01 am, the lab faxed the facility the results of t he urine culture. The lab report documented a list of 5 intravenous medications that werer effective against the identified organisms. On 6/3/13, the resident was observed in bed sleeping and a urinary foley catheter was noted to be drainingmilky yellow, cloudy, urine with what appeared tod be, sand like material in it. A family member of the residsente was prersent and indicated that she comes in to visit and has observed the color of Resident #1's urine to be "so dark, almost like tea, I am constantly telling them to give her water in her peg tube." RCM A was asked about Resident #1's urinary catheter. RCM A stated the facility protocol was "usually" to have orders for a urinary catheter, which included a schedule for the catheter to be changed. RCM A did not respond if the catheter currently inserted in Resident #1 was from 4/2/13 when the resident was sent to the ER and had one inserted then. After the investigation, the facility provided a copy of "ONHC Standing Orders; House protocol for Foley catheter care" that directed staff to "change catheter tube every 6 weeks and prn leaking, change catheter bag every 6 weeks and prn leaking, catheter care every shift." There was no documentation that the house protocol was documented on a MAR/TAR to communicate when the resident required, or received care as per the facility protocol. There was no documentation to support Resident #1 had her urinary catheter changed according to the facility policy and procedure. Resident #1's urinary catheter was changed 9 weeks later, after insertion on 4/2/13 at the ER . In addition, there were no PCP orders from the date of admission in March 2013 up through this investigation in June that indicated the resident was to have a foley catheter continuously or for what on-going medical reason th at it was necessary. <Resident #2> Resident #2 was admitted to the facility on [DATE], discharged on [DATE] with an anticipated return. Resident #2 readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident required extensive assistance with Activities of Daily Living (ADLs), was cognitively intact with no memory deficits, and was always incontinent of her bowel and bladder. Resident #2 was in her bed, observed with a urinary foley catheter. Her family member stated she was visiting as she did every day. The family member voiced her concerns about staff recognizing serious health problems that arose for Resident #2, especially the resident's kidney stones. The medical record was reviewed. The physician orders contained an order for [REDACTED]. The physician's orders were shown to the DNS, who stated they were incomplete and did not contain the required components. .

Based on iinterview and record review the facility failed to ensure licensed nurses (LN) met professional standards for medication administration for 1 of 6 current residents (#1) reviewed for medication and treatment administration. This failure placed all residents at risk for receiving the wrong medication and/or treatment and caused harm to Resident #1 when the wrong medication was applied to her legs. The Fundamentals of Nursing, 7th Edition, (Taylor, Lillis & LeMone), 2011 page 732 documented no medication may be given to a patient without a medication order from a licensed practioner." According to Fundamentals of Nursing, 7th Edition, 2011, page 738 states, "the rights of medication administration can help ensure accuracy when administering medications. Ensure that the (1) right medication is given to the (2) right patient in the (3) right dosage through (4) right route at the (5) right time. Additional rights have been suggested to include ensuring (6) the right reason and (7) the right documentation (Bales et al., 2004; Pape, 2003). 3/16/12 the Resident #1 stated her legs hurt and an LN applied cream to her legs that was not ordered for the resident's treatment. The resident said the nurse used a pink cream, "zinc oxide" on her legs to moisturize them. The resident stated the cream dried like cement, burned and hurt. They could not get it off. Due to the fragile condition of Resident #1's legs, this action caused the resident harm. Refer to F333 .

Based on observation, interview and record review the facility failed to ensure Residents were free of significant medication errors for 1 of 6 current residents (#1) reviewed for medication and treatment administration. This failure to ensure medication and treatments were administered as ordered placed residents at harm for receiving the wrong medication or treatment and caused harm to Resident #1 when the wrong medication was used in the physician ordered treatment to her legs. Findings include: Interviews and observations took place on 3/16/2012 Resident #1 had [DIAGNOSES REDACTED]. She was assessed by the facility as being alert, oriented and able to make her needs known. Resident #1 was bed ridden and dependent on staff for most of her activities of daily living. Resident #1's legs had been assessed as being [MEDICAL CONDITION], dry and scaley with some weeping. She had treatment orders which included [MEDICATION NAME] Cream (a cream containing dimethicone -skin protecting ingredient - used for moisturizing tender and fragile skin) to be applied twice a day to the lower extremities. Resident #1 she was lying in bed with her legs covered. Her legs were observed to be excoriated with open areas and weeping. When interviewed, Resident #1 stated her legs hurt. Resident #1 said the nurse used a pink cream, "zinc oxide" on her legs. Resident #1 said, "She put on the zinc oxide to moisturize my legs. It dried like cement and it burned and hurt. They could not get it off. They put warm towels on my legs to try to soak it off but it did not work. They then, at the suggestion of another resident, rubbed baby oil into it and it started to come off. Then they peeled it off and the skin came off too." Resident #1's chart was reviewed. According to the progress notes dated 3-11-12 night shift, the resident, " ...received [MEDICATION NAME] (2) x 1 this shift for pain which was effective per resident. Resident complained about her legs being lathered in a cream that 'dried out' , it appears to be EPC (extra protective cream which provides protection against irritation caused by urine or feces and does not wash off with repeated exposure. EPC contains zinc oxide which adheres to weepy macerated skin and is used usually to [MEDICAL CONDITION] diaper rash.) The skin under (the cream) is excoriated and weeping. Tried soaking in warm rags. Another resident suggested baby oil and the resident requested that the NAC (nursing assistant) rub her legs down with baby oil which effectively removed a lot of the cream." In the progress notes dated 3-12-12 1730 it was noted "Resident having complaints that skin on the bilateral lower extremities was burning related to a treatment given a few days prior. "The skin was assessed and noted residue from zinc oxide in the crevices from the dry skin ..." In an interview with Residential Care Manager (RCM) he stated he was still investigating what actually happened. He acknowledged Resident #1 did not have an order for [REDACTED]. She also stated she did not put the [MEDICATION NAME] cream on Resident #1's legs because it was not available and she used a moisturizing cream in a "green and white tube" instead. She did not notify the physician or receive an order to place a different cream on the resident's legs. A review of Resident #1's treatment administration record (TAR) indicated she had [MEDICATION NAME] cream applied on 3-10-12 even though the LN stated she did not apply the [MEDICATION NAME] cream. In separate interviews with LNs A, B, C, and D they all stated a physician order [REDACTED]. They also stated if a medication or treatment was not given as ordered it would be indicated on the TAR or the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive plan of care for 1 of 7 (#212) current sampled residents reviewed for pain. This failure caused the resident harm because he had experienced avoidable pain. Findings include: Resident #212 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident did not speak or understand spoken/written English as his primary language. The physician had ordered for the resident to receive narcotic pain medication every 3 hours as needed (prn order). The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On average the resident had received the narcotic medication during day and evening shifts. On 1/25/11 at 1:55 p.m., the resident was interviewed with a translator in his primary language. The resident stated via the translator, it is difficult for him because the nurses don't speak Spanish. He said he had been expecting his pain medication at 1a.m., like he had been receiving prior to being admitted to the facility, but had not received it because he was unable to communicate with the nurses his wants and needs. He stated he felt anxious because he understood only "a little" English, and did not speak English. He said it was very frustrating for him, he did not feel like he knew "what was going on." On 1/27/12 at 9:51 a.m., Resident Care Manager (RCM) A was interviewed. The RCM stated, he himself, had a list of questions he asked the resident and Licensed Nurse (LN) A probably did too, to anticipate the resident's needs. He indicated there was nothing scripted for the nurses to follow in the MAR indicated surveyor wanted." On 1/31/12 at 11:01 a.m., Resident #212 's son was visiting in the facility. The son stated the resident had called him at 3 a.m. He stated the resident was very upset because he was in "horrible" pain. The resident asked the son he to leave his home and come to the facility. The resident asked the son to translate to the staff to ask to receive his pain medications. The son stated he was angry the facility did not have a staff person available to communicate with the resident. He relayed his concern that the resident was ill, in pain, and then called the family to help him receive his medicine because there was no one to communicate in his primary language. The son stated his father said he does not get pain medications at night, although he is in terrible pain. Licensed Nurse (LN) B had come into the resident's room and stated the resident's pain medications were ordered prn and resident does not ask for them. The communication barrier between the resident and staff was brought to the LN's attention. The son translated for his father and stated Resident #212 wanted pain medications to be given throughout the night,and for the facility to contact the physician to approve the resident's request. At 11:43 a.m, RCM A indicated he had had a conversation with the resident and his son after the surveyor had spoke with the resident and family. RCM A verified the resident's concern and request to receive pain medication at 1 a.m. The surveyor brought to the attention of RCM A that the medication concern was brought up 7 days prior (1/25/12) in the initial resident interview. The RCM stated the resident told him (RCM A) he wanted to be woke up (to be given the medication) and the resident didn't feel like people were paying attention to him. .

