Every finding on record at Port Washington Post Acute

Based on interview and record review, the facility failed to ensure grievances were completed for 1 of 3 residents reviewed for resident rights. This failure placed residents at risk for continuation of concerns, decreased quality of care, and a diminished quality of life. Findings included.Review of the facility's policy titled, Grievance dated 08/2026, showed when a concern was voiced by a resident or family member, that concern should be directed to the appropriate department supervisor to evaluate and resolve the issue. The Social Services Director/Designee would investigate the concern and report findings to the administrator. The Administrator would then evaluate findings of the investigation and would take the appropriate action to resolve the concern and prevent further occurrences. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's electronic health record, showed they were on hospice services (end of life) and were severely cognitively impaired. Resident 1 passed away on 08/17/2026.Review of the grievance log, from 07/01/2026 to 08/21/2026, showed no grievance for Resident 1 on 08/08/2026. Review of progress notes, showed on 08/10/2026, social services had documented a phone call from CC1, Resident 1's daughter, who was concerned about a Certified Nursing Assistant (CNA) on Saturday who said Resident 1 was a check and change when they had asked to use the restroom. During an interview on 08/20/2026 at 11:48 AM, CC1, Resident 1's daughter, said on 08/08/2026 that Staff C, CNA, had refused to assist Resident 1 use the restroom because they had said Resident 1 was care planned to go in their briefs. During an interview on 08/21/2026 at 1:22 PM, Staff D, CNA, said they were present as Resident 1's 1:1 (continuous assistance) nursing aide during the incident on 08/08/2026. Staff D said another CNA had said Resident 1 could not be taken to the bathroom because they wore a brief, and confirmed this was Staff C who said this. Staff D said this made CC1 upset. Staff D said they then personally assisted Resident 1 to a bathroom and they were able to use a toilet. Staff D said they understood that Resident 1 was wearing a brief, but that did not mean Resident 1 was not allowed to use the restroom. During an interview on 08/21/2026 at 2:40 PM, Staff B, Social Services, was asked about their conversation with CC1 regarding Resident 1. Staff B, said CC1 called them upset about a CNA, and was upset Resident 1 was a check and change. When asked why this was not turned into a grievance, Staff B said they did not think CC1 wanted it to be one. During an interview on 08/21/2026 at 11:44 AM, CC1 said the facility had not offered to file a grievance on their behalf for Resident 1, they would have liked the facility to have done one, and this was the reason they had called the facility, to give them a chance to rectify the situation. During an interview on 08/21/2026 at 3:45 PM, Staff A, Interim Director of Nursing Services, said grievances should be done if a family member reports an incident to the staff. Staff A said a grievance should have been filed for Resident 1 regarding the incident on 08/08/2026. Reference WAC 388-97-0460

Based on observation, interview, and record review the facility failed to ensure timely assessment, monitoring, and implementation of appropriate interventions in response to oxygen saturation readings below residents' established parameters for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) reviewed for respiratory care, including one resident experiencing an acute change in condition (Resident 1). This failure placed residents at risk for worsening respiratory distress, delayed treatment, and a diminished quality of life. Findings included.<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease,COPD, (long term lung disease that blocks airflow) and acute on chronic respiratory failure with hypoxia (tissues don't get enough oxygen to function properly). On 08/09/2026, Resident 1 was diagnosed with COVID (a contagious respiratory illness). The admission Minimum Data Set (MDS), an assessment tool, dated 08/03/2026, showed Resident 1 was cognitively intact.On 08/18/2026 at 1:00PM, Resident 1's daughter and roommate at the facility, Resident 4 (not sampled) said on 08/11/2026 Resident 1 had been more tired than usual and had been sleeping for most of the day. Resident 4 said they became concerned around 10PM that evening as Resident 1 was not responding to them and called for Staff C, Certified Nursing Assistant (CNA) and asked them to get the nurse. After several minutes of waiting, Resident 4 called for Staff C again and asked them to test Resident 1's oxygen saturation which was 44%. Resident 4 asked Staff C to get the nurse. Several minutes more passed so Resident 4 again called for Staff C and told them they were going to call 911 if a nurse did not come within 5 minutes. Resident 4 said they waited about 7 minutes and then called 911.A review of the call light records, dated 08/11/2026, showed Resident 4 called for assistance at 9:55PM, 10:05PM, and 10:37PM. Emergency services arrived onsite at 11:15PM.On 08/18/2026 at 2:46PM, Staff C, CNA said they had answered Resident 4's call light on all three occasions and had attempted to find the primary nurse but could not. Staff C said it was a very busy night for call lights, and that they were trying to make sure they all got answered. When asked if an oxygen reading of 44% was an emergent situation, Staff C said it was, but they just got sidetracked.On 08/18/2026 at 2:54PM, Staff B, Licensed Practical Nurse (LPN) said on 08/11/2026 around 9PM they had administered medications to Resident 1 who seemed tired but was responsive. Staff B said they left the floor for their meal break around 10:00PM and told Staff D, Registered Nurse-Agency (RN), they were leaving. Staff B returned to the floor around 10:45PM. Staff B said they walked by Staff D who told them an aide had reported a 44% oxygen reading for Resident 1. Staff B said they ran to Resident 1's room, found them unresponsive, and began administering a high concentration of oxygen. Staff B said Resident 4 was on the phone with 911. Resident 1 was transferred to the hospital for more advanced treatments.<Resident 2>Resident 2 admitted to the facility on [DATE] with a diagnosis of COPD. On 08/05/2026, Resident 2 was diagnosed with COVID. The admission 5 day MDS, dated [DATE], showed Resident 2 was cognitively intact.Review of a provider's order, dated 07/15/2026, showed Resident 2 was to receive 2.5L (Liters) of continuous oxygen. There were no parameters established until 08/19/2026 when a new order was written for 2-5L of oxygen per minute to maintain oxygen saturation above 90%.Review of the August 2026 Medication Administration Record (MAR) showed oxygen saturation readings for Resident 2 of 84% on 08/06/2026, 89% on 08/11/2026, and 89% on 08/17/2026. There was no documentation of interventions for these readings or documentation of provider notification.<Resident 3>Resident 3 admitted to the facility on [DATE] and had a diagnosis of COPD. On 08/06/2026, Resident 3 was diagnosed with COVID. The admission 5 day MDS, dated [DATE], showed Resident 3 was cognitively intact.Review of the August 2026 MAR showed an oxygen saturation reading of 86% on 08/09/2026. There was no documentation of interventions for this reading or documentation of provider notification.On 08/18/2026 at 4:45PM, Staff A, Director of Nursing Services, said residents with oxygen saturation readings below 90% should be assessed by a nurse. Staff A said these readings should have interventions and be reported to the provider. Staff A said a reading of 44% was a medical emergency and should have been responded to promptly by both Staff D, RN-Agency, and Staff B, LPN. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review the facility failed to provide adequate protection for 2 of 3 residents (Resident 1 and Resident 2) reviewed for abuse. This failure allowed for a physical altercation to take place when Resident 2 attacked Resident 1 in their room.Findings included.Resident 1 admitted to the facility on [DATE] and had diagnoses of Alzheimer's and Dementia. The annual Minimum Data Set (MDS), and assessment tool, dated 06/05/2026 showed Resident 1 was moderately cognitively impaired and needed substantial assistance from staff for all care.Resident 2 admitted to the facility on [DATE] with a diagnosis of Vascular Dementia. The quarterly MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired.Review of Resident 2's Behavioral Care Plan, dated 01/26/2026, showed Resident 2 was placed on 1 to 1 supervision on 02/25/2026 due to wandering and behaviors. It showed Resident 2 would become verbally and physically aggressive with staff.An incident report, dated 08/04/2026, documented on 08/03/2026 at 8:30PM, Staff B, Certified Nursing Aide, was providing 1 to 1 supervision for Resident 2. Resident 2 was sleeping so Staff B began giving Resident 1 a bed bath. Resident 1 was making noise which awakened Resident 2. Resident 2 began yelling at Resident 1 and then proceeded to get out of bed and attack Resident 1 and Staff B. Resident 1 and Resident 2 slapped each other until Staff B could separate them. Staff B was scratched in the process.On 08/12/2026 at 3:30PM, Staff A, Administrator, said Staff B should not have left Resident 2 alone. Staff A said 1 to 1 supervision meant a staff person was responsible for making sure the resident being supervised was safe as well as all other residents.Reference WAC 388-97-0640(1)

Based on observation, interview, and record review the facility failed to consistently follow menus and religious food preferences for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) reviewed for nutritional needs. This failure placed residents at risk for demoralization and a diminished quality of life.Findings included.>Resident 1<Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2026, showed Resident 1 was cognitively intact and able to make their needs known.Review of a note sent by Resident 1 to the kitchen, dated 07/25/2026, documented Resident 1 was frustrated with the kitchen sending pork products. It stated in capital letters, I don't eat pork with three exclamation marks. Review of Resident 1's diet slip showed pork was listed under food dislikes.On 08/03/2026 at 2:40PM, Resident 1 said the menu they received on a weekly basis was not followed at least three times per week for lunch and dinner. Resident 1 said they had made it very clear to management that they did not eat pork for religious reasons, but they received pork products on a consistent basis.On 08/03/2026 at 5:30PM, Staff G, Certified Nursing Assistant, delivered Resident 1's dinner tray. Pepperoni pizza was observed on the plate. When asked if that meal should have been delivered due to the diet slip stating Resident 1 did not eat pork, Staff G said they didn't know.On 08/03/2026 at 5:45PM, Staff C, Dietician and Dietary Director, was shown Resident 1's tray. Staff C said Resident 1 should have received an alternative meal as the pepperoni was a pork product.>Resident 2<Resident 2 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 was cognitively intact and able to make their needs known.On 08/04/2026 at 12:40PM, Resident 2 said they had turned in a Grievance form due to several concerns with the food. Resident 2 said it was a waste of time to look at the menus as they were not always accurate. Resident 2 said they were often told food items had run out.Review of a Grievance form, dated 07/17/2026, showed four pages worth of concerns about the facilities dietary services including issues with the menu. Resident 2 said no one from management had addressed the grievance.>Resident 3<Resident 3 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact and able to make their needs known.On 08/04/2026 at 1:15PM, Resident 3 said the menu was not correct at least 3 times per week. Resident 3 said they turned in a Grievance form about not receiving the correct breakfast that was on the menu for two days. Review of the Grievance form, dated 07/06/2026, showed Resident 3 had not received the correct breakfast on 07/04/2026 and 07/05/2026. The grievance was followed up by Staff H, Social Services Director, who documented, An alternative meal was served for lunch over the weekend because of the hot weather and that the resident council president was supposed to have informed the residents. For a remedial action, Staff H wrote residents should be informed right away when meals are changed.On 08/04/2026 at 3:35 PM, Staff C, Dietician and Dietary Manager, said there were times the menu had to be changed because of ordering issues. When asked if food could be purchased in the community, Staff C said that it could, but that staff would have to purchase the food themselves and reimbursement could be delayed. Staff C said the menu should be followed as closely as possible and that residents should be given ample notice before any changes are made. Staff C said grievances should be followed up on in a timely manner.Reference WAC 388-97-1120(c) and 388-97-1180(1)

Based on observation, interview, and record review, the facility failed to provide meals based on resident preferences and listed allergies for 5 of 5 residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) reviewed for resident-centered nutrition. This failure placed residents at risk for harm, feelings of invalidation, and unmet dietary needs.Finding included.Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2026, showed Resident 1 was cognitively intact and able to make their needs known.On 08/03/2024 at 2:40PM, Resident 1 said they had an allergy to vaccines made with duck eggs but did not have an allergy to chicken eggs. Resident 1 said they had tried to clarify the allergy with the dietician and the doctor as they would like eggs, but that it continued to show as an allergen on their dietary tray slip. Resident 1 said sometimes they would get eggs on their tray for breakfast, and sometimes not. Resident 1 said on one occasion they only received a dry English muffin for breakfast and would have liked to have some eggs at least.Review of a dietary tray slip on 08/03/2026 showed Resident 1 was allergic to eggs.Review of a note sent to the kitchen by Resident 1, dated 07/25/2026, stated, I am not allergic to eggs. I've repeatedly straightened this out and have given up pretty much.Review of resident provided photograph, taken 07/27/2026, received 08/03/2026, showed a single English muffin on the tray. There were no condiment packets or any other foods.Resident 2 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 2 was cognitively intact and able to make their needs known.On 08/04/2026 at 1240PM, Resident 2 said the dietary staff rarely provided the meals that were requested. Resident 2 said they had complained on several occasions about their dislike for raw onions, especially in their salads, but they continued to receive them. Resident 2 said Hall A where they resided was always the last hall to receive their trays, and that if their evening meals were wrong, which they often were, there was no recourse as the kitchen would be closed or out of food.Review of a dietary tray slip, printed by Staff C, Dietician and Dietary Manager on 08/12/2026, showed Resident 2 disliked raw onions and beets.Review of a Grievance form, dated 07/17/2026 showed 4 pages worth of concerns about the facilities' dietary services including raw onions in salads, not providing the requested alternative meals, not providing the requested side items such as fruit bowls and side salads, and not providing double portions as requested.Review of Resident 2's menu, dated 07/20/2026 to 07/26/2026, showed Resident 2 had written requests for double portions for most proteins. Resident 2 had written requests for the addition of a fruit bowl for all breakfasts and a side salad/fruit bowl for all lunches and dinners. Large, capitalized words were handwritten on the menu that said, No onions.Observation of Resident 2's tray on 08/04/2026 at 12:45PM showed the main entree plus a side salad. There was one chicken breast even though the resident had requested 2 and there wasn't a fruit bowl as requested on Resident 2's menu for the week.Resident 3 admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact and able to make their needs known.On 08/04/2026 at 1:15PM, Resident 3 said they continued to receive beets and raspberries on their tray, even though they were allergic to them. Resident 3 said at one time they had told staff they did not like white cheese, such as parmesan, but they liked all other cheeses. Resident 3 said they never get cheese or dishes made with cheese.Review of a Dietary Profile, dated 10/07/2025, showed white cheese as a dislike. It showed Resident 3 had allergies to beets and raspberries. Review of a dietary tray slip, printed 08/12/2026 by Staff C, Dietician and Dietary Director, showed allergies to beets and raspberries but did not list cheese as a dislike.Resident 4 admitted to the facility on [DATE]. The annual MDS, dated [DATE], showed Resident 4 was cognitively intact and able to make needs known.On 08/04/2026 at 12:41, Resident 4 was observed with their lunch tray. It had the main entree and a side. It did not have the bowl of grapes that was listed on the menu for the day. Resident 4 said they were sad they did not receive the grapes, but that it was normal to not receive foods that were on the menu.Resident 5 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 5 was cognitively intact and able to make needs known.On 08/03/2026 at 4:08PM, Resident 5 said they did not feel like their preferences were honored. Resident 5 said they had repeatedly told staff they did not like cauliflower but continued to receive it on their tray. When asked when the last time they received it, Resident 1 said the last time it was on the menu a few days before. Resident 5 said if cauliflower was the vegetable that was being served, they would have it on their tray.Review of the dietary tray slip for Resident 5, printed on 08/12/2026 by Staff C, Dietician and Dietary Director, showed several dislikes including cauliflower.On 08/04/2026 at 3:35PM, Staff C, Dietician and Dietary Manager, said they were aware of Resident 1's request to update the egg allergy but that would require consultation with the doctor and that they just hadn't had time. Staff C said resident preferences should be honored and updated frequently to ensure resident satisfaction. Staff C said residents should never be served foods they are allergic to.Reference WAC 388-97-1100(1)(2)

Based on observation, interview, and record review, the facility failed to provide consitent bathing services for 2 of 3 residents (Resident 2 and Resident 3) reviewed for provision of personal care. This failure placed the residents at risk for skin impairments and a diminished quality of life.Findings included. >Resident 2<Resident 2 admitted to the facility on [DATE] with chronic wounds. The quarterly Minimum Data Set (MDS/an assessment tool), dated 06/05/2026, showed Resident 2 was cognitively intact and needed substantial assistance for Activities of Daily Living (ADLs).On 08/03/2026 at 12:20PM, Resident 2 said they had not received a bath in over 2 weeks. Resident 2 became tearful when explaining how uncomfortable they were. Resident 2 said they had skin conditions on their right hip and bottom that were causing itching and pain. Resident 2 said they were concerned about further skin break down due to not bathing enough.A Skin Progress note, dated 07/07/2026, documented Resident 2 had a left gluteus (buttock) blister and a right hip blister that were described as causing itching and pain.Review of the ADL Self Care Performance care plan, dated 07/31/2026, showed Resident 2 was to receive a shower or bed bath twice per week on Monday and Thursday evenings and as needed. It identified Resident 2 had a risk for impaired skin integrity related to immobility, obesity, and chronic wounds.Review of the task documentation for Bathing/Showering from 07/28/2026 to 08/04/2026 showed Resident 2 had received a bed bath on 07/08/2026, 07/25/2026, 07/29/2026, and 08/02/2026 for a total of four bed baths in eight weeks.>Resident 3<Resident 3 admitted to the facility on [DATE] with a stroke that affected the left side of the body. The quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact and needed maximum assistance for ADLs. Resident 3 had a history of pressure ulcers to their coccyx (tailbone area).Review of the ADL Self Performance care plan, dated 08/14/2024, showed Resident 3 was to receive bed baths on Wednesday and Saturday evenings and as needed. It showed Resident 3 was at risk for pressure ulcers to their bony prominences related to limited mobility and incontinence. The care plan documented there was a new skin impairment to the coccyx on 07/26/2026.Review of the task documentation for Bathing/Showering from 07/28/2026 to 08/04/2026 showed Resident 3 had received a bed bath on 07/11/2026 and 07/29/2026. Resident 3 did refuse on 07/15/2026 and 07/25/2026. Resident 3 received or refused four bed baths in eight weeks.On 08/04/2026 at 2:52PM, Staff F, Certified Nursing Aide/Shower Aide, said they were assigned at least 15 residents to give bed baths/showers for on an 8-hour shift. Staff F said they were also scheduled to give breaks to the aides that were providing one-to-one (1:1) supervision to residents. Staff F said they did the best they could but that they would often run out of time to complete the bathing tasks. Staff F said Hall A was especially difficult due to all of the bed bound residents.On 08/04/2026 at 3:14PM, Staff E, Infection Preventionist and prior Unit Manager, reviewed the documented bed baths for both Resident 2 and Resident 3. Staff E said they knew there was a shower aide, but they were not sure what hours they worked. When asked if providing bed baths and showers for 15 residents during an 8-hour shift and also taking lunch and covering breaks was doable, Staff E said probably not.On 08/04/2026 at 3:45PM, Staff A, Administrator, and Staff B, Director of Nursing Services, said they were unaware of the issues and concerns about lack of bathing. Staff A and Staff B said they did not know the bath aide was being asked to provide breaks for other aides. When asked if not receiving consistent bathing services could affect skin integrity and morale, Staff B said it could.Reference WAC 388-97-1060(1)-(3)

Based on observation, interview, and record review, the facility failed to provide palatable and properly cooked foods for 1 of 3 residents (Resident 1) reviewed for safe and attractive foods. This failure placed residents at risk of illness and a decreased quality of life.Findings included.Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/26/2026, showed Resident 1 was cognitively intact and able to make their needs known.On 08/03/2026 at 2:40PM, Resident 1 said they did not eat pork for religious reasons, and that it was documented on their care plan and their diet slip. Resident 1 said on 07/24/2026, they received pork chops for the noon meal. Resident 1 said they refused the meal and requested a cheeseburger. Resident 1 said they bit into the cheeseburger, found it was raw in the middle, and could not eat it. Resident 1 said they no longer asked for toast for breakfast because it was often burnt and inedible.Review of resident provided photograph, taken 07/24/2026, received 08/03/2026, showed a hamburger without a bun that had been cut in half and placed on top of each other. There was a thin line of brown/gray on the outside and reddish raw looking meat on the inside.Review of resident provided photograph, taken 07/22/2026, received 08/03/2026, showed a piece of toast with black raisins throughout. The edges of the toast were also blackened.On 08/03/2026 at 3:35PM, Staff C, Dietician and Dietary Manager was asked about the raw hamburger that was served. Staff C said they had heard about it but had not had time to start an investigation. Staff C said they did not know what employee had served the raw hamburger. When asked if meat should be temped before it was served, Staff C said it should be. When asked if the meat was temped for the burger at the requirement of 165 degrees or of it was served even though the temp was not acceptable, Staff C said they did not know. Staff C said toast should be lightly browned but not burnt.Reference WAC 388-97-1100(1)(2)

Based on interview and record review, the facility failed to ensure medication was available and provided for 1 of 3 residents (Resident 1) reviewed for significant medication errors. This failure placed residents at risk for inaccurate lab values, rehospitalization, and a diminished quality of life.Findings included.Resident 1 admitted to the facility on [DATE] with a history of complicated diagnosis to include heart and kidney transplants in 2022. The kidney transplant failed in 2025 which required Resident 1 to restart dialysis (process of removing blood, cleaning it, and removing extra fluid when the kidneys fail). The recent hospitalization and admission to the facility was due to upper extremity edema (swelling). The admission Minimum Data Set, an assessment tool, dated 06/05/2026, showed Resident 1 was cognitively intact.The hospital discharge medications list, dated 05/31/2026, showed Resident 1 had the following orders: Cyclosporine (immunosuppressant used to prevent organ transplant rejection, requires strict blood level monitoring) 75mg in the morning and 50mg at night.Sirolimus (immunosuppressant used to prevent organ transplant rejection, requires strict blood level monitoring) 0.5mg every other day, 4 hours after Cyclosporine.Prednisone (immunosuppressant used to prevent organ transplant rejection)5mg daily.Review of the hospital administration record, dated 05/31/206, showed Resident 1 had received 75mg of Cyclosporine the morning before discharge.A facility provider documented in a note, dated 06/01/2026, that Resident 1 had told them the hospital had stopped the Cyclosporine due to concerns over kidney function. The provider note acknowledged Resident 1 had a specific cardiac transplant team but did not document there had been any correspondence with them about medications.Review of the June 2026 Medication Administration Record (MAR) showed the medication Cyclosporine was not started until 06/09/2026.Review of the May 2026 and June 2026 MAR showed Sirolimus was not given until 06/12/2026 for a total of 6 missed doses.Review of the June 2026 MAR showed Prednisone 5mg was given until 06/11/2026 when the medication was increased to 40mg for 3 days and then was tapered back down with the last dose of 10mg being given on 06/19/2026. The 5mg dose was not resumed until 06/30/2026.On 07/22/2026 at 3:15PM, Staff A, Director of Nursing Services, said there had been issues with the pharmacy in obtaining medications. Staff A said communication with the heart transplant team about medications had been lacking. Staff A said they did not communicate with the cardiac transplant team until 06/30/2026 about the Prednisone. Reference WAC 388-97-1060(3)(k)(iii)

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment and equipment in Storage room [ROOM NUMBER] located diagonally across from the nurses' station. This failure placed residents and staff at risk for cross contamination, substandard infection control, injury, and a diminished quality of life.Findings included.On 05/19/2026 at 12:00 PM, Storage room [ROOM NUMBER] was entered to inspect feeding and intravenous (IV) poles. The door was not locked and, when opened, knocked into 3 IV poles. The poles were rusted, dirty, and very unstable when tested for stability. Equipment including portable bedside commodes, feeding pumps, and nebulizers (inhaled medication delivery systems) were seen scattered and piled around the small room. Some were visibly soiled but there was no way to tell if others were clean or dirty. Biohazard boxes for the disposal of sharps containers were stacked on top of each other. A full sharps container was observed setting on the edge of one of the boxes, not closed or locked.On 05/19/2026 at 12:15 PM, Staff A, Director of Nursing Services, viewed Storage room [ROOM NUMBER]. Staff A said they knew the room needed to be completely cleaned out and reorganized. Staff A said clean and dirty equipment should not be stored in the same room. Staff A said sharps containers needed to be closed and locked for safety. Staff A said they had ordered new IV poles and that the old ones needed to be thrown away. Staff A said all storage rooms needed to be locked to prevent residents from entering them.Reference WAC 388-97-3220 (1)

Based on observation, interview, and record reviews, the facility failed to identify, and to provide for needs and services in a timely manner for 2 of 3 residents (Resident 1 and Resident 2) reviewed for quality of care. This failure placed residents at risk for unmet needs and a diminished quality of life.Findings included.Resident 1Resident 1 admitted to the facility on [DATE] at 5:00 PM with a new Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube placed directly into the stomach through the abdominal wall). Resident 1 had a history of esophageal obstruction (blockage of the tube connecting the throat to the stomach) and difficulty swallowing. A nurse's note, dated 05/03/2026, documented Resident 1 was cognitively intact.On 05/18/2026 at 3:08 PM, Resident 1 said they only stayed at the facility for 1 night due to not receiving all of their medications and not receiving them via the PEG tube. Resident 1 said they only received 1 feeding at 8PM on 05/03/2026, that it was not done correctly, and that the pole it was attached to was dirty and not stable.Review of the hospital discharge orders, dated 05/03/2026, showed Resident 1 was to receive a 330 millimeters (mls) bolus of Jevity 1.2 (a type of formula) via the PEG tube every 6 hours, at 8AM, 12PM, 4PM, and 8PM.Review of the May Medication Administration Record showed the residual volume was to be checked prior to the bolus feeding utilizing a syringe. If the volume was greater than 100mls, the feeding was to be held for an hour. If the volume was still greater than 100mls after an hour, the doctor was to be notified. The residual volume was not tested before administration of the 8PM bolus.Review of the May Medication Administration Record showed Resident 1 did not receive 16 medications that were due between 4:30PM on 05/03/2026 and 12:00PM on 05/04/2026. The missed medications included ones for pain and for gastroesophageal reflux disease (a chronic digestive condition where stomach acid or bile repeatedly flows back into the esophagus).On 05/19/2026 at 3:50PM, Staff E, Registered Nurse, said Resident 1's medications were not delivered on 05/03/2026. Staff E said they could only administer the one medication that could be pulled from the Omnicell (an onsite medication storage unit) during their night shift. Staff E said they could not test the residual volume and could not administer the medication via the PEG tube because the facility did not have any syringes.An incident report, dated 05/19/2026, showed the anticipated delivery of Resident 1's medications wasn't going to be until 1PM on 05/04/2026.Resident 2Resident 2 admitted to the facility on [DATE] with a diagnosis of obstructive sleep apnea (condition where the throat muscles repeatedly relax and block the airway during sleep). The admission 5-day Minimum Data Set, an assessment tool, dated 05/12/2026, showed Resident 2 was cognitively intact.On 05/19/2026 at 12:30PM, Resident 2 said they were told by the hospital that the facility would have a Continuous Positive Airway Pressure (CPAP, delivers a steady stream of air to keep the throat open) machine and accessories when they arrived. Resident 2 said without it, they would wake up gasping for air and crying. Resident 2 said they had talked to Staff B, Social Services Assistant, Staff C, Assistant Director of Nursing, and Staff D, Charge Nurse, about the need for the machine but nothing was done. Resident 2 said a relative had finally brought the one from home 2 days prior, but it still had not been set up.On 05/19/2026 at 12:32PM, a CPAP machine was observed on the right bed side stand. It was not plugged in. There were no accessories, such as a mask and or tubing, attached to or by the machine.On 05/19/2026 at 1:12PM, Staff C, Assistant Director of Nursing, said they were not aware that Resident 2 needed a CPAP. Staff C said they did not know there was a CPAP in the room.On 05/19/2026 at 2:55PM, Staff B, Social Services Assistant, said they had spoken to Resident 2 about the CPAP when they went to welcome Resident 2 on 05/05/2026. Staff B said they brought it to the attention of Staff C, Assistant Director of Nursing, that same day.On 05/19/2026 at 3:35PM, Staff D, Charge Nurse, said they were aware Resident 2 had requested a CPAP. Staff D said they had meant to call the hospital and request the documentation from Resident 2's last sleep study but had not. Staff D said they did not have orders for the CPAP that was at the bedside.On 05/19/2026 at 4:00PM, Staff A, Director of Nursing Services, said residents should have needed medications and equipment provided in a timely manner. Staff A said equipment should be clean and in good working order.Reference WAC 388-97-1060(1)-(3)