Based on observation, interview and record review, the facility failed to ensure a functional communication system for 1 (#212) of 3 current sampled residents was provided to maintain or improve communication. This failure impeded the resident to communicate his needs and caused the resident psychological harm by experiencing anxiety and frustration. Findings include: On 1/25/11 at 1:55 p.m., the resident was interviewed with a translator in his primary language. The resident stated via the translator, it is difficult for him because the nurses did not speak Spanish. He stated he felt anxious because he didn't know what was going on. He stated he only understood "a little" English but it was very hard for him because he didn't speak English. He said it had been very frustrating for him. On 1/27/12 at 9:51 a.m., Resident Care Manager (RCM) A was interviewed. He stated that while providing care of the resident and trying to anticipate his needs, he stated he had a list of questions he asked the resident and Licensed Nurse (LN) A probably did too, but could not assure other nurses did as well. He indicated there is nothing scripted for the nurses to follow in the MAR indicated [REDACTED]. On 1/27/12 at 11:48 a.m., the resident was interviewed with Nursing Assistant Certified (NAC) A, who translated for resident. He stated with the translator he wanted to communicate better with staff instead of using generic phrases in his primary language like "how are you" etc,. He stated that staff who spoke his primary language were not always available. NAC A stated the facility in the past had used a piece of paper with pictures that would have the resident's primary language and English. The surveyor prompted NAC A to explain that to the resident and ask if he would like a communication board provided to him. The resident indicated he would like a communication board, to be able to communicate more than just a few phrases with the facility staff. On 1/31/12 at 11:01 a.m., the resident's son was visiting. The son was asked to translate for the surveyor. The resident was asked how communication had been going with the facility staff to express his needs. The resident began shaking his head side to side and waved his hands speaking a phrase repeatedly that his son translated as "no good, not good at all." The surveyor noticed a laminated board under some kleenex boxes, with a total of 6 pictures that had his primary language, five pictures had what appeared to be Spanish phrases, one picture did contain an English phrase and Spanish phrase. The first picture was a cartoon depicting a boy bent forward with his hands placed on his stomach, and tongue out of his mouth. There was a thought bubble that contained a picture of a pizza, hamburger, hotdog and one picture that was unclear. The Spanish word "Hambriento" was under the picture. A Spanish to English dictionary translated the word to mean "starved, hungry, or longing." Another picture of a boy with his mouth open, tongue hanging out, hands at his throat and sweat at his temples. There was a thought bubble with a picture of a glass filled with a substance. The words "I'm thirsty" were in English and the words "Tiene sed" were in Spanish. There was no translation in the Spanish dictionary for those words. The resident received his nutrition and fluids via the tube placed in his stomach. A cartoon with a circle face frowning had the words "dolor." This translated to "pain, ache, sorrow, distress, repentance, regret." A cartoon with a picture of a toilet had the words "El bano." This translated to mean "in the bathroom" not toilet. A cartoon picture of what appeared to be a shower, had the words "El ir a tomar una ducha." No translation was given for this phrase. A cartoon of a circle with eyes closed, fists clenched and "ZZZZ" next to the head had the word "Cansada." There was no translation for this word, but "tired" in Spanish is cansado. The resident pointed at communication board, frowned and tossed it aside. The resident's son was very upset and stated the board was not good enough. He stated the resident had called him at 3 a.m., very upset stating he was in "terrible pain" and no one (during the night shift) could understand what he needed. The resident asked the son to come in and translate for him to the staff. The son came in to the facility and translated the resident's needs to the staff. Refer to F 241 .

Based on interview, and record review, the facility failed to ensure accuracy of transcribed physician orders [REDACTED].#1) reviewed for medication administration. Failure to transcribe a physician order [REDACTED]. Findings include: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The resident received pain medication via a pain patch ([MEDICATION NAME] 50 mcg/hr). On 4/20/11 the resident's physician changed the order for pain medication. The order was for [MEDICATION NAME] (MS)[MEDICATION NAME] milligrams every 12 hours by mouth, for pain management and to discontinue the pain patch ([MEDICATION NAME] 50 mcg/hr) after the 1st dose of [MEDICATION NAME] 4/21/11 at 8:00 a.m. When the Licensed Nurse transcribed the new pain MEDICATION ORDERS FOR [REDACTED]. The transcribed direction to staff indicated it was informational only and did not explicitly state the patch needed to be removed on 4/21/11 at 8:00 a.m. The pain patch was not removed per physician order [REDACTED]. Resident #1 started taking the [MEDICATION NAME] milligrams at 8:00 a.m. and 8:00 p.m. on 4/21/11 while wearing the [MEDICATION NAME]. The resident continued to wear the [MEDICATION NAME] 24 hours longer than ordered. It was not she was still weariong the pain patch until the morning of 4/22/11 when the resident became sedated and confused from being over medicated. It was discovered the resident still wore the pain patch. The resident's phsycian evaluated the resident and ordered medication ([MEDICATION NAME]) to reverse the effects of the narcotic medications. The resident was not transferred to a hospital after receiving the [MEDICATION NAME] medication. Although the resident was placed in the facility log for "Alert Charting" for being over sedated and requiring [MEDICATION NAME] to reverse the narcotic medications, there is lack of documentation to support she was thoroughly assessed and closely monitored after the incident. Refer to F-157 and F-281. Interview with facility staff indicated they did not ensure the physician orders [REDACTED]. The facility action included education for Licensed Nurses on standards of practice for transcribing physician orders [REDACTED].