Based on interview and record review, the facility failed to ensure staff were adequately trained on newly implemented wander guard/elopement alarm system resulting in staff failing to recognize and respond timely to resident elopement alarms for resident assessed as at risk for wandering/elopement for 1 of 3 residents (Resident 1) reviewed for elopement. Resident 1 experienced harm when the resident exited the facility unsupervised in their wheelchair and then rolled down a hill, fell, and required emergency transport to the hospital where they were diagnosed with multiple facial fractures. This failure placed residents at risk of elopement, injury and a diminished quality of life. Findings included.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 01/26/2026, showed Resident 1 was cognitively intact. Resident 1 had a history of a large left sided stroke (brain injury) that affected their safety awareness.Resident 1's elopement care plan, with interventions revised 05/21/2025, documented, all staff will continue to remind [Resident 1] that he may use the courtyard for safe wandering. All staff will continue to remind [Resident 1] that he must remain within eye contact so staff can see him.Resident 1's risk for falls care plan, with interventions revised 06/02/2025, documented, resident is not allowed in patio or parking without staff lot areas due to demonstrated severe fall risk. May go into courtyard.Wanderguard to wheelchair to notify staff when resident is trying to enter the front patio due to severe fall risk from steep driveway.Review of an incident report, dated 04/18/2026, showed Resident 1 wheeled through the front doors at approximately 6:10 PM. An alarm sounded at the nurse's station but was turned off by Staff C, Licensed Practical Nurse (LPN). The facility's video surveillance showed Resident 1 left the patio area and proceeded towards a bus stop that was located in front of the facility. The bus stop was situated at the top of a significant hill. Resident 1 rolled down the hill in their wheelchair and fell onto the street. Staff were notified by a person passing by and the community member called 911 and Resident 1 was sent to the hospital at 6:35 PM after a brief assessment at the roadside by facility staff.Hospital records, dated 04/19/2026, documented Resident 1 had multiple sinus fractures and a fracture under the left eye with bruising.On 05/07/2026 at 1:45 PM, Staff B, Social Services Director, said the WanderGuard system that had been in place would cause the front doors of the facility to close automatically when a resident wearing the bracelet would pass by the sensor located a few feet from the doors. Staff B was aware a new system had been installed recently but was not aware of how it functioned.On 05/07/2026 at 1:50 PM, Staff A, Director of Nursing, said a new system had been installed on 04/09/2026 and Resident 1 had received a new bracelet. Staff A said staff had not been educated about how the new system worked.On 05/07/2026 at 2:19 PM, Staff C said a beeping alarm had sounded several times during their day shift on 04/18/2026. Staff C said they had not known what the alarm was for. Staff C said another staff member told them to just hit reset at the nurse's station and at the front doors. When asked if they had looked outside when resetting the alarm at the door, Staff C said they had not. Staff C said they had worked for the facility for two years and was not aware Resident 1 had a WanderGuard bracelet.On 05/07/2026 at 3:10 PM, Staff A, DNS, said staff should have been in-serviced on the new system when it was installed. Staff A said a WanderGuard alarm should be responded to immediately to avoid potential and avoidable accidents.Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review the facility failed to prevent an altercation between 2 out of 3 residents (Resident 2 and Resident 3) reviewed for freedom from abuse. This failure placed residents at risk for injury, psychosocial harm, and a diminished quality of life. Finding included .Resident 2 admitted to the facility on [DATE] with diagnoses of anxiety, major depression, Schizophrenia (severe brain disorder that causes individuals to interpret reality abnormally, often resulting in delusions, hallucinations, and severely disorganized thinking and nicotine dependence). The quarterly Minimum Data Set, (MDS, and assessment tool) showed Resident 2 was cognitively intact. Resident 2 had a history of verbally and physically attacking other residents as documented in behavior notes dated 11/13/2025 and 02/11/2026, and 03/21/2026. After the 11/13/2026 incident, Resident 2 was assigned a staff member who would provide 1:1 supervision while Resident 2 was awake. Resident 3 was admitted to the facility on [DATE] with a diagnosis of nicotine dependence. The quarterly MDS showed Resident 3 was cognitively intact. A Behavior note, dated 04/18/2026, documented Resident 2 and Resident 3 had a verbal confrontation at the smoke shack. Resident 2 was cussing at Resident 3. An Incident Report, dated 04/19/2026, documented that on that day at 10:30 AM, Resident 3 was in the smoking shack. Resident 2 went outside and into the smoking shack without their assigned staff member. Resident 2 parked their wheelchair in front of Resident 3 and began speaking confrontationally. Resident 2 pushed Resident 3's wheelchair to which Resident 2 responded by waving a lit cigarette in Resident 3's face and grabbing their hand. The altercation caused both residents to fall out of their wheelchairs. No injuries were sustained. On 04/07/2026 at 1:45 PM, Staff B, Social Services Director, said they were responsible for the staffing and supervision of the smoking area. Staff B said there was a smoking attendant that was supposed to be outside during the set smoking hours. Staff B said there was not a smoking attendant outside at 10:30 PM on 04/19/2026.On 04/07/2026 at 3:45 PM, Staff A, Director of Nursing Services, said Resident 2 should not have been outside without their assigned staff member. Staff A said there had been some confusion about staffing responsibilities on 04/19/2026. Staff A said the assigned staff member had taken a lunch break at the time they were supposed to be with Resident 2. Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to have sufficient staff to provide and supervise care for their residents as evidenced by information from 3 resident interviews (Resident 1, Resident 2, and Resident 3) and 3 staff interviews. The facility had insufficient staff to ensure residents received adequate assistance for their Activities of Daily Living (ADLs). This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, showed Resident 1 was cognitively intact and needed partial to moderate assistance with ADLs. Resident 1 had an indwelling foley catheter (a tube in the bladder to drain urine).On 04/06/2026 at 1:15 PM, Resident 1 was observed with a full urine bag hanging on the side of the bed. Resident 1 said they were concerned about getting a urinary tract infection due to the bag being full most of the time. Resident 1 said they hadn't seen an aide all day, except to drop off their lunch tray.Resident 2 was admitted to the facility on [DATE]. The quarterly MDS dated [DATE] showed Resident 2 was cognitively intact and needed minimum assistance with ADLs.On 04/06/2026 at 1:33 PM, Resident 2 said there was a noticeable decrease in the number of aides and nurses in the last couple of weeks since the interim Administrator had arrived. Resident 2 said they would often have to leave their room to find help as no one answered the call light. Resident 2 said they were concerned for other residents who needed a lot of help.Resident 3 was admitted to the facility on [DATE] with a diagnosis of paraplegia (loss of sensation and function to the lower body). The annual MDS showed Resident 3 was cognitively intact and needed substantial assistance for some of their ADLs. Resident 3 had a colostomy (allows stool to pass into a bag outside of the body).On 04/06/2026 at 1:45 PM, Resident 3 said they had a care plan to be out of bed by 9AM. Resident 3 said they were lucky if they were out of bed by lunch. Resident 3 said it takes 2 aides to use the Hoyer (mechanical) lift to get them out of bed, and they were repeatedly being told by aides that another aide could not be found to help. Resident 3 said they emptied their own colostomy and would frequently throw the feces filled bag onto the floor because no one would come to get it.On 04/06/2026 at 2:05 PM, Staff C, Certified Nursing Aide (CNA), was asked why Resident 1's urine bag was so full. Staff C said they were the only aide on the unit. Staff C said there had been a change to the staffing ratios, that agency staff were no longer being used, and that double shifts and overtime had been cut. Staff C said they did not have time to complete all the ADL tasks assigned to them.On 04/06/2026 at 2:10 PM, Staff E, CNA, became tearful and said they were trying to care for 16 residents. Staff E said there was no way showers could be completed. When asked if there was a shower aide, Staff E said there was not.On 04/06/2026 at 2:15 PM, Staff D, CNA, said they had been an aide for over three years at the facility, and the staffing was the worst they had ever seen it. Staff D said getting residents up and changed was about all they could do. Staff D said many of the required care tasks would not be completed. Staff D said they could not take breaks or take a lunch.On 04/07/2026 at 10:00 AM, Staff B, Staffing Coordinator, said about three weeks prior, they had been instructed by the interim Administrator to reduce day shift aides from 13 to 7, evening shift from 11 to 7, and night shift from 7 to 4. Staff B said the facility had two residents who required 1:1 supervision for all shifts. Staff B said the expectation was that the aides working the floor would take turns. The interim Administrator was not available for interview.On 04/06/2026 at 4:00 PM, Staff A, Regional Nurse, said they were not aware of the staffing cuts and that the numbers were not acceptable. Staff A said they would immediately reinstate the previous staffing numbers. Staff A said they would also be hiring shower aides.Reference WAC 388-97-1080(1)

Based on interview and record review, the facility failed to ensure discharge planning included involvement of community agencies and medication management for 2 of 3 Residents reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, re-hospitalization, and a decreased quality of life.Finding included.A facility Discharge Policy, revised 12/16/2026, did not address the before discharge needs of the following: medication ordering, medication management teaching, the coordination of home care services, and/or equipment needs. It did not have guidance that would ensure follow-up appointments in the community were made before leaving the facility.Resident 1Resident 1 admitted to the facility on [DATE] with diagnosis of diabetes and dementia. A quarterly Minimum Data Set (MDS), an assessment tool, dated 01/29/2026, showed Resident 1 was cognitively intact. Resident 1 was discharged home on [DATE].A Social Services progress note written by Staff C, Social Services Director (SSD), dated 02/06/2026, documented, The resident was safely discharged from [facility] with all their belongings back home.A Discharge Plan of Care form, dated and signed by Staff C on 02/06/2026, documented Resident 1 needed assistance with bathing, toileting, and dressing to be provided by family and personal caregivers. There was no documentation about medication teaching or about follow-up appointments that had been made.On 03/12/2026 at 4:09 PM, CC1, Case Manager for Home and Community Services (CM for HCS), said Resident 1 was a client and that they provided caregivers in the home. CC1 said they were not notified that Resident 1 was discharging so caregivers couldn't be scheduled. CC1 said the family called them with questions about sliding scale insulin administration as they had not received training from facility nurses before discharge.Resident 2Resident 2 admitted to the facility on [DATE] with diagnosis of unspecified cognitive impairment, adult failure to thrive and need for assistance with personal care. The admission MDS, dated [DATE], showed Resident 2 was moderately cognitively impaired. Resident 2 discharged home on [DATE].Review of a hospital Case Management note, dated 12/31/2026, prior to Resident 2's initial admission to the facility showed concerns about Resident 2's safety at home and Resident 2's family's (who also resided in the home) ability to care for the resident.A Social Services Progress note written by Staff C, dated 02/13/2026, documented, The resident was safely discharged from [facility] with all their belongings back home.A Discharge Plan of Care form, dated and signed by Staff C on 02/13/2026, documented Resident 2 was cognitively intact and needed assistance for most Activities of Daily Living (ADLs) that the family would be providing. In home care was not ordered, medication refills were not sent to any pharmacy, and a follow up appointment with the primary physician was not made.Review of a Medical Doctor/Nurse Practitioner progress note, dated 02/26/2026, showed Resident 2 was readmitted to the facility on [DATE] as they were, not receiving care and had to return to the hospital before returning to the facility. It said Resident 2 ran out of medications about a week after being back home.On 03/12/2026 at 4:09 PM, CC1, CM for HCS, said they had not been notified that Resident 2 was discharging. CC1 indicated although Resident 2 was not a client yet, based on identified concerns, involvement would have been expected upon referral.On 03/17/2026 at 1:55PM, Staff C, Social Services Director, said they thought they had contacted CC1, CM for HCS, for both Resident 1 and Resident 2. Staff C said they had tried to set up Home Health services for Resident 2 but did not start the process until the day of discharge. Staff C said they did not know anything about medication re-ordering or teaching for discharges. Staff C said they did not typically make follow-up appointments.On 03/12/2026 at 4:30PM, Staff B, Director of Nursing Services, said they were not aware of the lack of coordination related to discharges. Staff B said they would be evaluating the entire discharge process and creating new policies and procedures. Staff B said neither Resident 1 nor Resident 2 had safe discharges.On 03/12/2026 at 4:50PM, Staff A, Administrator, said several changes needed to be made to the discharge process.Reference WAC 388-97-0800

Based on observation and interview, the facility failed to provide attractive, palatable, and flavorful food for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) reviewed for food quality. This failure placed residents at risk for health complications related to weight loss, less than adequate nutritional intake, and a diminished quality of life.Finding included.On 02/20/2026 at 12:30 PM, a sample tray was received from the kitchen. The meal consisted of creamed corn, green beans, baked chicken breast, a small yeast roll, a glass of milk, a container of apple juice, and a small container of light gray pudding with pearls. The creamed corn and green beans were running together on the plate. The creamed corn had bits of burnt areas. The green beans had pieces that had strings that could not be chewed and had to be removed. The main dish had no seasoning and was very bland. The pudding tasted faintly of chocolate and was dripping off the spoon. There was no butter for the roll.RESIDENT 1Resident 1 was admitted to the facility on [DATE] with diagnosis of tracheal cancer with voice box removal. Resident 1 had a feeding tube for most of their nutrition but also enjoyed taking in food orally. The admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 was moderately cognitively impaired. Resident 1 had a pureed (smooth and pudding like) diet.On 02/20/2026 at 12:45 PM, Resident 1 was observed sitting up in bed with a lunch tray in front of them. The food had not been touched. Resident 1 said the food looked unappealing, that it had no flavor, and that they had no desire to eat it. The tray was observed to have a large pile of pureed food that was not identifiable. There were no seasoning packets available on the tray. RESIDENT 2Resident 2 was admitted to the facility on [DATE]. An admission MDS, dated [DATE], showed Resident 2 was cognitively intact.On 02/20/2026 at 12:40 PM, the lunch cart for Hall C was brought. At 12:55 PM, trays had been passed and the lunch cart was left in the hall by the nursing staff. Resident 2 had not received their lunch tray. At 1:00 PM, Staff B, Certified Nursing Assistant, was asked why Resident 2 had not received a lunch tray. Staff B went to the cart, found the lunch tray, and delivered it to Resident 2.On 02/20/2026 at 1:10 PM, Resident 2 was observed with an untouched lunch tray in front of them. When asked why they had not eaten, Resident 2 said the food had been cold and terrible since they got there. Resident 2 stated, Breakfast has been a glob of eggs and some type of muffin that I can't even swallow. They brought me two bowls of dried cereal without any milk.RESIDENT 3Resident 3 was admitted to the facility on [DATE]. A quarterly MDS, dated [DATE], showed Resident 3 was cognitively intact.On 02/20/2026 at 1:32 PM, Resident 3 said the food at the facility was terrible. Resident 3 said it had been getting better a few months ago, but that it was declining in quality, consistency, and flavor. Resident 3 said the facility used too many liquid eggs for meals, including dinners.On 02/20/2026 at 4:00 PM, Staff A, Registered Nutritionist/Kitchen Manager, said they were unaware of the complaints regarding food. Staff A said they addressed food complaints at the food council meeting. When asked how residents would voice their opinion if they could not attend a meeting, Staff A said they would rely on floor staff to deliver the message. When asked if they were aware of the weight losses, Staff A said they were, that they addressed concerns every day at stand up. When asked if food quality, including appearance and taste, could affect weight, Staff A said they could.On 02/20/2026 at 4:10 PM, Staff A, Administrator, said they had been under the impression that the food quality was getting better. Staff A said the managers would be making more of an effort to taste the food and to make rounds after meals to ascertain resident satisfaction.Reference WAC 388-97-1100(1)(2)

Based on observation, interview, and record review, the facility failed to ensure altered consistency liquids were provided and consistent with resident's orders for 2 of 3 residents (Resident 2 and Resident 4) reviewed for hydration. This failure placed residents as risk for dehydration, aspiration (inhalation of foods or liquids into the airways), and a decreased quality of life. Findings included .RESIDENT 2Resident 2 was admitted to the facility on [DATE] with post-stroke (blood supply to a part of the brain is blocked) swallowing difficulties. An admission Minimum Data Set (MDS, an assessment tool) dated 02/10/2026, showed Resident 2 was cognitively intact.On 02/20/2026 at 1:10PM, Resident 2 was observed with an untouched lunch tray in front of them. Resident 2 had chapped lips and dry facial skin. There were no fluids on the tray. When asked why they had not eaten, Resident 2 said the food had been cold and terrible since they got there. Resident 2 stated, Breakfast has been a glob of eggs and some type of muffin that I can't even swallow. For 2 mornings they have brought me 2 bowls of dried cereal without any milk.On 02/20/2026 at 1:15PM, Staff B, Certified Nursing Aid, was asked why Resident 2 did not have any fluids. Staff B went to Resident 2's room and looked at the diet slip on the tray. They stated, The diet slip says no drinks on the tray. When asked what that means, Staff B said it must mean Resident 2 needed an altered liquid texture and that they would have to ask the nurse. On 02/20/2026 at 1:20PM, Staff C, Licensed Practical Nurse, was asked by Staff D about liquids for Resident 2. Staff C consulted the orders in the computer and said Resident 2 needed to have Level 2 (nectar thickened liquids). Staff C went to the locked nourishment/snack room, removed a carton of nectar thick juice from the shelf, poured a glass, and handed it to Staff B to give to Resident 2. No other Level 2 beverages were seen in the refrigerator where they would have been placed after opening. When asked how the aides would know what type of liquid to give a resident, Staff C said they would need to ask the nurse. RESIDENT 4Resident 4 admitted to the facility on [DATE] with post-stroke swallowing difficulties. The admission MDS showed Resident 4 was cognitively intact. Review of a dietary order, dated 02/16/2026, showed Resident 4 was to receive Level 2 liquids. On 02/20/2026 at 12:30PM, Resident 4's tray was delivered to their room. The diet slip on the tray had nothing written about liquid textures. There were two containers of normal consistency juices on the tray. On 02/20/2026 at 1:50PM, Resident 4 was observed in bed with a container of normal consistency cranberry juice. When asked about the juice, Resident 4 said the aides bring him the containers of juice when he asks. Resident 4 said they hated the nectar thickened fluids, especially the water, but knew they were not getting enough fluids. On 02/20/2026 at 4:00PM, Staff A, Registered Dietician/Kitchen Manager, said all residents should be receiving enough fluid, and of the correct consistency. Staff A said residents with altered fluid consistency should be monitored for compliance and hydration. Staff A said there should be a quick reference system to communicate to floor staff what resident's fluid consistency needs are. Reference WAC 388-97-1060(3)(i)

Based on interview and record review, the facility administered Seroquel, an antipsychotic medication, without proper assessment, diagnosis, or interventions needed for this drug regimen for 1 of 3 residents (Resident 1) reviewed for unnecessary medications. Failure to complete a thorough evaluation before starting the medication as well as failure to provide necessary monitoring during the therapy placed residents at risk for sedation, a decreased quality of life, and death. Finding included .Resident 1 admitted to the facility on [DATE] with a history of encephalopathy (disease or damage to brain function) related to Glioblastoma (brain cancer). The admission Minimum Data Set, an admission tool, dated 8/08/2025, showed Resident 1 was moderately cognitively impaired and needed extensive assistance for most activities of daily living.A psychiatry note, dated 8/21/2025, documented Resident 1 was confused and minimally engaged. The impression was Resident 1 had unspecified cognitive disorders which were worsening due to recent medical events. The note stated, No obvious need for psychotropic intervention.On 8/26/2025 at 3:23PM, Staff B, former Director of Nursing Services (DNS) obtained an order for Seroquel, 50 milligrams (mg) to be given every morning, and 150 mg to be given at bedtime for anxiety and depression. There was no documentation of any behaviors explaining why the medication had been started. There was no Psychopharmacologic Medication Informed Consent signed by Resident 1 which would have reviewed risks and benefits, side effects, and the need for gradual reduction of the medication. The care plan, dated 9/24/2025, showed Seroquel was added by Staff C, Social Services Assistant, as an anxiolytic (anti-anxiety) medication. The care plan was revised by Staff D, Registered Nurse, on 10/31/2025 but was not corrected. The care plan did not have the correct assessment, interventions, including non-pharmacologic, or monitoring of an antipsychotic medication. The care plan did not address a plan for gradual reduction of the medication. On 12/30/2025 at 2:15PM, Staff B, DNS, said they did not know why Seroquel had been started. Staff B acknowledged there was no documentation that would support that drug regimen. Reference WAC 388-97-1060(3)(k)(i)

.Based on observation, interview and record review, the facility failed to identify, address, and adjust care needs for 5 of 5 residents (Resident's 1, 2, 3, 4 and 5) who experienced dementia-related behaviors, and/or the negative impacts of those behaviors. This failure placed residents at risk of not achieving or maintaining their highest practicable level of mental and psychosocial well-being.Findings included.Resident 1Resident 1 admitted to the facility on [DATE] and had a history of Neurocognitive Disorder with Lewy Bodies (brain disease with dementia like symptoms, including disorganized thinking, memory loss, vivid hallucinations, and mood swings.) The admit Minimum Data Set (MDS), dated [DATE], showed Resident 1 was severely cognitively impaired. Resident 1 had a walker and was able to ambulate around the facility. A review of November 2025's Certified Nurse Aide (CNA) Behavior Monitoring form documented the following:Yelling/Screaming - 11/10/2025, 11/12/2025, 11/14/2025Wandering - 11/10/2025, 11/12/2025, 11/13/2025, 11/18/2025Sexually inappropriate - 11/14/2025, 11/19/2025No interventions were added or recorded on the Behavior Monitoring form. Resident 1's care plan, dated 8/15/2025, did not have wandering, sexually inappropriate, or yelling/screaming listed as behaviors. It did not have any interventions listed. The Kardex (a tool used by certified nursing assistants) did not provide guidance or interventions for staff to use for behaviors. Resident 2Resident 2 was admitted to the facility on [DATE]. The admit MDS, dated [DATE], showed Resident 2 was cognitively intact and needed limited assistance for Activities of Daily Living (ADLs).On 11/27/2025 at 3:17PM, Resident 2 said Resident 1 came into their room uninvited on several occasions, especially at night. Resident 2 said about three weeks prior, Resident 1 had come into their room and urinated on their bed while they were in it. Resident 2 said Staff C, Assistant Director of Nursing Services (ADNS), knew about this incident. Resident 3 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], showed Resident 3 was cognitively intact and needed limited assistance for ADLs. On 11/27/2025 at 3:20PM, Resident 2's roommate, Resident 3 spoke up and said on one of those occasions, about three weeks prior, Resident 1 took off all their clothes, climbed into the bed, and attempted to initiate sexual contact. When asked what they would do when these visits occurred, Resident 2 and Resident 3 said they would yell at Resident 1 and call for staff to help. Both residents expressed anger, frustration, and feelings of helplessness about these visits from Resident 1. On 11/27/2025 at 3:42PM, Staff C, ADNS, said they knew that Resident 1 was wandering into rooms and that sometimes things went missing. Staff C denied any knowledge of Resident 2 being urinated on or Resident 3 being sexually assaulted. When asked how care staff would know what interventions to employ with Resident 1, Staff C said by following the Kardex which was created by the care plan. On 11/27/2025 at 4:00PM, Staff C, Social Services Director, was asked if there were any investigations completed for either Resident 2 or Resident 3's accusations. Staff C said they were not aware these incidents had occurred. When asked if Resident 1 had wandering or sexually inappropriate behaviors, Staff C said they had wandering behaviors. When asked to review the documentation on November 2025's Behavior Monitoring form, Staff C said they were surprised Yelling/Screaming and Sexually inappropriate behaviors were noted. Staff C said there were no interventions in place for Resident 1's behaviors. Resident 4Resident 4 admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances. The admission MDS, dated [DATE], documented Resident 4 was moderately cognitively impaired. Resident 4 needed extensive assistance for most activities of daily living.An admission Progress note, dated 9/17/2025, documented yelling out behaviors. A facility Psychiatry note, dated 9/18/2025, documented Resident 4 was heard yelling from the hall, but when approached, was confused, agitated, and distressed. On the following dates and times, Resident 4 was heard yelling and screaming and their door was closed for each observation. 11/13/2025 at 1:15PM and 3:10PM.11/21/2025 at 2:00PM and 4:15PM.11/24/2025 at 1:30PM and 4:15PM.Resident 5 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 5 was cognitively intact and needed moderate assistance for ADLs. On 11/24/2025, Resident 5, whose room was two doors down from Resident 4's, said they heard screaming and yelling about 18 hours a day. Resident 5 said they had migraines from the yelling and had to wear ear plugs to bed every night. Resident 5 said the screaming affected their ability to sleep, rehabilitate, and to enjoy any quality of life. When asked how the staff responded to the yelling, Resident 5 said they didn't seem to know what to do. On 11/24/2025 at 1:56PM, Staff D, Certified Nursing Assistant, said they document behaviors on the Behavioral Monitoring form but there wasn't any place to document interventions. When asked how they would know what interventions to try, Staff D said they would look at the Kardex. Staff D said the Kardex for Resident 4 did not provide guidance for personal or psychosocial care. Staff D said they keep Resident 4's door closed due to other residents complaining. Review of Resident 4's Behavior Monitoring form from 11/11/2025 to 11/24/2025 documented 12 days of Yelling/Screaming, three days of Kicking/Hitting, six days of Grabbing, and nine days of Abusive LanguageReview of Resident 4's care plan, dated 9/26/2025, showed interventions for antidepressant and antipsychotic medications but did not address any of the behaviors being documented by the CNAs, or how to manage them. On 11/25/2025 at 4:30PM, Staff A, Administrator, said the care plans should be person centered and be specific to each resident. Staff A said Resident 1 and Resident 4 did not have adequate interventions in place for their behaviors. Reference WAC 388-97-1040(1)(a)-(c)

.Based on interview and record review, the facility failed to ensure scheduled care and services for 2 of 3 residents (Resident 1 and Resident 2) reviewed for quality of care. This failure placed the residents at risk for decline in hygiene, unidentified weight changes, and diminished feelings of well-being.Findings included.Resident 6Resident 6 admitted to the facility on [DATE] with diagnoses to include a fractured femur (leg bone) and legal blindness. The 5-day Minimum Date Set (MDS), an assessment tool, dated 9/02/2025, showed Resident 6 was moderately cognitively impaired. Resident 6 needed extensive assistance for Activities of Daily Living (ADLs). Review of Resident 6's orders, dated 8/30/2025, showed weights were to be obtained weekly for four weeks. No weight was recorded until 9/12/2025 and was documented as172 pounds. One more weight was recorded on 10/03/2025 and was documented as 162 pounds, a loss of 10 pounds. Resident 6's care plan, dated 10/01/2025, two days before they discharged , did not address any care needs. There were no directions for staff in regard to bathing, obtaining weights, or what to do about refusals of care. The care plan showed Resident 6 had a nutritional risk due to co-morbidities (presence of two or more diseases or medial conditions).On 11/24/2025 at 4:30PM, documents were requested from Staff A, Administrator, for showers/bathing received by Resident 6 during their stay at the facility. No documents were provided.Resident 7Resident 7 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 7 was cognitively intact. Resident 7 needed extensive assistance with ADLs. Resident 7's care plan, dated 10/23/2025, showed they were to receive a bath twice weekly and as needed. A sponge bath was to be given when a full bath or shower could not be tolerated. The care plan did not have directions for staff about refusals. Review of the Bathing Task form, a tool used by Certified Nursing Assistants (CNAs) to document, showed the following:On 11/23/2025 and 11/06/2025, not applicable was marked.On 11/10/2025, 11/13/2025, and 11/20/2025, refused was marked.On 11/23/2025 a shower was given.Review of Resident 7's orders, dated 10/24/2025, showed weights were to be obtained weekly for four weeks. A weight of 129 pounds (lbs) was obtained on 10/23/2025, 126.6 lbs obtained on 11/05/2025, and 126.5 lbs obtained on 11/07/2025. No other weights were documented. On 11/21/2025 at 4:10PM, Staff B, Licensed Practical Nurse, Unit Manager, was asked what the expectation was for obtaining weights after admission. They said weights should be obtained on the date of admission and weekly times four weeks. When asked if the wheelchair scale on B hall was functioning, Staff B said they didn't know. Staff B said they had heard it wasn't working a while ago but that would be a question for maintenance. Maintenance staff were not available for questioning. On 11/24/2025 at 4:30PM, Staff A, Administrator, said weights should be obtained weekly as ordered. Staff A said they didn't know the wheelchair scale was not functioning. Staff A said showers/baths should be offered at least twice per week and as the resident requests. Staff A said they did not know why not applicable would ever be marked for showers/baths. Staff A said care plans should reflect personalized care needs, including interventions for refusal of care. Reference WAC 388-97-1060(1)-(3)

Based on interview and record review, the facility failed to provide consistent specialized services for 1 of 3 residents (Resident 1) reviewed for rehabilitation therapies. This failure placed residents at risk for delayed maximum function and a diminished quality of life. Findings included.Resident 6 was admitted to the facility on [DATE] with diagnoses to include a fractured femur (leg bone) and legal blindness. The 5-day Minimum Date Set (MDS), an assessment tool, dated 9/02/2025, showed Resident 6 was moderately cognitively impaired. Resident 6 needed extensive assistance for Activities of Daily Living (ADLs). Review of the Occupational Therapy (OT) and Physical Therapy (PT) care plans and orders showed Resident 6 was to receive services five times per week for four weeks for each therapy. The services start date was 9/1/2025 and ended on 9/29/2025, the certification period. Review of the OT progress notes showed Resident 6 received a total of nine visits from OT during the certification period, 11 visits short according to the care plan.Review of the PT progress notes showed Resident 6 received a total of 14 visits during the certification period, six visits short according to the care plan.Resident 6 was served a notice that insurance would no longer be covered on 9/18/2025 and was discharged on 9/20/2025. On 11/25/2025, Staff A, Administrator, said all residents should receive specialized services according to their care plan.Reference WAC 388-97-1280(1)(a)(b)(4)

.Based on interview and record review, the facility failed to assess and monitor identified wound(s), perform ordered treatment(s), identify risk factors for skin breakdown, develop and implement interventions, and ensure routine skin check were conducted for 1 of 2 residents (Resident 8) reviewed for non-pressure skin conditions. Resident 8 experienced harm when their abdominal wound increased in size/worsened. These failures placed other residents that required would care at risk for altered wound healing, avoidable wound decline, delayed identification and treatment of newly developed wounds, pain, infection and a diminished quality of life. Findings included. Resident 8 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set showed the resident was cognitively intact, had diagnoses of peripheral vascular disease (PVD, a slow and progressive disorder of the circulatory system, characterized by narrowing, blockage, or spasms in blood vessels or arteries, which can lead to reduced blood flow to the limbs causing pain and/or ulceration) and diabetes, was free of pressure, diabetic, arterial or venous stasis ulcers, and had a surgical wound.Review of a hospital wound note, dated 08/29/2025, documented Resident 8 had a dehisced surgical wound (separation of wound edges along the suture line resulting in the wound re-opening) to the midline abdomen, that measured 9.8 centimeter (cm) x 2.8 cm x 0.5 cm, with a red granulated wound bed, serosanguinous drainage (a mixture of thin yellow serous fluid and blood, often appears pink in color) and a wound area of 27.44 cm2.Resident 8's admission nursing assessment, dated 08/30/2025, showed they admitted with an abdominal wound and amputated toes of the right foot. The assessment did not include wound measurements or wound characteristics (e.g. wound bed tissue type, type/amount of drainage etc.) No other skin issues were identified. An admission Summary nurses' note, dated 08/30/2025 at 4:27 PM, documented the resident had a wound vac (negative pressure wound therapy, uses negative pressure or suction to increase blood flow, oxygen delivery and nutrient supply to the wound area and removes drainage and debris, to decrease risk of infection and promote faster wound healing) in place to the midline abdomen, and noted all toes on the right foot were amputated.The hospital transfer orders/paperwork, dated 08/30/2025, showed a wound vac at 125 mm/Hg (millimeters of mercury) continuous suction, was placed by hospital staff prior to transfer. Dressing changes were to be completed twice a week and as needed.Review of the comprehensive care plan, dated 08/30/2025, did not show development of goals and interventions that directed care of the abdominal wound, use of the wound vac , or frequency of skin assessments. No interventions were identified that would minimize the risk for further breakdown or wound decline. Review of the August and September 2025 Treatment Administration Records (TARs) showed there was no documentation from 8/30/2025 until 09/12/2025 related to wound care for Resident 8.Resident 8's electronic medical record (EMR) showed no documentation the wound care and wound vac orders had been transcribed. There was no documentation that the abdominal wound had been assessed, measured and monitored or that any skin checks or wound assessment were performed from admission until 9/12/2025 for Resident 8's right calf wound or until 09/23/2025 for Resident 8's abdominal wound.Review of a nurses' note, dated 09/12/2025 at 1:37 AM, documented Resident 8 had a new 3 centimeter (cm) x 3 cm x 0.5 cm ulcer to the right posterior calf. The wound bed was 75percent slough (non-viable tissue consisting of dead yells, proteins and debris), with serosanguinous drainage. The resident reported the area was painful to touch. Staff notified the provider, obtained a treatment order and the resident was referred to the wound clinic for evaluation.Review of the September TAR, after it was initiated 09/12/2025, showed an order to treat Resident 8's right lateral LE wound (not present on admission). The TAR did not document the resident's abdominal wound, use of the wound vac and the need for twice weekly dressing changes. still failed to identify the residents' abdominal wound, use of a wound vac and need for twice weekly dressing changes. A wound consult note, dated 09/16/2025, showed the resident had a 5.5-centimeter (cm) x 2.4 cm x 0.2 cm, non-pressure wound to the right lateral LE. The wound required mechanical debridement. The provider documented devitalized (dead) tissue was removed to the level of healthy bleeding tissue which included biofilm (a thin, slimy film of bacteria that can adhere to the surface of a wound). The debridement extended down to the level of subcutaneous tissue (bottom layer of skin containing fat tissue, blood vessels, nerves and other components.) Resident 8's abdominal wound, use of wound vac, was not assessed or addressed in the wound care.A wound consult note, dated 09/23/2025 (24 days after admission to the facility), showed Resident 8's midline abdominal wound was assessed to be 9.02 cm x 4.09 cm x 0.3 cm, and had a wound area of 36.89 cm2. This showed in the 24 days since admission, Resident 8's abdominal wound had increased in area by 9.45 cm2 The wound consult practitioner documented the wound had been present less than 30 days, the wound bed was 100% granulated with sanguineous exudate (drainage that mostly contains fresh, bright-red blood) and showed no clinical signs of signs of infection. The wound clinician recommended staff cleanse the wound with wound cleanser, pat dry with a gauze sponge, apply Hydrofera Blue (dressing used to keep wound bed moist and prevent bacteria) to the wound bed, skin prep to peri wound, and cover with a foam dressing secured by tape three times a week and as needed. This showed in the 24 days since admission, Resident 8's abdominal wound had increased in area by 9.45 cm2.On 10/16/2025 at 4:38 PM, Staff C, Charge Nurse, said staff had found an ulcer on Resident 8's right LE and the resident was referred to wound care for the LE ulcer. Staff C explained that Resident 8's abdominal wound was not assessed because they had not been informed the resident had an abdominal wound yet. When asked if they could find any documentation to show staff assessed, monitored or performed dressing changes or otherwise provided care to the abdominal wound between the resident's admission to the facility and the wound consult on 9/23, Staff C said, no.On 10/30/2025 at 2:34 PM, when asked if wound care services were provided (e.g. treatment, dressing changes, assessments, monitoring etc.) during the first 16 days for Resident 8's LE ulcer or first 24 days for Resident 8's abdominal wound, Staff B, Director of Nursing, said, We found the same thing that you did. When asked if Resident 8's right LE ulcer should have been identified by staff before it had sloughed and required mechanical debridement, given they required maximal assistance from staff with lower body dressing, Staff B said, yes.Reference WAC 388-97-1060 (1).