Based on observation, interview and record review the facility failed to consistently and timely implement care and services to prevent development and timely healing of pressure ulcers for 1 of 1 Sampled Residents (#17) who developed a Stage III pressure ulcer. This failure potentially caused pressure ulcers to develop and delay healing or cause them to reoccur. Failure to consistently monitor and make timely changes to treatment led to an increase in ulcer wound size and stage. This constituted harm for this resident. Findings include: Resident #17 was admitted to the facility on [DATE]. The resident's past medical history included a heart condition, diabetes, [MEDICAL CONDITION], lung disease, a prior stroke, resulting in the need for a feeding tube, loss of function on the left side of the body and [MEDICAL CONDITION] (difficulty with speech). On 1/16/11, the resident had the feeding tube replaced. Record review revealed a skin risk assessment documented on 7/19/10 Resident #17 had a moderate risk for development of pressure ulcers. Risk factors included slightly limited ability to communicate discomfort or need to be turned; limited ability to feel pain in one or two extremities; presence of very moist skin; could not walk and required assistance to sit in a wheelchair; very limited ability to change body position independently and required nutrition through a feeding tube and maximum assistance with repositioning. During observation on 4/14/11 at 10:00 a.m. Nursing Assistant (NA) C and NA D provided extensive assistance to Resident #17 for personal care and to get dressed. Following care, both staff placed a sling beneath the resident and used a mechanical lift to transfer the resident from the bed to a wheelchair. When the resident attempted to speak, it was slurred and difficult to understand. During observation on 4/16/11 at 9:45 a.m. Resident #17 lay on a specialty air mattress. NA F raised and held the resident's leg above the bed while Licensed Nurse (LN) E removed a dressing from the lateral side of the resident's left lower leg. Observation revealed beneath the dressing there were two open ulcers, one above the other, that both exposed tissue below the surface of the skin. LN Staff E reported staff changed the dressing approximately every three days. >Lack of Investigation> Refer to F272 for interviews related to facility failure to initially assess and investigate potential factors that caused Resident #17 to develop three skin abrasions on the lower left leg on 8/11/10. <Lack of Monitoring> The facility form titled "Skin Grid", a skin form used to monitor and track progress of skin wounds, dated 8/10/10, documented the facility identified three different skin abrasions on Resident #17's left lower leg. The Skin Grid documented the following information related to the three skin wounds: WOUND #1 The Skin Grid dated 8/11/10, documented one abrasion measured 0.5 centimeters in length (cm, a linear measurement; 2.54 cm = 1 inch) and 0.5 cm in width. On 8/17/10, licensed staff described the abrasions as a "dry scab." On 8/26/10, The Skin Grid documented the wound size decreased to 0.3 cm by 0.3 cm. and described the wound as an "area pink." WOUND #2 The Skin Grid dated 8/11/10, documented a second abrasion measured 0.5 cm by 0.5 cm. On 8/17/10, staff documented the abrasion reduced in size to 0.3 cm by 0.3 cm and a scab fell off and revealed a shallow red and yellow wound bed. On 8/26/10, the skin form documented the same 0.3 cm by 0.3 cm area as a "scabbed area." WOUND #3 The Skin Grid documented Resident #17's third abrasion measured the same size (1.0 cm by 0.8 cm) on 8/11/10, 8/17/10 and 8/26/10. On 8/26/10 the form and described the wound as an intact "scab". On 4/15/11 at 2:40 p.m., Resident Care Manager (RCM) C reported Resident #17's three initial skin abrasions identified in August 2010 developed into two separate pressure ulcers. On 4/18/11, the Director of Nursing (DNS) provided a summary of monitoring of the resident's skin wounds on the facility form titled "In House Pressure Ulcers Weekly Report". The report documented Resident #17 had two Stage II pressure ulcers on the left lower leg on 10/26/10. One pressure ulcer on the resident's top left calf measured 4.0 cm by 4.0 cm. The second pressure ulcer located on the bottom left calf measured 2.0 cm by 2.0 cm. The National Pressure Ulcer Advisory Panel (NPUAP) identifies a Stage II pressure ulcer as a partial thickness loss of dermis that presents as a shallow open ulcer with a red pink wound bed. On 1/17/11, the Skin Grid forms documented the pressure ulcer on the top left calf unstageable and measured 3.0 cm by 2.0 cm. The form also documented the pressure ulcer on the left middle calf unstageable and measured 2.0 cm by 1.0 cm. NPUAP identifies an unstageable pressure ulcer as a full thickness tissue loss of skin covered by either slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. The facility did not provide documentation to indicate they monitored Resident #17's three left lower leg skin wounds between 8/26/10 and 10/26/10, (a period of eight weeks). During this time period, two scabs and one 0.3 cm by 03 cm pink area developed into two Stage II pressure ulcers. Between 10/26/10 and 12/28/10 "In House Pressure Ulcers Weekly Reports" documented staff continued to monitor the Stage II pressure ulcers on the top left calf and the bottom left calf. On 12/28/10, the weekly report documented both of the pressure ulcers remained Stage II. The report did not identify the depth of the ulcers. The facility did not provide documentation to indicate the staff monitored either Stage II pressure ulcer between 12/28/10 and 1/17/11 (a period of 20 days). On 1/17/11, staff documented on Skin Grid forms the Stage II pressure ulcers as "unstageable". During an interview on 4/15/11 at 2:40 p.m. RCM C reported the resident's pressure ulcers should have been monitored weekly. <Treatment> Physician order [REDACTED]. The "In House Pressure Ulcer Weekly Report" dated 10/26/10, documented the size of the top left calf Stage II pressure ulcer measured 4.0 cm by 4.0 cm. The report dated 11/2/10 documented the top left calf pressure ulcer increased in size to 5.0 cm by 5.0 cm and remained Stage II. During the period of 11/9/10 through 12/28/10, the weekly report documented the top left pressure ulcer remained Stage II and decreased to 3.0 cm by 3.0 cm. During the period of 8/11/10 through 12/28/10 treatment records documented licensed staff treated the initial skin abrasions and scabs with the same dressing material, Allevyn, for six months. The wounds increased in size and stage from when they were initially discovered. On 4/17/11 at 3:20 p.m. the DNS reported licensed staff placed Allevyn dressings even on scabs. When asked how staff should have treated Resident #17's wounds initially, the DNS reported the scabs should have been left open to dry. The DNS reported staff needed education regarding treatment of [REDACTED]. Licensed staff obtained a physician order [REDACTED]." The therapy note documented licensed staff debrided the second ulcer covered with black eschar. The note documented necrotic tissue remained since it was "too painful for further debridement." Following wound debridement on 2/23/11, licensed nursing staff obtained a physician order [REDACTED]. No other change in treatment was documented prior to this date. On 2/28/11, the physician observed the pressure ulcers and ordered administration of an antibiotic to be given three times a day for seven days . A timeline provided by the DNS documented this as the first time the physician observed Resident #17's left leg ulcers. A progress note, dated 3/13/11, documented the left top calf ulcer developed into a Stage III ulcer. On 4/17/11 at 3:20 p.m., the DNS reported the resident's lower leg wound appeared infected at that time. NPUAP identifies a Stage III ulcer as full thickness tissue loss. Subcutaneous fat may be visible. <Lack of Communication with the Physician> On 4/18/11 the DNS provided a timeline of events related to Resident #17's pressure ulcers. The timeline documented the physician visited Resident #17 on 8/13/10, two days after the initial identification of three skin wounds, but no documentation was present indicating the physician looked at the resident's wounds during the visit. Although the wounds were identified 8/11/10, documentation indicated the physician was not notified of the resident's status until 10/26/10. On 10/26/10, licensed staff faxed a note to the physician, documenting the resident had one 4.0 cm by 4.0 cm wound and one 2.0 cm by 2.0 cm wound on the left calf. The fax did not indicate the stage of the wounds or identify the wounds developed from abrasions. No other documentation was present indicating the physician was notified prior to 10/26/10. No documentation was present to indicate licensed staff communicated changes in condition of left leg pressure ulcers from 10/26/10 through 2/23/11, when an order for [REDACTED]. On 4/17/11 at 3:20 p.m., when asked if staff referred the resident to a wound specialist, the DNS reported the facility had a wound specialist visit the facility but did not know if the specialist saw the resident. No documentation was provided indicating the wound specialist saw Resident #17. The facility failed to initially investigate potential causes of three small abrasions identified on 8/11/10 and consistently monitor them for Resident #17. The abrasions developed into two unstageable pressure ulcers on 1/17/11. One of the pressure ulcers developed into a Stage III pressure ulcer on 3/10/11. Licensed staff could not provide documentation to indicate they maintained physician communication regarding changes in the condition of the wounds after initial identification on 8/11/10 until 10/26/10, or between 10/26/10 and 2/23/11. The facility did not timely obtain orders to change wound treatments to attempt to promote healing. .