Based on observation, interview, and record review, the facility failed to ensure menus were followed and modified diet textures were prepared in accordance with established guidelines and physicians' orders for 2 of 2 residents (Residents 35 & 125) reviewed for diet textures who were at serious risk for aspiration (inhalation of foods/fluids into the lungs), pneumonia, and choking. The facility's lack of an effective system to ensure residents at risk received the correct food texture represented a potential serious outcome including death and constituted an Immediate Jeopardy (IJ). Additionally, the facility failed to make a reasonable effort to honor food preferences for 1 of 7 residents (Resident 61) reviewed for food quality, placing the residents at risk for decreased intake, weight loss and a diminished quality of life. On 06/14/2024 at 1:08 PM, the facility was notified of an IJ at CFR S483.60 F803, Menus meet Resident Needs/Prep in Advance/Followed, related to the facility's failure to follow the menu for residents on pureed diets, and the residents were served and assisted with eating the wrong diet texture. The facility removed the immediacy on 06/17/2024 with onsite verification from surveyors by conducting interviews of staff and reviewing the updated puree recipes. Findings included . <Resident 35> Resident 35 admitted to the facility on [DATE]. Review of the 04/03/2024 Minimum Data Set (MDS, an assessment tool), showed the resident had severe cognitive impairment, was on a mechanically altered diet, and required substantial to maximal assistance with eating. Review of a diet order, dated 04/04/2024, showed Resident 35 was on a pureed diet (food that has been blended, mixed, or processed into a smooth and uniform texture) Review of a progress note, dated 05/13/2024, showed Resident 35 had an episode of choking at breakfast, requiring staff to intervene and perform the Heimlich maneuver to clear the airway. Review of a swallowing problem care plan (CP), dated 05/21/2024, showed Resident 35 had intermittent episodes of coughing and choking with meals and staff were directed to alternate small bites and sips, check the resident's mouth after meals for pocketed food and debris, keep the head of bed elevated 45 degrees during meals and for at least thirty minutes afterwards, instruct the resident to eat slowly, and to chew each bite thoroughly and provide the diet as ordered. Review of a progress note, dated 05/21/2024, showed the nurse was called to Resident 35's room due to the resident coughing and having difficulty swallowing during the lunch meal. The nurse alternated providing small bites of food followed by small sips of fluid, but the resident's coughing with attempts to swallow persisted. On 06/14/2024 at 8:19 AM, Staff V, Certified Nursing Assistant (CNA), delivered Resident 35's breakfast tray. Staff V elevated the resident's head of bed to approximately 60 degrees, sat down and began assisting the resident with their meal. At 8:36 AM, Resident 35's breakfast tray was observed, and the tray card identified the resident's diet as dysphagia [difficulty swallowing] pureed. When asked to describe the foods and textures on the tray, Staff V, who was assisting Resident 35 to eat, said there were regular textured scrambled eggs, chopped sausage, and pureed pancakes. <Resident 125> Resident 125 admitted to the facility on [DATE]. Review of the 06/18/2024 admission MDS showed the resident had severe cognitive impairment, received hospice services, and required an altered texture diet. Review of the physicians' orders, (date order was written unknown) but order was current on 06/14/2024, showed Resident 125 was on a regular, pureed diet, with thin liquids. On 06/14/2024 at 8:34 AM, Staff Q, CNA, was observed delivering Resident 125's breakfast tray. Staff W, CNA, who was already in the resident's room began setting up the meal as Staff Q exited the room. At 8:36 AM, Resident 125's breakfast tray was observed. The tray card identified the resident's diet as dysphagia pureed. When asked to describe the foods and textures on the tray, Staff W, who was assisting the resident with the meal, identified regular texture scrambled eggs, chopped sausage and pureed pancakes. When asked what diet was on the resident's tray card, Staff W stated, pureed. On 06/14/2024 at 8:50 AM, Staff Z, Regional Nurse Consultant (RNC), confirmed Resident 35's tray card showed the resident was on a dysphagia pureed diet. When asked to describe the food and associated texture Staff Z, RNC, said there was chopped sausage and pureed pancakes. No scrambled eggs remained on the tray at that time. Resident 125's tray had already been removed from the floor. On 06/14/2024 at 9:59 AM, Staff D, Head Cook/ Dietary Manager in Training, indicated residents' meal trays were triple checked for accuracy prior to being delivered to ensure the diet type and texture were correct. Staff D explained the triple check process as follows: First check- the cook read the tray card, identify the diet type and texture, and plated the meal; Second check- the tray then went to the dietary aide to add the cold dishes and beverages. The dietary aide would review the tray card, validate that what was on the tray was correct, and then place the tray in the tray cart for delivery; Third check- when direct care staff removed a meal tray from the tray cart, they would check the tray card against the diet type and texture present on the tray and validate accuracy prior to delivering it to the resident. At 10:03 AM, when asked how regular scrambled eggs and chopped sausage made it through the triple check and were served to Resident 35 and 125 without staff identifying the wrong texture diet was provided, Staff D said they were scheduled to train the new cook on how to read tray cards that day, 06/14/2024, but the dietary aide had called off, so they could not provide the level of oversight of the new cook that they normally did because they had to work as the dietary aide, preparing the cold dishes and beverages for the meal. Staff D said Staff X, Certified Dietary Manager (CDM), a CDM from another facility who was training Staff D for the Dietary Manager position, hadn't yet arrived for the day. Staff D confirmed staffing and their inability to provide oversight of the new cook contributed to the diet texture errors. At 11:41 AM, when asked if dietary staff had access to and utilized a recipe when preparing pureed diets, Staff D stated, no. On 06/17/2024 at 1:53 PM, Staff N, Regional Registered Dietitian, said that kitchen staff were to follow recipes when making pureed food. Staff N said recipes for pureed meals were reviewed and updated and dietary staff had been educated in their use. <Resident 61> Resident 61 admitted to the facility on [DATE]. Review of the 01/25/2024 admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had diagnoses of stroke and malnutrition and had significant weight loss of greater than 5% in a month or 10% in six months. On 06/11/2024 at 2:23 PM, Resident 61 said they ate well at breakfast but had not had lunch and dinner because the facility primarily served vegetables and some form of pasta for those meals. Resident 61 said they had informed Staff H, Social Services Director (SSD), and multiple other staff members on multiple occasions about his dislike of pasta and vegetables and had completed a food preference form where they listed their likes and dislikes. The resident indicated despite the above, the kitchen continued to frequently serve pasta and vegetables for lunch and dinner. Review of the electronic health record (EHR) showed a Nursing to Nutrition Referral Communication form was completed on 02/12/2024 for food preferences. Review of Resident 61's progress notes showed the following documentation: 01/29/2024- social services note Resident not eating due to food dislikes. 02/05/2024- social services note Resident not eating due to food dislikes. 02/12/2024- social services note documented, a dietary referral is required for the following reasons: Food preferences. 02/19/2024- social services note documented Resident 61was not eating due to food dislikes. 02/26/2024- social services note documented Resident 61was not eating due to food dislikes. 03/28/2024- nurse's note documented Resident 61 said they believed their appetite was fine. They were not eating because they didn't care for the food the facility was provided. 04/14/2024- nurse's note documented Resident 61 was on alert for weight loss and indicated it was due to not liking the food the facility provided. Review of the EHR showed Staff H, SSD, completed a Food Preference Record on 06/07/2024, which identified Resident 61 did not want pasta for lunch or dinner, did not want applesauce or broccoli and little rice. On 06/17/2024 at 11:59 AM, Staff H, SSD, said they spoke directly to Staff Y, former Dietary Service Manager, about Resident 61's food preferences at the end of May 2024, and Staff Y was supposed to have input them into the dietary computer. Staff H indicated when they followed up one to two weeks later, the resident's preferences still had not been input into the dietary system. Staff H said they completed a second Food Preference Record on 06/07/2024, again delivering it directly to Staff Y, the former DSM. Staff H reported a CNA, whose name they did not recall, had also informed Staff Y of Resident 61's food preferences, but Staff Y failed to enter them into the dietary computer. Review of the tray card on 06/14/2024 and 06/17/2024, showed Resident 61's likes/dislikes still had not been input into the dietary computer, thus were not reflected on the tray card. On 06/17/2024 at 2:27 PM, when asked if Resident 61's food preferences had been input into the dietary computer Staff N, Regional RD, stated, No. Refer to F802. Reference WAC 388-97-1100(1) 50488

Based on observation, interview, and record review, the facility failed to provide necessary care and services to treat and prevent worsening or development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for 4 of 6 sampled residents (Resident 1, 2, 3 and 4), reviewed for pressure ulcers. Resident 1 experienced harm when they had deterioration of a pressure ulcer to the right buttock that required surgical treatment and the development of three additional pressure ulcers. These failures placed residents at risk for pressure ulcer development, deterioration of existing pressure ulcers, pain, and a decreased quality of life. Findings included . <RESIDENT 1> Resident 1 was admitted on [DATE] with diagnoses including incomplete paraplegia (partial loss of sensation and control of body) and spinal fusion surgery (two or more bones in the spine permanently joined). The Minimum Data Set (MDS), an assessment tool, dated 01/27/2024, showed Resident 1 was dependent on staff to roll left and right in bed, sit on the side of the bed and transfer out of bed. The MDS showed Resident 1 was occasionally incontinent of urine, always incontinent of bowel and dependent on staff for all toileting care needs. Resident 1's care plan, dated 01/23/2024, and reviewed with family on 01/24/2024, showed Resident 1 had a potential for a pressure ulcer and showed the following interventions: educate resident/family/caregivers as to cause of skin breakdown including transfer/positioning requirements, frequent repositioning, monitor/document/report to MD change in skin status, needs pressure relieving mattress, notify nurse immediately of any new areas of skin breakdown. Resident 1's Admission Assessment, dated 01/20/2024, showed a left buttock 2.0 centimeter (cm) by 2.0 cm stage 1 wound (as an observable pressure related alteration of intact skin with persistent redness and/or changes in the skin's temperature or consistency as compared to the adjacent area of the body). Resident 1's Skin Assessment, dated 01/22/2024, showed a drawing of the back of a body with a circle on the lower back and documentation of, redness, barrier cream with peri care. The assessment also showed a circle on the right buttock with documentation of 10.0 centimeters (cm) x 6.0 cm x 0.05 cm. Review of Resident 1's physician orders showed an order, dated 01/22/2024, for wound care to the right ischial tuberosity (bone at the bottom of the pelvis), Stage 3 (pressure ulcer with full thickness loss of skin exposing subcutaneous tissue), size 10 cm x 6.0 cm x 0.0 cm, clean with normal saline and pat dry with gauze and cover with dry dressing until resolved. The order was discontinued on 01/22/2024 and another order was written for wound care to the right ischial tuberosity, size 10 cm x 6.0 cm x 0.0 cm, clean with normal saline and pat dry with gauze and cover with dry dressing until resolved (the stage 3 was removed from the order). Resident 1's physician order, dated 01/22/2024, showed redness to sacrum (bony structure at base of spine) and barrier cream with every peri care. Resident 1's Interdisciplinary Team (IDT) weekly skilled review, dated 01/22/2024, showed therapy evaluated and treated Resident 1 and said the resident needed a bariatric air bed and had sternal and cervical precautions (restrictions of certain movements to prevent disruption of healing). Resident 1's Wound Specialist's Progress report, dated 01/23/2024, showed Resident 1 was seen on 01/23/2024 for an initial evaluation and had no open wounds at the time of the assessment and no follow up was required. Resident 1's Progress Note-MD History and Physical, dated 01/25/2024, showed the assessment and plan for Resident 1 was assistance with all activities of daily living and meticulous attention to vulnerable skin areas. Resident 1's Admission MDS, dated [DATE], showed Resident 1 had one Stage 3 pressure ulcer that was present on admission and was at risk for a pressure ulcer. Resident 1's Total Body Skin Evaluation, dated 01/30/2024, showed a skin concern on the left buttock with tx [treatment] in progress. Resident 1's Total Body Skin Evaluation, dated 02/03/2024, showed a skin concern in the groin with redness to scrotum. On 02/20/2024 at 9:58 AM, Collateral Contact 1 (CC1), said they were at the facility with Collateral Contact 2 (CC2) daily for hours at a time to visit Resident 1. CC1 said they made several complaints to the management of the facility regarding staff not providing care to Resident 1. CC1 said there were times Resident 1 was left lying in their urine and feces, not repositioned and was in pain when staff moved them. CC1 said they were told that Resident 1 had a red area on their bottom, but it was superficial, and the wound team would not be following them because it was not necessary. CC1 said they do not remember staff coming in to reposition and/or provide care to the resident except once. CC1 said they had to request staff provide care and when Resident 1 did not want to be turned, because it was uncomfortable, the staff would just leave. CC1 said in the initial care conference meeting, they had requested an air mattress because they knew it was difficult to turn Resident 1 because they were in pain from spinal surgery and their clinical condition, but the staff did not place the air mattress until a few days before Resident 1 went to the hospital on 02/17/2024. CC1 said they were unaware the resident had wounds until the nursing assistants asked if they wanted to see them on 02/11/2024. CC1 said they were there for hours a day and had no idea the resident had the bed sores. CC1 said Resident 1 was now in the hospital with four bedsores and would probably need surgery. On 02/21/2024 at 9:40 AM, CC2, said they were at the facility daily from morning until late afternoon with Resident 1. CC2 said Resident 1 had spinal surgery and they did not like to turn because it was uncomfortable, and the staff were not careful when turning and providing care. CC2 said the therapists knew how to move Resident 1 so they participated in therapy. CC2 said the staff were not cleaning Resident 1 and they had to sit in a dirty brief. CC2 said they were told that Resident 1 had only superficial wounds and was not a candidate for wound care consultant. On 02/27/2024 at 10:23 AM, Staff E, Assistant Director of Nursing, said they completed the skin assessment on 01/22/2024 and Resident 1's buttock looked like a deep tissue injury. When asked why they had not described the wound in the assessment, Staff E said they were instructed to only document measurements for wounds on admission and/or when wounds were found and then wait for the wound consultants to provide wound assessment and documentation. Staff E said they had obtained a physician order for a right ischial tuberosity stage 3 on 01/22/2024 but had discontinued the order and obtained a new order the same day without the stage 3 in the order because they were told not to stage the wound. Staff E said on 02/12/2024, Resident 1's family member had requested Staff E to look at the wounds on the resident's bottom. Staff E said they measured the wounds and documented the measurements, and the resident was scheduled to be seen by the wound specialist the following day. Staff E said they were not aware the wounds had progressed since admission. Staff E said the resident was resistive to turning since admission. When asked why the resident was refusing to turn, Staff E said the family had indicated the resident had recent spinal surgery and they were uncomfortable. Staff E said they had told the care team to make sure to reposition the resident and they thought the staff were doing this because they had seen the resident in a chair a few times. When asked if there were any other interventions the staff put in place to prevent skin breakdown due to the resident's reluctance to turn/reposition, Staff E said no. Staff E said due to Resident 1's skin condition on admission and reluctance to reposition, the resident should have had a low air loss mattress and there should have been a wound nurse to monitor the wounds. Review of Resident 1's IDT meeting notes dated 01/22/2024, 01/29/2024, and 02/05/2024 showed no documentation of Resident 1's skin and/or resistance/refusal of care concerns. Review of Resident 1's bed mobility task record, dated 01/23/2024 through 02/13/2024, showed no documentation Resident 1 had refused bed mobility. Resident 1's Wound Specialist Progress report, dated 02/13/2024, showed an unstageable pressure ulcer (full-thickness pressure injuries in which the base of the wound is covered with dead tissue) on the right lateral buttock measured 6.49 cm x 7.4 cm x 0.01 cm, an unstageable pressure ulcer on the sacrum measured 2.11 cm x 2.25 cm x 0.01 cm, an unstageable pressure ulcer on the left medial (middle) buttock measured 3.13 cm x 2.12 cm x 0.01 cm and an unstageable pressure ulcer on the left lateral (relating to the side) buttock measured 1.79 cm x 2.33 cm x 0.01 cm. Review of hospital records, dated 02/21/2024, showed Resident 1 was scheduled for surgical debridement of their right buttock wound on 02/21/2024. On 02/27/2024 at 11:12 AM, Staff D, Director of Nursing, said stage 1 and stage 3 pressure ulcers were considered an active wound. Staff D said that the wound specialists had assessed Resident 1 on 01/23/2024 and had determined the resident had no open wounds and did not require follow up. Staff D said they did not know why the MDS indicated the resident had a stage 3 pressure ulcer on admission because the MDS nurse worked remotely and the assessment by the wound specialists showed no wounds on 01/23/2024. Staff D said the staff encouraged the resident to turn and reposition. When asked if the staff did anything else to avoid Resident 1 from getting pressure ulcers, Staff D said no. <RESIDENT 2> Resident 2 was admitted on [DATE]. The admission MDS, dated [DATE], showed the resident was cognitively intact, and required substantial/maximal assistance of staff to roll left to right in bed and/or transfer out of bed. The MDS showed the resident was at risk of a pressure ulcer and did not have a current pressure ulcer. On 02/20/2024 at 11:58 AM, Resident 2 said the staff were supposed to turn them, but they did not change them regularly and made the resident stay in bed. Resident 2 said their bottom was raw with sores and hurt. Resident 2's care plan, dated 01/12/2024, and reviewed with the family and resident on 01/18/2024, showed the resident with a skin concern, required extensive assistance with bed mobility and education to the resident/family/caregivers as to the cause of skin breakdown to include frequent repositioning. Resident 2's admission assessment, dated 01/12/2024, showed excoriation (irritation) 7 x 8 on the coccyx. Resident 2's skin assessment, dated 01/12/2024, showed a drawing of a body and an X in the middle of the buttocks with excoriation/open area 2x3 documented. Resident 2's Total Body Skin Evaluation, dated 01/15/2024, showed excoriation 7 x 8 on the sacrum. Resident 2's behavior symptom, toilet use, and bed mobility task record, dated 01/12/2024 through 01/19/2024, showed no instances of rejection of care and/or refusal of care. Review of Resident 2's progress notes, dated 01/12/2024 through 01/19/2024, showed no documentation of the resident refusing and/or resistive to the plan of care. Resident 2's Care Conference note, dated 01/18/2024, showed no documentation of the resident refusing and/or resistive to the plan of care. Resident 2's Wound Specialist progress report, dated 01/19/2024, showed a stage 3 pressure ulcer to the right lateral sacrum measuring 1.15 cm in width x 2.39 cm in length x 0.2 cm in depth. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnosis of dementia. Resident 3's care plan, dated 10/25/2023, showed Resident 3 had a pressure ulcer, required extensive assistance with bed mobility, toileting and required frequent repositioning. On 02/08/2024 at 4:04 PM, CC3 said they placed a video camera in Resident 3's room because they were concerned about care at the facility, and they could not be present all the time. CC3 said the resident was not being changed and/or turned frequently and Resident 3 had a severe wound on their backside. Review of the facility's investigation, dated 01/26/2024, showed the facility investigated an allegation made by CC3 that Resident 3 had not received care all night based on surveillance obtained from a camera placed in Resident 3's room by CC3. The facility's investigation stated Resident 3 was not provided incontinence care and/or repositioning for an entire shift and the staff had not followed the plan of care. <RESIDENT 4> Resident 4 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 4 was cognitively impaired, dependent on staff for toileting and transfers, frequently incontinent of urine and at risk for a pressure ulcer. Resident 4's skin care plan, dated 06/13/2020, showed the resident had a potential for a pressure ulcer related to immobility and education to the resident/family/caregivers as to the cause of skin breakdown to include frequent repositioning. Resident 4's Kardex (care instructions for staff), showed Resident 4 was to be checked for incontinence upon rising, before and after meals and before bed. On 02/07/2024 at 11:03 AM, 11:26 AM, 12:00 PM, 12:33 PM, 12:49 PM, 1:19 PM, 1:28 PM, 1:45 PM, 2:10 PM and 3:13 PM Resident 4 was observed sitting in the wheelchair. At 3:43 PM, Staff F, Certified Nursing Assistant (CNA), said they were assigned to Resident 4 and provided care to Resident 4 after breakfast at approximately 9:00 AM. When asked if they had provided care since 9:00 AM, Staff F said they had not provided care since 9:00 AM and Resident 4 had been up in their wheelchair since 9:00 AM, but they had provided the resident with a sweater. On 02/20/2024 at 9:49 AM, 9:57 AM, 10:19 AM, 10:50 AM, 11:08 AM, 12:00 PM, 12:18 PM, 12:47 PM and 1:00 PM Resident 4 was observed sitting in their wheelchair. At 1:28 PM the resident was observed leaving the facility on an outing. At 2:01 PM, Staff G, CNA, said they were assigned to care for Resident 4 and had provided care to Resident 4 at approximately 7:00 AM and placed the resident in the wheelchair for breakfast. When asked if they had provided care since 7:00 AM, Staff G said the resident had not wanted care after breakfast and they were busy and if the resident did not ask and/or complain they sometimes forgot to go back and check again. Staff G said the resident should have received care at least twice during their shift and that had not happened. <FINAL INTERVIEWS> On 02/27/2024 at 11:55 AM, Staff D, Director of Nursing, said they expected residents' skin to be evaluated weekly and wounds to be monitored. Staff D said the skin evaluations for Resident 1 and Resident 2 had not met their expectation and interventions had not been put in place to avoid pressure ulcers. Staff D said the staff had not followed the plan of care for Resident 3 and Resident 4 to treat and/or prevent further pressure ulcers. On 02/27/2024 at 12:35 PM, Staff A, Administrator, said the care provided to Resident 1, 2, and 3 was not what the facility wanted to provide, and they would be putting something in place to prevent it from occurring again. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1), reviewed for medication errors, was free from a significant medication error. Failure to ensure medications were administered to the right resident resulted in harm to Resident 1 when their blood pressure dropped dangerously low and who required transportation to the hospital to receive medical intervention. Findings included . According to the facility's procedure on Medication Administration (undated), provided to surveyor on 09/15/2022, the licensed nurse will check the following to administer medication: right medication, right dose, right dosage form, right route, right resident, right time. Resident 1 admitted to the facility on [DATE] with multiple diagnoses, including cancer, [CONDITION(S)] and high blood pressure, for medical management and rehabilitation. Resident 2 admitted to the facility on [DATE], with multiple diagnoses, including diabetes with complications, [CONDITION(S)], high blood pressure, and peripheral vascular disease, a blood circulation disorder. Review of Resident 1 and Resident 2's Medication Administration Records for August 2022 showed Resident 1 was ordered to receive 50 mg [MEDICATION(S)] (used to treat high blood pressure), and received Resident 2's ordered dose of 100 mg of [MEDICATION(S)]. In addition, Resident 1 received two other medications used to treat high blood pressure, Losartan and [MEDICATION(S)], as well as [MEDICATION(S)], a diuretic (water pill), also used to treat high blood pressure. Resident 1 did not have blood thinners or anticoagulants ordered, and received Resident 2's doses of [MEDICATION(S)], an anticoagulant (blood thinner), and [MEDICATION(S)], an antiplatelet medication used to prevent blood clots. Resident 1 did not have orders for insulin (a blood sugar lowering medication) and received an injection of [MEDICATION(S)] insulin, a long-acting insulin that works for over 24 hours. A late entry nursing note, dated 08/25/2022 at 12:30 PM, documented Resident 1 was given medication intended for another resident. The note stated the mistake was realized almost immediately, the provider was informed and assessed the resident and gave orders to monitor the resident's blood pressure and to report if the systolic (upper number) dropped below 90, or the diastolic (bottom number) dropped below 50, and to monitor the resident for excessive bleeding. A nursing note dated 08/25/2022 at 1:19 PM, documented Resident 1's blood pressure was low at 86/53. On 08/26/2022 2:58 PM, a Nursing Home to Hospital Transfer Form documented Resident 1 was being transferred to the hospital with an abnormally low blood pressure of 74/34. On 08/26/2022 at 4:22 PM, a hospital emergency department provider documented Resident 1 received another resident's medications the day before at noon and had also received his own morning medications. The provider documented Resident 1 was on 50 mg of [MEDICATION(S)] daily and was given an additional 100 mg the day before (08/25/2022). The provider documented that was likely the primary reason Resident 1 had [CONDITION(S)] (low blood pressure), and he was also given other blood pressure medications and anticoagulants. The hospital Discharge Summary, dated 09/07/2022 at 7:07 AM, documented Resident 1 went to the facility for one day and presented back with [CONDITION(S)] after receiving medications intended for another patient at the facility. The provider documented that Resident 1's hospital stay was complicated by [CONDITION(S)] requiring intensive care unit admission and the use of pressors (intravenous medications used to maintain blood pressure). On 08/29/2022 at 4:35 PM, Staff C, a Registered Nurse, said both Resident 1 and Resident 2 had recently admitted to the facility; Resident 2 admitted on [DATE] and Resident 1 admitted on [DATE]. Staff C said she did not know either of the residents. Staff C said she made a mistake and gave the wrong medications to Resident 1. Staff C said she realized the error as soon as she got back to the medication cart. On 08/30/2022 the facility incident report conclusion documented Staff C administered Resident 2's ordered medication to Resident 1 that morning without correctly identifying the right resident. Included in the medications were four medications to treat high blood pressure, two anticoagulants, an injection of long-acting insulin, as well as five other medications. The facility documented the failure to identify the correct resident prior to medication administration caused a physical decline in the resident's status, resulting in hospitalization . On 09/15/2022 at 2:39 PM, when asked, Staff B, a Registered Nurse and Resident Care Manager, said to administer medications safely, nursing should always follow the six rights of medication administration. On 09/15/2022 at 5:27 PM, Staff A, the interim facility administrator, said they were aware the medication error had occurred and it had been addressed. Reference WAC 388-97-1060(3)(k)(iii) .