Based on observation, interview and record review the facility failed to ensure residents were free from urinary tract infections and provided appropriate care to prevent infection for 1 of 1 current sampled residents (#1) reviewed for recurrent urinary tract infections. This failure caused actual harm to the resident. Findings include: All interviews were done on 2/17/11. Resident #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required extensive assistance with activities of daily living and was incontinent of bladder and bowel. On 2/17/11 at 7:45 a.m. the resident was lying in bed. The resident said he needed some help because of pain he had been having for several months when urinating. Resident #1 said he also had an infected area on his penis and had surgery months ago to enable staff to thoroughly cleanse the area to prevent further infections. Nursing Assistant (NA) A entered the resident's room to provide morning care at 7:50 a.m. NA A was unable to fully retract the foreskin and cleanse the area secondary to scare tissue. Between October and January the resident had four urinary infections. The infections were caused by multiple bacteria normally found in the bowel.

Based on observation, interview and record review, the facility's governing body failed to ensure effective oversight and implementation of care and services related to medication administration and pain management. The governing body's failure to ensure sufficient qualified nursing staff followed the facility's standards of professional practice and ensure residents care and services were provided timely and adequately for medication and pain management resulted in an immediate jeopardy finding. This failed practice negatively impacted former Residents #s 1 & 2, current residents # 7, 9, 10, 11 with potential to affect all residents in the facility. In addition, review of the licensee's historical compliance over the last 12 months revealed a significant pattern of regulatory non-compliance. Findings include: 1) During this current survey, sub-standard of care / immediate jeopardy was found at: a) F -333, Medication Errors - residents are to be free of any significant medication errors. 2) Also the survey found sub-standard of care at pattern harm level H at: a) F- 309 Quality of Care related to lack of timely pain management and wound care. 3) In addition, the facility was found out of compliance at harm level in the following areas: a) F- 241 Dignity for failure to ensure care and services were provided in a manner that maintained or enhanced the resident's dignity at level G b) F- 281 Services Provided Meet Professional Standards when nursing staff failed to take appropriate actions to medication changes and changes in resident condition at level G c) F -353, Nursing Services for failure to ensure sufficient qualified nursing staff provided care and services to attain/maintain residents' well-being at level H HISTORY During the past 12 months this facility has been repeatedly out of compliance. Including this present complaint survey, the facility has had 21 complaint visits conducted over this past 12 months. Ten of these 21 visits resulted in citations for regulatory violations. Including this complaint visit, the facility has received 28 Ftag violations. Two of the 28 violations have been at immediate jeopardy/substandard care. ( 1/15/10 for F 309 Quality of Care and this current survey F 333 Medication Error.) In addition, with the findings from this current survey, the facility has had a total of 8 harm level citations within the same time period. This facility also received an additional 9 citations from their annual health full survey inspection plus 3 citations related to their Life Safety Code annual survey conducted in March 2010. Between January 1, 2010 and December 31, 2010 this facility has been out of compliance 186 of 365 days. Currently in 2011, the facility has been out of compliance for 27 days. 4) The following citations which appear in this report have been previously cited in this past calendar year. a) F- 157, Failure to ensure residents' physicians or residents' legal representative were immediately consulted with a physician when there was an accident/incident involving the resident which resulted in injury and/or had the potential for requiring physician intervention (7/14/10=G). b) F- 225, Failure to conduct thorough investigations of alleged violations and ensuring employees are without history of disqualifying crimes (2/4/10=A, 10/28/10=D, 11/19/10=D). c) F- 281-Failure to ensure services are provided meet professional standards of quality (1/15/10=E , 3/4/10 =D, 1/4/11 =D ). d) F-309 Failed to provide necessary care and services to attain/maintain the highest practicable well-being (1/27/10=Immediate Jeopardy, 3/4/10=D, 7/14/10=G ,). e) F-312 Failure to ensure residents received assistance to maintain good nutrition, grooming and personal and oral hygiene (3/4/10=D). f) F-333, Failure to ensure residents are free of any significant medication errors (8/11/10=D). The facility governing body failed to ensure that the facility was operated in a manner to effectively implement plans of correction to sustain [MEDICATION NAME] compliance not only to ensure compliance with state and federal regulations but to meet the health and safety needs of residents. This was determined to be an immediate jeopardy.