Based on observation, interview, and record review, the facility failed to implement interventions including assistive devices consistent with a resident's needs, assessments, and care plan for one of three residents (Resident 1), reviewed for accidents. This failure caused Resident 1 to have an avoidable fall out of bed that resulted in harm, including left hand and foot fractures, cuts and bruising to the face, foot and leg, and a concussion that caused pain, suffering and loss of confidence in facility administration. Findings included . Resident 1 was admitted to the facility originally on 04/09/2016, and was readmitted on [DATE] with multiple diagnoses, including history of a stroke, muscle weakness, and absence of a lower extremity. The Minimum Data Set, an assessment tool, dated 06/10/2022, documented Resident 1 was alert and oriented, and required extensive assistance of staff for activities of daily living, including bed mobility. A Physical Therapy Discharge Summary, dated 06/25/2021, documented Resident 1 used bedrails on the right and the left, as well as a trapeze, for bed mobility. A Safety Device Data Collection, Evaluation and Information, dated 12/13/2021, documented the use of an air mattress with bolsters. The safety device was identified to help Resident 1 improve self-function with skin prevention and comfort, and to treat the medical symptom of weakness and absence of a lower extremity. A Safety Device Data Collection, Evaluation and Information, dated 12/13/2021, documented the use of bilateral mini mobility bars (side rails) to help Resident 1 improve self-function to assist with bed mobility, and to treat the medical symptom of weakness and absence of a lower extremity. Resident 1's care plan, initiated 10/09/2017 and revised 04/15/2021, documented the resident's use of safety devices including an air mattress for pressure relief, bilateral mini mobility bars to allow for independence with repositioning in bed, and a trapeze for bed mobility. The care plan documented use of the safety devices was to be evaluated quarterly. The Nursing Quarterly Evaluation, dated 06/08/2022, Section M, Risk for Mobility/Risk for Falls/Safety, under Safety Devices, documented in a check-box marked yes, that Resident 1 required a safety device (e.g., trapeze, specialty mattress, bed against the wall, high/low bed, mat on floor, mobility bars, etc.). Resident 1's Kardex (a condensed care plan, for use by facility certified nursing assistants), documented use of safety devices, including air mattress with bolsters, bilateral mobility bars, and trapeze while in bed and during transfers. A nursing to therapy communicated note, dated 06/20/2022 at 06:00 AM, documented Resident 1 was showing a possible change in condition in the following areas: Falls. Comments: fall out of bed with injury. A 06/21/2022 provider encounter note documented, Follow-up after fall from bed onto face 06/20/2022. The patient is being seen today for injuries from a fall from his bed. The facility made policy changes regarding rail use on beds, so his rails were removed. He fell from his bed and landed on his face. He was sent to the Emergency Department, where he was diagnosed with a facial fracture, wrist fracture and foot fracture. He also had facial lacerations and a skin tear on his hand. Later in the same note the provider documented: will try to reinstitute bed rails for this patient in an effort to prevent another event. The facility's investigation, dated 06/22/2022, concluded: Root cause of this fall was the resident being unable to maintain his grip on the trapeze bar which allowed him to roll of the bed as he was being turned for care. Resident did have mobility bars until recently when the policy was changed to remove them from all beds using air mattresses. A trapeze was then put in place of the mobility bars. A 06/27/2022 nursing note documented Resident 1 was up in wheelchair for a short time today. Has difficulty with thinking clearly while awake. States his tremors are worse. Provider notified. Provider responds that resident 1 suffered a concussion from his recent fall and will have cognitive delay for several weeks. Keep splint on left hand for stability to fractures. A 06/30/2022 provider note documented, 06/20/2022 fall from bed. Concussion, fractures to left hand and wrist, lacerations to right foot. 06/29/2022 still not at baseline. Confusion, unable to feed himself or stay awake. Tremors are worse than before. On 07/06/2022 at 2:05 PM, Resident 1 was observed with a hand and wrist splint in place, healing cut on his nose and facial bruising. Resident 1 said he was not asked about the rails being removed, they just did it. Resident 1 said it was much easier for him to use the side rails. Resident 1 said he held onto the rails when staff provided care to maintain his position. When asked about the rails being removed, Resident 1 said he warned and warned them (facility administration) that someone would be hurt. Resident 1 said when the fall happened, his hand slipped from the trapeze and there was nothing to stop him from falling off the bed and he fell face-first to the floor. When asked what the facility had done to prevent the accident from happening again, Resident 1 said, Not a damn thing. On 07/06/2022 at 3:15 PM, Staff B, an anonymous licensed nurse, said someone at Corporate read something and decided to pull the bed rails off all the beds with air mattresses. Staff B said Resident 1's fall happened about four days after the bed rails were removed. Staff B said, [Resident 1's] fall should never have happened. He was approved for them (the bed rails). You have far more falls than you do entrapments. On 07/06/2022, When asked about resident consent, Staff B said the residents were told the rails were being removed, they were not asked; they did not have a choice. On 07/08/2022 at 11:35 AM, Staff C, an anonymous licensed nurse, said someone at Corporate (facility management) read something and came out with a blanket statement that all the bed rails had to be removed from residents who had air beds. Staff C said Resident 1's fall should never have happened. Staff C said use of the trapeze by itself has been quite ineffective for Resident 1's bed mobility. On 07/08/2022 at 3:40 PM, when asked, Staff A, a Registered Nurse and the Director of Nursing Services, was not able to provide a facility policy on the use of bed rails. When asked, Staff A said there had not been a reassessment of the functional abilities of any residents, including Resident 1, prior to the bed rails being removed from the beds. When asked, Staff A did not believe the medical director had been involved in the decision to remove the bed rails from residents with air mattresses. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to operationalize all components of the infection prevention and control program to maintain a safe and sanitary environment and to prevent transmission and control the spread of COVID, a highly transmissible infectious disease caused by the the [MEDICAL CONDITION]. There were multiple breaches in the infection prevention and control program which included: 1. did not fit test N95 masks (evaluate the seal of the N95, a mask designated for specific use in the prevention or transmission of respiratory infections); 2. did not consistently utilize Personal Protective Equipment (PPE, equipment designed to protect the wearer from injury or the spread of infection or illness, i.e. N95 mask, eye protection, gloves and gowns) in accordance with federal and state regulations; 3. did not properly report cases of COVID-19 to the Complaint Resolution Unit (CRU, a state reporting agency) for 17 of 20 residents (Resident #s 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24) and for three of 36 staff (Staff F, P and Q) reviewed for infection control process; 4. did not properly implement a surveillance system that ensured all staff were screened for COVID-19 prior to being allowed access to resident care areas (tracking and monitoring for infectious diseases), and did not have a system for tracking COVID-19 staff testing, and ensure the infection control data collection tools contained the required information for four of four months (September, October, November and December 2020) reviewed for infection control program. These failures placed all residents and staff at risk for contracting COVID-19 due to improper wear of the N95 mask, inadequate monitoring of the COVID-19 surveillance and infection control programs, lack of reporting of COVID-19 positive cases when identified, and not having a system for tracking recommended staff COVID-19 testing. In addition, these failures increased the likelihood of serious harm and/or death of residents and staff related to increased exposure to COVID-19 during a global pandemic, and constituted an immediate jeopardy situation (IJ). On January 6, 2021, the facility was informed of the (IJ) and on January 8, 2021, the IJ was removed and validated during an on-site visit to the facility on [DATE]. Findings included . Review of the CMS April 02, 2020 guidance titled, COVID-19 Long-Term Care Facility Guidance, showed the following direction: 1) Long-term care facilities should immediately implement symptom screening for all. 2) In accordance with previous CMS guidance, every individual regardless of reason entering a long-term care facility should be asked about COVID-19 symptoms and they must also have their temperature checked. 3) Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents. Review of the facility's document titled, CORNERSTONE COVID-19 INTERIM INFECTION PREVENTION AND CONTROL GUIDANCE . policy dated 08/04/2020 showed, Facility staff are required to sign an attestation regarding the presence of signs/symptoms of COVID-19 and document their temperature in the presence of another staff member/designee who will validate that all information has been entered, is accurate and meets criteria for entrance. Review of the United States Department of labor - OSHA (Occupational Safety and Health Administration) dated 06/08/2011 showed that section 1910.134(a)(2) documented the following. A respirator shall be provided to each employee when such equipment is necessary to protect the health of such employee. The employer shall provide the respirators which are applicable and suitable for the purpose intended. The employer shall be responsible for the establishment and maintenance of a respiratory protection program, the program shall cover each employee required by this section to use a respirator. Review of a State of Washington Department of Social and Health Services - Nursing home provider letter dated 08/04/2020 documented the following: .have staff fit tested for respirator masks (N95) as soon as possible. This will ensure that if a situation occurs, such as a confirmed case of COVID-19 in your facility, your staff are ready to don the N95 masks and wear them in accordance with Centers for Disease Control and Prevention (CDC) guidance. This will remove any delay associated with staff fit testing in the event of a crisis. Furthermore, the letter documented the following: There are multiple fit testing options available including: -Occupational health clinics and some urgent care clinics perform fit testing. -Fire stations may have staff who are qualified to fit test and could volunteer to do this. In a rural community with smaller facilities, they may be willing to do this. -Nursing homes connected with a hospital system have staff who are qualified to perform fit testing. -A facility can get their own staff qualified to perform fit testing. Review of a document from the facility's local health department, Kitsap Public Health District (KPHD) to the facility's Administrator, Staff A, Executive Director (ED) on 12/30/2020 documented the following: Fit test all staff using N95 masks. -Contact Kitsap Public Health if you are unable to access fit test kits for additional resources. -Contact Kitsap Emergency Operations Center (EOC) for additional PPE resource needs. Review of the facility's policy titled, Surveillance for Infections, dated September 2017, showed, The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions and to prevent future infections. It further showed that data collection and recording included a variety of criteria for the definition of infection for surveillance. The required data included resident's admitted , date of onset of infection, date of positive diagnostic test, and precautions taken (interventions and steps taken that may reduce the risk and spread of infection). In addition, this policy showed that for targeted surveillance using facility-created tools, guidelines that were to be followed included: DAILY (as indicated): Record detailed information about the resident and infection on an individual infection report form . MONTHLY: Collect information from individual resident infection reports and enter line listing of infections by resident for the entire month. PERSONAL PROTECTIVE EQUIPMENT (PPE) / FIT TESTS N95 During interview on 12/15/2020 at 3:34 PM, when asked if the facility was following what was required from the Local Health Department related to usage of PPE, Staff B, Director of Nursing Services (DNS), stated, Yes. Review of the facility's C-Wing map provided by Staff B, DNS, on 12/15/2020 at approximately at 3:45 PM showed, Isolation Unit with a yellow highlighted parameter of the unit that included, the location of the Isolation Barrier, (a floor to ceiling barrier that separates a section of the hallway from the rest of the facility) and showed the exit door at the end of the C-Wing. During an interview on 12/15/2020 at 4:25 PM, Staff B, DNS, stated that in the facility's quarantine/isolation unit, the staff wore gowns, goggles and surgical masks because there were no COVID-19 cases in the facility. During an interview on 12/15/2020 at 5:20 PM, when asked if the quarantine/isolation unit was created and utilized to rule out COVID-19 due to potential for exposure from the hospital and/or wherever the resident was being admitted from, Staff B, DNS, stated, Correct. Staff B, DNS, stated that there were 11 double occupancy rooms on the quarantine/isolation unit. Additionally, when asked if the local health department was informed that the facility created a quarantine/isolation unit and recommended that it was not necessary to use N95 masks in that unit, Staff B, DNS, stated that she needed to follow up with the Regional Nurse/Infection Preventionist, (responsible for the facility's activities aimed at preventing health care-associated infections by ensuring that sources of infections are isolated to limit the spread of infectious organisms), Staff J, Registered Nurse (RN), and provide the answer to the surveyor. Staff, B, DNS, did not provide the requested information. During an interview on 12/15/2020 at 5:25 PM, when asked if staff had been fit tested for N95 masks, Staff B, DNS, stated that they were in the process; however, the facility had not been able to get the hood (a piece of equipment used to fit test N95 masks). Additionally, Staff B, DNS, stated that the hood was ordered yesterday (12/14/2020) and should arrive on Thursday (12/17/2020). Staff B, DNS, further stated that she had attended the local health district webinar and was able to conduct staff fit testing. An observation on 12/15/2020 at 6:16 PM showed the C-wing with a floor to ceiling zippered barrier that blocked rooms near the middle of the C-wing hallway and had a sign posted, Do Not Enter. An observation and interview on 12/15/2020 at 6:35 PM, in the quarantine/isolation unit (C Wing), Staff L, Licensed Practical Nurse (LPN), wore a surgical mask and eye protection. Staff L, LPN, stated that PPE used for resident care included surgical mask, eye protection, gown, and gloves. In addition, Staff L, LPN, stated that there were no positive or suspected COVID-19 cases in the unit. An observation on 12/15/2020 at 6:38 PM showed, Resident #2 sat on the side of the bed approximately six feet away from the open doorway. Resident #2 did not have a mask on. An observation and interview on 12/15/2020 at 6:40 PM showed that Staff M, Nursing Assistant Registered (NAR), had on a surgical mask and eye protection and then donned a gown, and gloves prior to providing to Resident #3. Resident #3 had on a surgical mask. During a telephonic interview on 01/08/2021 at 10:00 AM, when asked what would be a reason for a resident's door to be left open on the quarantine/isolation unit prior to identified Covid-19 cases in the facility, Staff B, DNS, stated that it was more of a new admission unit and that everyone on the unit had been tested negative for Covid-19 prior to admissions. In addition, Staff B, DNS, stated that new admissions were kept on the unit for 14 days to monitor for signs and symptoms of Covid-19; however, all residents had been asymptomatic (showed no signs and symptoms). Staff B, DNS, further stated that if a resident was at risk for falls or was claustrophobic (having an extreme or irrational fear of confined places) the door may be opened; however, we would practice social distancing and encourage the resident to wear a mask which would be care planned. An observation on 12/28/2020 at 12:25 PM showed multiple staff wearing PPE gear to include an N95 masks in the COVID positive unit. During an interview on 12/28/2020 at 12:30 PM, Staff B, DNS was asked about the staff wearing N95 masks and whether they had been fit tested . Staff B, DNS stated that the staff were required to wear N95 mask now that COVID positive residents were in the facility; however, the facility was unable to get any fit test equipment to be able to get the staff tested . Staff B, DNS further stated that she had watched a live KPHD webinar to receive the necessary training but she had yet to Fit Test her staff due to lack of testing equipment and that the supply staff had been attempting to get the equipment but was denied. Review of a document titled, PPE inventory tracker, with a start date of 10/19/2020 showed #400, N95 masks were stored in the administrator's office; however, no fit test equipment was documented on this tracker log sheet. During an interview on 12/28/2020 at 12:35 PM, Staff C, Staffing and Supply Coordinator, stated that she had ordered the fit testing equipment for the N95 mask on 12/15/2020; however, the order was awaiting approval from the corporate account supplier. Review of a document titled, Acknowledgement by Supplier, dated 12/15/2020 showed a purchase order had been created on 12/15/2020 for fit testing equipment and was initially approved by the administrator on 12/15/2020 at 12:43 PM and by the corporate supply staff at 12:51 PM. However, the facility still had not received the equipment and no additional record review revealed that the facility had reach out to another entity to acquire the testing equipment. During an interview and observation on 12/28/2020 at 12:45 PM with Collateral Contact H, Department of Health, (DOH) representative a discussion related to the facility's COVID outbreak and the need for facility staff to wear the N95 masks and fit testing was conducted. Collateral Contact H, DOH, stated that she had concerns from an earlier visit to the facility of staff observed incorrectly wearing the N95 masks. Collateral Contact H, DOH further stated that on 12/25/2020 she had returned to the facility and taught several staff the proper techniques needed to create an adequate formed seal with the N95 mask and the need for staff to be fit tested . During the discussion, Staff A, ED, approached and was observed wearing an N95 mask. Collateral Contact H, DOH stated that Staff A's, ED, N95 mask was not sealed properly due to his facial hair and that the mask did not have a secure enough seal which showed a gap around his facial cheek. During multiple observations on 12/28/2020 between 11:00 AM to 1:00 PM multiple staff wore the N95 masks without a proper seal (within the RED zone (A/B wings) for COVID positive residents) that ensured a form fit around the staff's nose and mouth area. Staff D, NAR was observed to have not molded the N95 nose clip over her cheeks and bridge of her nose in order to obtain a tight seal. In addition, Staff E, Nurse Assistant Certified, (NAC) was observed with facial hair which created an incomplete seal around the facial (cheek) area, which created a gap. Staff D, NAR and Staff E, NAC were both unable to state whether they had a N95 fit test prior to wearing of the mask; however, were instructed to wear the N95 mask while there was COVID positive cases in the building. During a telephonic interview on 01/08/2021 at 10:00 AM, when asked if the local health department had been contacted to inform of the facility's inability to obtain fit testing equipment/supplies, Staff A, ED, stated that he, instead, contacted the Kitsap Emergency Preparedness District. Staff A, ED, stated that they had a positive COVID-19 test in the facility on 12/17/2020, and that was when the local health department was contacted and informed that they were unable to get fit testing equipment. During a telephonic interview on 01/11/2021 at 8:43 AM, Collateral Contact R, KPHD, stated that if a resident was under quarantine or isolation it was recommended for staff to use a fitted N95 mask and eye protection. During an interview and observation on 01/11/2021 at approximately 11:45 AM, Staff B, DNS, was also observed wearing an N95 mask; however, the mask that she wore lacked a tight seal around the facial cheek area and a visible gap was observed. Staff B, DNS, stated that the N95 mask that she wore was the only ones that they had and that she understood that she needed a smaller mask to create a tight seal. In addition, Staff B, DNS, had been fit tested ; however, had failed the test. During a follow up telephonic interview on 01/13/2021 at 3:13 PM, Staff B, DNS, stated that she had started fit testing staff on the N95 mask on 01/08/2021 after the facility had received fit testing equipment on 01/07/2021. When Staff B, DNS, was asked why the fit testing equipment was not ordered sooner, Staff B, DNS, stated that she was informed that the facility had attempted to get the equipment from other sources during the year; however, the facility was unable to provide any documentation that this occurred prior to 12/13/2020. Review of the KPHD letter dated 12/19/2020 to Staff A, ED, made the following public health recommendations showed that all staff must wear surgical masks at a minimum for COVID negative patients and wear full aerosal precautions with N95 masks, face shields, gloves and gowns for positive or quaratined patients; however observations on 12/28/2020 recommendations were not implemented. STAFF SCREENING Review of multiple documents titled, Staff COVID-19 + Attestation (the act of witnessing the signing of a formal document and then also signing it to verify that it was properly signed by those bound by its contents) and was (a legal acknowledgement of the authenticity of a document and a verification that proper processes were followed) log(s), dated from 12/16/2020 through 12/28/2020 showed multiple facility staff had not completed the document correctly and/or at times not signed in on the attestation log. In continued review, the documents showed that staff had signed their names; however, left multiple blank areas and/or had documented a Yes annotation to indicate if they had any respiratory symptoms such as difficulty breathing, sore throat, cough congestion, nausea, vomiting, diarrhea, chills, fever, shortness of breath, muscle aches, malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify), change in ability to taste or smell, and runny nose. Additionally, the staff was required to document in a subsequent column and answer, Yes if they had met the criteria for return to work per the CDC (Centers for Disease Control and Prevention) guidelines. Staff had to provide documentation to the facility of negative tests or meet symptoms based criteria and if they did not have this information or had symptoms they would be asked to leave. This column had multiple missing annotations as to whether the staff had met the return to work criteria. Review of the attestation log sheet dated 12/15/2020 through 12/16/2020 showed two staff had no temperatures logged, and five staff had not annotated whether they had any signs or symptoms of COVID listed on the form. On 12/17/2020 the log had four areas left blank for symptoms of COVID and one staff had documented a yes that they had signs and symptoms of COVID; however, no annotation was documented to whether they had met the CDC guidelines to return to work. On 12/18/2020, five staff had not documented whether they had any signs or symptoms of COVID and one staff did not have a temperature documented. On 12/19/2020 the log showed three staff had documented a yes to whether they had signs and symptoms of COVID; however, no annotation was documented on the log to whether they had met the CDC guidelines to return to work. On 12/20/2020 two staff had left blank whether they had signs and symptoms of COVID and two staff had documented that they had signs and symptoms; however, no annotation was documented on the log whether they had met the CDC guidelines to return to work. From 12/21/2020 to 12/28/2020 the facility's attestation log continued to show multiple blanks on the document as well as lack of follow up after staff documented a, yes answer for whether they were exhibiting signs and symptoms of COVID. Further review of the attestation log sheet dated 12/17/2020 showed that Staff F, NAC, had documented Yes for having signs and symptoms of COVID and had documented a temperature of 99.9 F (Fahrenheit); however, the log was left blank as to whether Staff F, NAC had met the criteria to work per the CDC guidelines. Review of a document titled, Forest Ridge Health and Rehabilitation - Day Schedule, dated 12/17/2020 showed Staff F, NAC had worked on the B wing within the facility. Review of a document titled, LTC Respiratory Surveillance Line List, dated 12/21/2020 showed Staff F, NAC had a COVID positive test that was collected on 12/17/2020. Review of the attestation log sheet dated 12/24/2020 showed that Staff N, NAC had documented Yes to having had signs and symptoms of COVID ; however, the log was left blank as to whether Staff N, NAC had met the criteria to work per the CDC guidelines. Review of a document titled, Forest Ridge Health and Rehabilitation - Day Schedule, dated 12/24/2020 showed Staff N, NAC had worked within the facility including C wing. Review of a document titled, LTC Respiratory Surveillance Line List, dated 12/28/2020 showed Staff N, NAC had a COVID positive test result from a test collected on 12/21/2020. Review of the attestation log sheet dated 12/23/2020 showed that Staff O, LPN/Unit Manager (LPN/UM) had not documented whether she had any signs and symptoms of COVID. On 12/24/2020, Staff O, LPN/UM, documented a, Yes however, the log was left blank as to whether Staff O, (LPN/UM) had met the criteria to work per the CDC guidelines. Review of a document titled, Forest Ridge Health and Rehabilitation - Day Schedule, dated 12/24/2020 showed Staff O, (LPN/UM) had worked in the B wing within the facility. Review of a document titled, LTC Respiratory Surveillance Line List, dated 12/31/2020 showed Staff O, (LPN/UM) had a COVID positive test result from a test collected on 12/23/2020. Review of the attestation log sheets dated 12/17/2020 through 12/28/2020, Staff A's, ED signature was missing. An observation of Staff A, ED on 12/28/2020 showed the ED's office was located within the COVID wing of facility. During an interview on 01/04/2021 at approximately 3:30 PM, Staff G, NAR/ Transportation Coordinator (TC), stated that she worked the receptionist area on occasion; however, was unable to state why there were several blank areas on the document. Additionally, Staff G, NAR/TC stated that if the staff had answered a Yes in the initial column then staff were instructed to be screened and signed off by a nurse in order to determine if they met the criteria to return to work. Furthermore, Staff G, NAR/TC stated that on occasion she had to remind staff to check in and sign the documentation at the reception desk prior to entering into the COVID positive area of the facility. During an interview on 01/05/2021 at 12:45 PM, Staff B, DNS stated that she had already identified inconsistencies with the facility's surveillance log and that the NAC that was in charge of the log has been counseled to ensure compliance. Staff B, DNS also stated that she was aware of the recommendations from the LHD guidance to allow workers to come back to work earlier than their quarantine period as long as they worked with COVID positive residents and that they (staff) did not show any signs or symptoms of COVID. During a follow up interview on 01/05/2021 at 2:15 PM, Staff B, DNS stated that the Staff A, ED should have check in and signed on the attestation sheet if he came in thru the red zone/front door. In addition, Staff B, DNS stated that Staff F, NAC, was counseled and should have reported her elevated temperature and any signs and symptoms of COVID. Furthermore, Staff B, DNS, stated that the receptionist was there to ensure that staff signed in but the individual responsibility was on the staff to self-report any signs and symptoms of COVID. Review of a letter from a DOH representative dated 12/19/2020 to the facility's administrator (Staff A, ED) showed that the following recommendations were to be in place until there were no active spread (no new cases for 28 days) of COVID-19 in the facility: Actively screen employees instead of allowing self-attestation. -Cases so far reported having no symptoms and we recommend being judicious about screening and excluding staff. -Supervisors should be vigilant in keeping staff out of facility if they have any symptoms. -Remind staff that symptoms may be mild and do not always include fever or loss of taste or smell. Review of DOH recommendation dated on 12/19/2020 staff screening had not been fully implemented when reviewed on 12/28/2020. REPORTING COVID Review of the facility's, LTC Respiratory Surveillance Line List, dated 12/21/2020 showed 17 residents (Resident #s 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 24) and three staff (Staff #s F, P and Q) reviewed for infection control and prevention had been tested on [DATE] and received a positive result for their COVID tests. During an interview on 12/28/2020 at 1:35 PM, Staff A, ADM stated that there must have been a breakdown as to who was supposed to report the COVID positve resident and staff cases during their most recent outbreak. Staff A, ADM stated that he intially contacted the LHJ during an earlier outbreak and the DNS reported to the state CRU, Complaint resolution Unit) however there was a breakdown as to who was to contact the state and the reporting of COVID positve case only was to the LHJ and not to the state. During an interview on 12/28/2020 at 1:35 PM, Staff A, ED, stated that there must have been a breakdown as to who was supposed to report the COVID positive resident and staff cases during their most recent outbreak. Staff A, ED, stated that he initially contacted the LHD during an earlier outbreak and the DNS reported to the CRU; however, there was a breakdown in reporting. STAFF TESTING During an interview on 12/15/2020 at 6:26 PM, Staff A, ED, stated that as of last week, the facility was now testing staff for COVID-19 every week; however, prior to that they were testing staff monthly which was mandated by the Local Health Department. Staff A, ED, stated that residents were to be tested if they showed signs and symptoms of COVID-19 per the local health department. During a telephonic interview on 01/08/2020 at 10:00 AM when asked if documentation could be provided on how staff testing was tracked for October, November and December 2020, Staff B, DNS, stated Yes, we have a spreadsheet. On 01/08/2020 at 3:19 PM an email was sent to Staff A, ED, requesting the facility's documented tracking system for testing staff and residents for COVID 19 for the months of September, October, November and December 2020. During a telephonic interview on 01/12/2020 at 2:18 PM, when asked how the facility kept track of the monthly testing of staff prior to having positive cases of COVID-19, Staff A, ED, stated that they did a list of who they tested but did not check them off and that everything was electronic and results were in their computer system. In addition, Staff A, ED, stated that all tests were negative for October and November 2020 until their first COVID-19 case in December 2020. The facility did not provide documentation to this surveyor, of their tracking system for conducting Covid-19 tests for staff prior to the first identified case of Covid-19 in the facility, to ensure staff testing was being conducted as required. INFECTION CONTROL Review of facility's infection control antibiotic surveillance/usage tools for September, October and November 2020, showed that the tools did not include the needed data collection and recording requirements per the facility's policy. The missing data included resident admitted , date of onset of infection and if any precautions were taken (i.e. isolation precautions, to create barriers between people and germs to help prevent the spread of germs), date of positive diagnostic test and/or date of the test results, and did not show the date the infection was resolved. In addition, there were no individual resident infection reports provided to review. During a telephonic interview on 01/08/2021 at 10:00 AM, when asked about missing data collection and recording requirements according to the facility's Surveillance for Infection, policy, Staff B, DNS, stated that she should have provided a separate infection control line listing with the required information and that she would email the actual line listing and not the antibiotic tracker. When asked about the daily (as indicated) targeted surveillance record that detailed information about the resident and infection on an individual infection report form that was to be used per the Surveillance for Infections, policy, Staff B, DNS, stated that they did not use a daily tracking form when residents had an infection or were on antibiotics; however, residents were charted on in the progress notes and put on alert charting. On 01/13/2021 at 10:11 AM, Staff B, DNS, provided the following information via email: -October's 2020, October Antibiotic Surveillance Tool -November's 2020, November Antibiotic Usage Tool -December's 2020, December Antibiotic Usage Surveillance, tool. The October and November tools provided were the same that were provided previously and continued to have missing required data. Review of the December Antibiotic Usage Surveillance, dated December 2020, showed it was missing data that included resident admitted , date of onset of infection and if any precautions were taken, date of positive diagnostic test and/or date of the test results, and did not show the date the infections were resolved. Reference: WAC 388-97-1320(1)(a)(b)(2)(a)