Based on observation, interview and record review, the facility failed to ensure 4 of 10 sampled residents (#s 9 & 11 and Former residents #s 1 & 2) were free of significant medication errors. This failure of multiple facility licensed nurses over several shifts to recognize multiple medication errors and provide immediate response to Residents #9 and #2 placed them at great risk for over sedation and complication resulting from overmedication and/or under medication. The lack of oversight of the right dose of medication being administered and lack of immediate response to gross over medication reflected a medication delivery system that was determined to be immediate jeopardy. According to the Lippincott Fundamentals of Nursing 7th Edition, 2011, page 742 "ENSURING CORRECT ADMINISTRATION OF MEDICATIONS" ensures accuracy in medication administration: right drug, right reason, right dose and preparation, right patient, right time, right route and right documentation." 1) Resident #1 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. The resident was receiving an infusion of a narcotic pain medication ([MEDICATION NAME]). Refer to F-tag 281, 309 On 12/26/2010 Resident #1 received 2 new physician orders [REDACTED]. [MEDICATION NAME] means relief of pain by a patient controlled delivery system with continuous flow of [MEDICATION NAME]) with an increased setting using 10mg/ML concentration and to add a [MEDICATION NAME] ([MEDICATION NAME] Patch-slow release narcotic that is applied to skin) to be changed every 3 days. On 1/29/2010 the pharmacy notified a Licensed Nurse (LN) the pharmacy were sending a syringe to the facility for the resident with a change in the concentration from 100/1mg to 1000/1mg with instructions to adjust the dose to reflect the change. The concentration was increased by 10 fold from the original order and syringe content. The LN failed to recognize this change as a significant concern which could potentially result in a medication over dose leading to possible death. The LN failed to make a special notation in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The LN did not follow facility protocol and document the information in a facility communication book called the "24 Hour Report" which provided communication to other staff members. The syringe was hung and started infusing at 10:45 p.m. The new syringe had two fluorescent green labels which stated "CAUTION": "Concentration change". LNs K & E did not notice and/or comprehend the warning labels on the syringe. Neither LN checked to ensure the concentration of [MEDICATION NAME] was infusing at the correct rate to deliver the correct dose ordered by the physician. The LNs hung the syringe and infused the [MEDICATION NAME] without adjusting the infusion rate to reflect the increased concentration. This resulted in the resident receiving 10 times more than the physician ordered. The resident received 1000 mg of [MEDICATION NAME] in 9 and one-half hours, between 10:45pm and 9:15am ("A large overdose of [MEDICATION NAME] can cause asphyxia (stop breathing) and death by respiratory depression if the person does not receive medical attention immediately. The minimum lethal dose is 200 milligrams of [MEDICATION NAME]" Medline Plus-[MEDICATION NAME] overdose, Update Date: 2/3/09. Updated by: John E. Duldner, Jr., MD) along with the added dose of 25mcq of [MEDICATION NAME] via patch (The use of [MEDICATION NAME] with other narcotic can intensify the effects of [MEDICATION NAME] to depress breathing, depress the brain, sedate, and lower blood pressure-drugs.com). A facility policy for ADMINISTRATION OF NARCOTIC INFUSION stated monitoring the resident included vital signs to be completed 30 minutes after initiation of the infusion. No documentation was found to support this was completed. The resident was never monitored during the nine and half hours period the pump was infused for any adverse effects, changes in neurologic sign and systems, vital signs or effect of the medication for pain control/comfort level per protocol. The next morning on 12/30/10 at 9:15 a.m. the LN noted the syringe was empty. The LN failed to recognize the medication error at the time and attempted to get another syringe from the pharmacy. The pharmacy was contacted and the same LN that received the notice the day before stated that the syringe should not be empty. Another LN then noted the syringe contained an increased concentration (10 times the concentration) and was infusing at too fast a rate. Although 2 LNs were now aware of the significant medication error. No treatment was sought immediately by the nursing staff when the gross overdose was discovered. At 9:30 a.m. the resident was assessed to be "comfortable" but no other assessment data was documented except the respiratory rate of 12 breaths per minute (12 to 22 bpm is normal). With breaths per minute at the lower end of the scale further assessment or monitoring was needed and not done. [MEDICATION NAME] depresses breathjing and the resident had received a massive dose. The infusion was adjusted to the prescribed rate and infusion continued until 12:15 p.m. At 12:15 p.m. the resident's physician was notified (3 hours after the error was first noted) the resident's respiratory rate was decreased to 10 bpm. A physician order [REDACTED]. No assessment information was documented to reflect the resident's response to the [MEDICATION NAME] or any other actions, treatment to include a second dose of [MEDICATION NAME] was given per overdose standard practice of care. There was no documentation that stated the doctor was notified/updated of no response after given a reversal medication or request for additional orders. The next entry into the nurses' notes at 1:30 p.m. stated the family was notified of the resident's condition and they made a request to send the resident to the hospital. The facility called for an ambulance to transport the resident to the hospital. At 2:15 p.m. (45 minutes after the facility was notified of the family's request to transfer the resident) an ambulance arrived to transport the resident to a hospital. There was no documentation to address the reason for this 45-minute delay to seek care. Interview with Administrative team members stated the two LNs did not follow policy and procedure or standards of practice when administering the intravenous infusion of pain medication. They did not note the fluorescent green labels to caution staff the concentration of the medication was changed. 2) Former Resident #2 pain management plan of care was developed on 12/14/10 and had interventions included: "Administer pain medication as ordered." On 12/30/10 the resident's Surgeon ordered for [MEDICATION NAME] 2 milligrams (mg) per tablet, 1-2 tablets to be administered by mouth every 4 hours as needed for pain. According to a nursing progress note date 1/6/11 at 11:30 a.m., the resident "feels current pain management regiment is not effective." The resident's physician was notified. On 1/6/11 at 7:15 p.m. the resident's physician ordered a new pain medication regiment; [MEDICATION NAME] mg by mouth every 12 hours and [MEDICATION NAME] 2 mg by mouth every 2-4 hours as needed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of the narcotic disposition record and MAR from 1/7/11 to 1/13/11 revealed the resident was given [MEDICATION NAME] of 4 mg 16 times over the six days period. On 1/12/11 the resident was given [MEDICATION NAME] 4 mg at 9:15 a.m., 11:15 a.m. and 1:30 p.m. The resident was given twice the amount of [MEDICATION NAME] ordered. The record showed eight different LNs administered [MEDICATION NAME] for the resident during this period. On 1/20/11 at 4:30 p.m. LN D stated the LN who was assigned to the resident was responsible for administering medications for the resident and ensuring the medications were given as ordered. At 5:25 p.m. the Resident Care Manager (RCM) stated the LNs were responsible for checking the medications against the original order to ensure proper dosage. The RCM said the LNs were expected to follow the nursing process for administering medications. The RCM said the previous order should have been completely crossed out. He said the new order should have been written in a new slot in the MAR. The RCM stated the LNs had their skills checked and reviewed during orientation. The RCM said he was available as a resource and the LNs were responsible for asking for assistance when they were not familiar with a medication. 3) Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented. The resident was dependent on staff for administering his IV medications. On 1/4/11 the resident's physician ordered for [MEDICATION NAME] 1.25 Grams (Gm) to be administered every 12 hours intravenously until 1/18/11. On 1/9/11 the resident's physician ordered for a [MEDICATION NAME] trough (a therapeutic level) to be drawn on 1/11/11. Review of the MAR from 1/1/11 to 1/18/11 revealed the LN initial was circled for the evening dose 1/8/11 and 1/9/11. The MAR indicated [REDACTED]. According to the medication note on the back of the MAR, dated 1/9/11, no time, "med not available-pharm (pharmacy) to send." [MEDICATION NAME] was a medication that required timely administration and therapeutic level was routinely monitored. The therapeutic level could have been affected when the medication was not administered consistently. The was no documentation the facility communicated with the resident's physician in regard to the [MEDICATION NAME] not being available and was not administered timely as ordered. On 1/19/11 at 2:30 p.m. the resident was sitting in his wheelchair in his room. The resident stated about ten days ago several times he got his [MEDICATION NAME] either late or did not get it at all. He was told the medication was not available and had to wait for the pharmacy to deliver. The resident said he told an administrative member and he was told she would look into it. On 1/20/11 at 4:40 p.m. LN D said when a medication was not available in the facility, it had to sent from the pharmacy. LN D stated the LNs were responsible for contacting the facility pharmacy to get the medication delivered. LN D said the time for a medication to arrive may vary. At 5:25 p.m. The RCM said the LNs were expected to communicate with the pharmacy when a medication was not available in the facility. The RCM stated the LNs were responsible for ensuring medications were administered timely and as ordered. 4) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was dependent on staff for activities of daily living including toileting and mobility. The resident stated she waited all day on 1/18/11 for her pain medication and finally received it "this morning" at 12:30 a.m. She stated she had "awful pain." Review of the resident's record confirmed she did not receive pain medication on 1/18/11. The resident stated she had to wait until the medication was delivered to the facility. Refer to 425.

Based on observation, interview and record review the facility failed to provide necessary care and interventions related to pain management including over medicating and under medicating 7 of 12 sampled residents (#s 5, 6, 9, 11, 12 and former residents #s 1 & 2) reviewed for care and services. The facility also failed to monitor residents and obtain timely urgent medical evaluations of treatments. The facility also failed to provide dressing changes ordered by a physician. Findings include: <Pain Management> The facility policy and procedure for ADMINISTRATION OF NARCOTIC INFUSION stated the physician order [REDACTED]. The physician should be notified promptly of adverse events. 1) Former Resident #1 was receiving an infusion of a pain medication. Refer to F-tag 333. On 12/29/2010 a pharmacy communicated with a Licensed Nurse (LN) they were sending pain medication with a changed concentration (10 times the original concentration). The LN failed to document the next delivered syringe of [MEDICATION NAME] would have an increased concentration of 10 fold in the 24 hour report which provided ongoing communication to other staff members. On 12/29/2010 two LNs hung a new syringe of pain medication at 10:45 p.m. The two LNs failed to follow the facility policy and procedure to verify the accuracy of the physician order. No documentation was found to support the resident was assessed or monitored when the infusion was started or during the infusion (10 hours and 45 minutes) after administration of IV pain medication. The next morning on 12/30/10 at 9:00 a.m. the day shift LN documented Resident #1 was without signs and symptoms of pain or discomfort. There is no documentation to indicate the LN realized the [MEDICATION NAME] syringe was infusing at an incorrect rate. There was no documentation indicating the licensed nurse conducted an assessment of the resident to include the [MEDICATION NAME] infusion. No documentation was found to support the residents vital signs were obtained. At 9:15 a.m. the Resident Nurse Manager (RCM) realized the incorrect amount of [MEDICATION NAME] had infused, the rate of the infusion was corrected. The physician was not notified of the error. The next entry in the nurses' notes was for noon on 12/30/2010 stated the LN documented the resident as unresponsive. The LN contacted the resident's physician and received an order to administer an injection of [MEDICATION NAME] (medication to reverse the effects of the narcotic pain medication). There was no documentation to describe the resident's response to this drug. The next entry into the nurses' notes was 1 hour and 30 minutes later and stated the family was notified of the resident's condition. The family requested to send the resident to the hospital. The facility called for an ambulance and the resident was transported to a hospital 2:15 p.m. (45 minutes after a decreased in respirations were noted). Interview on 1/20/11 at 6:00 p.m. with Administrative team members stated the LNs did not follow protocol for hanging the [MEDICATION NAME] syringe and failed to monitor the resident during the infusion. 2) Resident #6 was receiving chemo therapy and required pain management when needed. The resident had the following pain medications ordered by her physician on 1/11/11, [MEDICATION NAME] SR (slow release) 20 mg to be administered every 12 hours. [MEDICATION NAME] and Tylenol were to be administered every four hours as needed for break through pain. A pain management plan of care was developed on 1/11/11 and had interventions included: "Administer pain medication as ordered." According to a nursing progress note dated 1/18/11 at 9:20 a.m. the resident was "in bed crying aloud." The resident complained her leg was "hurting so bad." The LN assessed the resident and documented the resident complained of "severe pain" and "swelling noted to R (right) outer hip." The resident's family requested for the resident to be transferred to the emergency room for an evaluation. The resident's physician was contacted to get an order for [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility did not medicate the resident for her break through pain (available every four hours) until 5:00 p.m. On 1/20/11 at 2:55 p.m. the resident was sitting in her wheelchair in her room. The resident's son and his wife were at the resident's beside. The resident stated she was upset because her pain medications were consistently given late. The last dose of pain medication for breakthrough pain was given at 9:45 a.m. The resident could receive a dose of pain medication at 1:00 p.m. The resident and her son stated they had asked LN D for a pain medication at 1:00 p.m. The resident stated she had been waiting for almost two hours and still had not gotten her pain medication. The resident stated she would not ask for pain medication if she was not in pain. The resident said she was afraid to go to bed at night because she might be in pain and could not get anyone to help. At 3:40 p.m. the resident stated she was still waiting for her pain medication. At 4:20 p.m. the resident stated LN D just gave her pain medication. The resident stated it was not unusual for her to wait three hours for a pain medication. On 1/20/11 at 4:40 p.m. LN D stated the LNs were responsible for administering pain medication as ordered. LN D stated the LNs were expected to administer pain medications timely and keeping the resident pain free should be a priority. LN D stated she gave the resident her pain medication around 4:20 p.m. when Resident #6 asked for it. The LN for the evening shift was unaware the resident requested pain medication at 1:00 p.m. At 5:25 p.m. the Resident Care Manager (RCM) stated pain management was the first priority and pain medication should be administered as soon as possible. The RCM stated he considered pain as an "emergency." 3) Former Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted after he had parts of his foot amputated. The resident was alert and oriented. The resident was able to communicate his needs to staff. The resident had the following pain medications ordered by his physician on 12/14/10, [MEDICATION NAME] and [MEDICATION NAME] to be administered four times a day as needed and Tylenol to be administered every four hours as needed. According to the facility's documentation dated 12/14/10 the resident had "Persistent pain (Chronic)." His pain was related to the left toes amputation. A pain management plan of care was developed with goals included: "Decrease persistent pain to a tolerated level" and "pain relief within 30-60 minutes." The plan of care had interventions included: "Administer pain medication as ordered." According to a nursing progress note dated 12/14/10 at 6:10 p.m. the resident "c/o (complained) of pain to left foot." According to the facility's documentation the resident was given two [MEDICATION NAME] at 1:50 a.m. The resident was "winning (sic) in bed" and the resident rated his pain level (0 being no pain and 10 being the worst pain experienced) as a "10." The facility did not administer pain medication for the resident almost eight hours after he reported of having pain. Refer to 425. 4) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was dependent on staff for administering her pain medications. The resident had the following pain medications ordered by her physician on 1/3/11, [MEDICATION NAME] 5-10 mg to be administered every 8 hours as needed for pain. On 1/18/11 the resident's call light was on from 8:20 p.m. to 9:00 p.m. The resident was interviewed on 1/19/2010 about call light response. The resident stated she often waits longer than 20 minutes on a regular basis for assistance. She stated she waited all day yesterday for her pain medication and did not receive it until the morning of 1/19/11. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Licensed nurse D (LN) was questioned about the resident's complaint. She stated she had given the resident a dose of medication on 1/19/11 at 10:50 a.m. There was no medication given on 1/18/11 space. She had mistakenly documented on the 1/18/11 space and then corrected the document. The LN stated Resident #11's pain medication was not given on 1/18/11 and a supply arrived to the facility the morning of 1/19/11 due to pharmacy delivery. Refer to 425. <Wound Management> 5) Resident #5 was admitted to the facility in December 2010 with [DIAGNOSES REDACTED]. An apparatus called a Wound Vac was applied. This consists of a sponge like material placed on the wound and sealed to create a vacuum. The physician orders [REDACTED]. The scheduled changes were due on Mondays, Wednesdays and Fridays. On Monday, 1/3/11 the wound vac was changed. On Wednesday 1/5/11 the wound vac was not changed. On 1/6/11 documentation indicated the resident requested to have a numbing medication applied before the dressing change. The record indicated the numbing medication was not applied because it was not available in the facility. The dressing was not changed and the resident's physician was not notified of the incident. No explanation was given regarding the unavailability of the medication. Refer to 425. On 1/7/11 an attempt to change the dressing was unsuccessful. The resident's dressing could not be removed. The resident was transported to a hospital. During an interview with hospital staff on 1/12/11, Resident #5's skin had grown into the dressing and had to be surgically removed. Interview with members of the Administrative team indicated they were not aware the dressing had not been changed according to physician orders. 6) Resident #12 was admitted to the facility in July 2006 with [DIAGNOSES REDACTED]. Observation of Resident #12 the evening of 1/18/11 revealed her chin was dark red approximately 2 and 1/2 inches in diameter with 3 dime sized purulent masses. The LN asked the resident how her chin felt and the resident responded "better." Review of the resident's record indicated the resident was noted to have a "...inflamed lesion to chin, states "I've had it for a couple days, I think it is a boil." Will notify day shift." No additional monitoring was noted. On 1/18/2011 (two days later) a physician order [REDACTED]. Interview with members of the Administrative team indicated they were not aware there was a two day delay in physician notification for Resident 12's inflamed chin with purulent masses. 7) Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented. The resident was dependent on staff for changing his surgical dressing. On 12/26/10 the facility notified the resident's physician there was a "significant change to L (left) hip drainage, light orange thick drainage c (with) soft spot in the middle part of incision." The resident was receiving an antibiotic as a treatment for [REDACTED]. On 12/30/10 the resident's Orthopedic ordered for the dressing on his left hip to be changed every 12 hours. Review of the treatment record from 1/1/11 to 1/17/11 the resident should have received 34 dressing changes. The resident received 19 dressing changes. The resident refused five times. The resident did not receive a dressing change 10 times. The resident's dressing was not changed at all on 1/8/11 and 1/10/11. On 1/19/11 the resident was in his wheelchair in his room. The resident stated his dressing was scheduled to be changed twice a day. The resident said his dressing was not changed twice a day for most days and someday it was not changed at all. The resident said sometime he had asked the LN for a dressing change because the fluid had built up in the dressing and he was told they did not have time to change it. The resident said he told the administrative staff and he was told she would look into it.

Based on observation, interview and record review, the facility failed to have sufficient numbers of qualified staff to provide and supervise care for residents with complex health care needs for 9 of 12 (#s 4, 6, 7, 9, 11 & 12 and former residents #s 1, 2 & 5) sampled residents. The facility did not have sufficient staff that was skilled and/or experienced in providing timely and needed care to a residents. The care provided was not supervised in a manner to provide consistency in therapeutic approaches to avoid actual harm. Staff did not adequately assess, evaluate or document information needed to formulate effective and timely interventions. The harm resulted from a failure to provide accurate and timely pain management, wound care, delayed response to call for assistance, failure to bathe or shower or provide toileting and incontinent care or the delivery of basic activities of daily living. Nursing assistants were not supervised adequately to ensure required interventions were implemented. Findings include: 1) Refer to 42CFR 483.25(m)(2), F-333, Residents Free of Significant Med Errors, for specific examples of failure by facility nursing staff to ensure the delivery of quality nursing care related to medication services. Residents #s 1, 2, 9 & 11 were harmed as a result. 2) Refer to 42CFR 483.25, F-309, Quality of Care, for failure of LNs to provide pain management, wound management provide prompt medical evaluation to prevent deterioration in condition. Residents #s 6, 9, 11, 12 and former residents 1, 2 and 5 were harmed. 3) Refer to 42CFR 483.15(a), F-241, Quality of Life, for specific examples of failure by facility staff to meet residents incontinent care needs, providing assistance with activities of daily living needs in a timely manner which resulted in a lack of dignity. Residents #s 4, 6 & 11 were harmed as a result. During interviews with residents and/or families (residents #s 4, 6, 9 & 11) complained of problems with receiving care or assistance from staff due to lack of sufficient staffing. All 5 of these residents gave examples of prolonged waits for assistance when they requested help from staff either verbally or by activating their call light. The residents complained of waits at least 20 minutes to a day to receive assistance with toileting and/or pain management. Resident #7's family members were interviewed on 1/19/11 and 1/20/11. The family members said Resident #7 had a family member with him up to 12 hours a day since the resident was admitted . The family members said the direct care staffs were "wonderful" but they were short of staff. 5) Refer to 42CFR 483.10 (b) (11), F-157, Notify of Changes, for facility failure to immediately consult and provide timely notification to residents' physicians and families for acute change in condition and changes in treatment. Residents #s 11, 12 and former residents 1 and 5 were harmed. 5) Refer to 42CFR 483.20 (k) (3) (1), F-281, Services Provided meet Professional Standards, for facility failure to ensure professional standards were followed when information was received from the facility pharmacy, immediately notifying a physician of a medication. These failures caused Resident # 1 to receive a potentially lethal dose of narcotic medication, overmedication of Resident #2 and delayed treatment increasing a worsening condition. 6) Refer to 42CFR 483.60 (a) (b) F-425, Pharmaceutical Services, for facility failure to ensure an effective pharmaceutical system was in place to provide timely and accurate medications including intravenous medications and/or missed medication. This resulted in harm for 5 of 7 current sampled residents (#s 7, 9, 10, 11 & 12).

Based on observation and interview and record review, the facility failed to ensure 4 of 7 current sampled residents (# 4, 6 & 11) reviewed for dignity, received toileting assistance in a timely manner. The facility also failed to ensure residents who were continent with bowel and bladder did not wear incontinent brief. This failure caused psychological harm to residents #5, 6 & 11 and placed the residents at risk for receiving care in a manner diminished their self-esteem and self-worth. Findings include: 1) Resident #6 was alert and oriented and able to communicate her needs to staff. The resident was continent of bowel and bladder. She was dependent on staff for assistance with her activities of daily living and toileting. A urinary continence plan of care was developed on 1/11/11 with goals included: "Will maintain dignity despite incontinence" and "Will be clean and dry with the use of incontinence products." The interventions to be implemented were: "Change incontinent product PRN (as needed)" and "Change soiled clothing as needed." On 1/20/11 at 2:55 p.m. the resident was sitting in her wheelchair in her room. The resident's son and his wife were at the resident's beside. The resident stated the first night she was in the facility she wet her bed. She put on her call light, waited for two hours and no one help her. The resident stated she knew when she had to go to the bathroom. The resident said she felt humiliated and very embarrassed because this had never happened to her. The resident said if she could walk she would had gotten up and "walked out of here." The resident stated she was afraid to go to bed at night because she may needed help and could not get anyone to help. The resident said "They make me wear attends." She felt embarrass because it was new to her. The resident said when she asked the staff to change her attends because her attend was wet the staff told her she could "go (urinate) on the attends two times" before it needed to be changed. Refer to F-312 At 3:00 p.m. the resident's roommate stated several times she went and got the staff to come to help Resident #6 because Resident #6 had waited a long time. The resident's roommate said she could get help when she was in her wheelchair but not when she was already in bed because she could not transfer herself into her wheelchair. The resident's roommate said she yelled to summon staff for help for her roommate. The resident's roommate said staff had told her she could wet (urinate) twice before her attends needed to be changed because it was the product the facility used. On 1/20/11 at 4:40 p.m. Licensed Nurse (LN) D stated the resident was continent of bowel and bladder and able to tell if she needed to use the bathroom. LN D said the incontinent brief was only used if the resident had requested. LN D stated she could not recall if the resident requested to wear incontinent brief. LN D stated nursing staff was responsible for assisting the resident with toileting and changing the resident's incontinent brief. LN D said the resident's brief should be changed when the resident requested. At 5:10 p.m. Nursing Assistant C stated staff members were expected to answer the residents' call lights and assist the residents with their toileting need immediately. At 5:25 p.m. the Resident Care Manager (RCM) stated if the resident did not want to wear incontinent brief then staffs were expected to respect the resident's decision. The RCM said the nursing staffs were responsible for ensuring the residents' dignities were reserved. 2) Resident #11 was dependent on staff for activities of daily living including toileting and mobility. On 1/18/11 the resident had her call light on from 8:20 p.m. to 9:00 p.m. The resident was interviewed on 1/19/2010 at 2:00 p.m. about call light response. The resident stated she often waits longer than 20 minutes on a regular basis for assistance. She stated she needs help to the bathroom but staff do not always respond in time and sometimes becomes incontinent. 3) Resident #4 was unable to use her call light. The resident had difficulty communicating and relied on staff to anticipate her needs. On 1/18/11 the resident's call light had not been activated but she was heard calling out from 8:00 p.m. to 9:30 p.m. Interview with family members on 1/19 & 1/20/11 revealed the resident's needs are not consistently met in a timely manner. The resident had to wait for assistance with toileting and had become incontinent while waiting. Staff members were not available to assist with toileting around meal times because they were in the dining rooms assisting other residents. Although the resident's record indicated she was a total assist, had frequent incontinence and on a toileting program, no plan to meet her toileting needs was found. The family stated the resident would be continent if toileted when needed.

Based on observation, interview and record review the facility failed to ensure professional standards were followed when information was received from the facility pharmacy, immediately notifying a physician of a medication error for 2 of 12 sampled residents (Former residents #1 & 2) reviewed for nursing services. These failures caused Resident # 1 to receive a potentially lethal dose of narcotic medication, overmedication of Resident #2 and delayed treatment increasing a worsening condition. Findings include: 1) Resident #1 received an infusion of a narcotic pain medication ([MEDICATION NAME]). Refer to F-tag 333. On 1/29/2010 a pharmacy notified a Licensed Nurse (LN) the pharmacy was sending a syringe to the facility for the resident with a change in the concentration increased 10 fold from the original order and syringe content. According to the facility Director of Nursing Services (DNS), the LN failed to follow the facility policy to document the next delivered syringe of [MEDICATION NAME] would have an increased concentration of 10 fold in the 24 hour report which provided communication to other staff members. On 12/29/2010 two LNs hung a new syringe of pain medication at 10:45 p.m. The new syringe had two fluorescent green labels which stated caution: concentration change. The LNs hung the syringe and infused the [MEDICATION NAME] without adjusting the infusion rate. This caused the resident to receive 10 times the physician ordered concentration of medication. The LNs did not follow steps to ensure accuracy for the administration of medication for so the resident would receive the correct amount of medication at the correct rate. The next morning on 12/30/10 at 9:15 a.m. the LN noted the syringe was empty. The pharmacy was contacted and the facility notified the syringe should not be empty. The LN then noted the syringe contained an increased concentration (10 times the concentration) and was infusing at too fast a rate. At 9:30 a.m. the resident was assessed to be "comfortable." The resident's physician was not notified of the significant error until 3 hours after the error was noted and the resident's respiratory rate was decreased. At 12:15 p.m. the resident's physician ordered a medication to reserve the effects of the narcotic. No documentation in the nurses' notes indicated the resident's condition was monitored to evaluate the effects of the medication per standard of care of a patient with an overdose. Interview with Administrative team members stated the two LNs did not follow policy and procedure or standards of practice when administering the intravenous infusion of pain medication. They did not note the fluorescent green labels to caution staff the concentration of the medication was changed. 2) Former Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted after he had partial foot amputated. The resident was alert and oriented. The resident was able to communicate his needs to staff. Former Resident #2 pain management plan of care was developed on 12/14/10 and had interventions included: "Administer pain medication as ordered." On 1/6/11 at 7:15 p.m. the resident's physician ordered a pain medication regiment; [MEDICATION NAME] mg by mouth every 12 hours and [MEDICATION NAME] 2 mg by mouth every 2-4 hours as needed. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. Review of the narcotic disposition record and MAR from 1/7/11 to 1/13/11 revealed the resident was given [MEDICATION NAME] of 4 mg 16 times over the six days period. On 1/12/11 the resident was given [MEDICATION NAME] 4 mg at 9:15 a.m., 11:15 a.m. and 1:30 p.m. The resident was given twice the amount of [MEDICATION NAME] ordered. The record showed eight different LNs administered [MEDICATION NAME] for the resident during this period without identifying the medication errors.

Based on interview and record review, the facility failed to ensure an effective pharmaceutical system was in place to provide timely and accurate medications including intravenous medications for 4 of 7 current residents (#s 7, 9, 11 & 12). This resulted in a delay of initiating and/or missed medication doses for 4 of 7 current sampled residents (#s 7, 9,11 & 12) reviewed for medication administration. These failures caused avoidable harm for residents and increased the risk for health complications. Findings include: 1) Refer to F 328 for Resident #7 and Resident #9. 3) Refer to F 309 & 333 for Resident #11. 4) Refer to F 309 for Resident #12.