Based on interview and record review. The facility failed to ensure one of three Resident (Resident #1) screened attended follow up appointment with Surgeon. Resident #1 developed serious complication related to the surgical incision and was readmitted to the hospital; Failure to ensure Resident #1 received follow-up with Vascular Surgeon prevented / delayed suture removal and increased Resident #1's potential for infection. Also the facility failed to provide evidence of timely and through investigation for one of five incident reports reviewed. The facility could not rule out neglect or implement appropriate corrective action without a thorough investigation. Findings Included: Resident #1 Admission Record reflects admission to the facility on [DATE] for rehabilitation following a completed traumatic amputation of the right lower leg at knee level. Other admitting [DIAGNOSES REDACTED]. Review of documents titled Report of Consultation dated 10/23/18 for resident #1 showed follow-up appointment with Staff C, MD on 11/11/18 at 1:00pm. In interview on 01/04/19 at 11:44 AM with Staff C, MD reported Resident did not return for follow up appointment after surgery. Staff C, MD reported sutures would normally be removed at follow-up appointment 3 weeks to a month after surgery. Staff C, MD reported his medical assistant keeps notes on missed appointments. Staff C, MD reported his concern was the failure of the facility to ensure patient to attended follow-up appointments. Staff C, MD reported frustration the patient was not sent to hospital sooner for the infection present in both wounds. Review of document titled Telephone notes 12/11/18 Staff J, Medical Assistant 'Health Partners [MEDICATION NAME], Vascular Surgery' showed conservation with facility on 12/11/18. I received a call from facility on Tuesday wanting to know when they can bring Resident #1 in for an evaluation since they think that her wound is dehisced .I asked them why she did not make it to her scheduled appointment the first time and then asked why she no showed the second appointment. Per the nursing staff they are not sure what happened with the transportation but that, it was a fault on their end. Review of hospital record health record for Resident #1 showed readmission to hospital on [DATE]. Sutures were still in place from her surgery on 10/10/18 and she had developed a large pressure ulcer in the sacral area. In interview 12/13/18 4:25pm Staff B, Director of Nursing (DNS) stated she was unsure why Resident #1 did not return for follow-up appointment, she believed the Resident was frequently non-compliant but she would have to investigate. In interview on 01/17/19 at 3:25 PM with Staff B, DNS she reported that there was a lack of documentation showing the Resident #1 refused to attend follow-up appointments. Staff B, DNS could not provide documentaqtion that any investigation had been done to determine why Resdient #1 missed follow-up appointments. Staff B, DNS reported she was still unsure what had actually happened that Resident did not attend follow-up appointment and that she has now taken over oversight of all Resident's appointments and transportation request. She reports Resident's appointment will become part of our standup meeting every morning. In interview on 01/08/19 at 4:30 PM with staff B she reported she was aware that some Resident's did not get their morning medications on 01/07/19 and that she had already started an investigation. Review of the accident / incident report documents provide on 01/17/19 related to multiple residents missing medication on 01/07/19 failed to show a thorough investigation. There was no documentation of medication errors that transpired because of missed medications. There was no documentation that identified the other Residents affected. The incident report failed to identify the staff involved. The investigation did not include any documentation of staff interviews. The investigation did not thoroughly identify how affected Residents were impacted. The Investigation Summary stated No patients showed adverse side effects from missing medications. See Tag 0697 for interviews with Resident #4 and Resident #5, they identified being in increased pain and discomfort because of missed pain medication. Review of the updated accident / incident Report summary provide on 01/25/19 related to multiple residents missing medication on 01/07/19 failed to show a thorough investigation. The investigation showed no documentation of medication errors that transpired, failed to identified the other Residents affected and failed identify adverse effects for some Residents that missed medications.

Based on interviews, observations and record review, the facility failed to prevent pressure ulcers in three of six residents (Resident #s 1, 2, and 3) screened for pressure injuries. This failure put Residents at risk for complications associated with skin damage. Resident #s 1, 2, and 3 were harmed when they developed facility acquired pressure injuries. Findings included . Resident #1 Resident # 1 Admission Record reflects admission to the facility on [DATE] for rehabilitation following a completed traumatic amputation, right [MEDICAL CONDITION] (BKA). Other admitting [DIAGNOSES REDACTED]. MDS (Minimum Data Set, a comprehensive assessment) dated 10/22/18 showed Resident required extensive two person assistance for bed mobility and transfer. Resident #1 was not able to walk. MDS assessment showed Resident #1 did not have pressure injuries on admit. Review of facility Incident Report dated 10/24/18 showed that during a routine skin check on 10/24/18 Resident #1 was observed to have stage two pressure injury to the sacral coccyx area. The wound measured 4.0cm X 6.5cm X 0cm in depth. An investigation identified that Resident #1 has recently become incontinent and coupled with her [MEDICAL CONDITION] and lack of movement had caused the pressure injury to develop on her back side. A referral to Wound Consultant was generated and resident #1 received services from Wound Consultant starting 11/06/18. Record review of Resident #1's closed medical record showed Resident #1 admission assessment did not address risk for pressure injuries. Resident #1 received weekly services from a Wound Consultant. Review of theWound Consultant notes reveal that on 12/04/18 Resident #1's sacral wound had worsened and was identified as an acute Stage four pressure injury and measurements were 6.5cm X 6.3cm X 2cm in depth. On 12/11/18 the Resident's sacral wound was given a status of 'Not Healing' and measures 6.5cm X 6cm X 2cm depth. Recommendations were made for an immediate consultation with the Vascular Surgeon. An interview on 12/27/18 at 1:56 PM with Staff B, Registered Nurse (RN), Director of Nursing (DNS), she reported that she believed that the pressure injury had occurred at the hospital, but since the nursing staff did not document it on admit it is the facility's responsible. Staff B, DNS reports that when the pressure injury was identified the Resident's care plan was edited to ensure she got out of bed each morning and stayed up until after lunch; that she would eat in the dining room and that when she was in bed she would allow staff to assist her to reposition every two hours. Staff B reported that she believed that the Resident's noncompliance contributed to the pressure injury. Staff B reported she it was not made clear who was going to update care plan and further stated we should have monitored her compliance closer. Review of Resident #1's care plan revealed it did not show a problem for non-compliance of treatments or medical appointments. Resident #1's care plan identified sacral area pressure ulcer 10/24/18 but did not initiate interventions until 11/07/18. Care Plan did not identify Resident should be up daily for lunch and that staff would ensure she was repositioned every two hours when in bed. Review of Resident #1's medical record showed there was an absence of documentation that Resident #1 refused wound care or refused to reposition in bed. In an interview on 01/11/19 at 6:24 PM Staff F, Licensed Practical Nurse (LPN) reported she had cared for Resident #1 frequently before resident readmitted to the hospital. When asked about Resident #1 being non-compliant with care. Staff F stated she did not remember the resident being non-compliant with dressing change and turning. In interview on 01/04/18 at 11:44 AM with Staff C, MD reported Resident did not return for follow up appointment after surgery. He reported frustration that the patient was not been seen sooner for the infection that was present in both wounds. Review of medical records from Resident #1's hospital admission physician's documentation on 12/13/18 reflect stage IV decubitus ulcer and wound infection of right BKA surgical wound both infected and Resident is suspected to be septic (infection through the blood stream)as primary [DIAGNOSES REDACTED]. Resident #2 Review of Resident #2 Medical Record reflects admission to the facility on [DATE] [DIAGNOSES REDACTED]. Resdient #1's admission assessment failed to identify risk of pressure injuries. The Resident's care plan did not include interventions to prevent pressure injuries. Review of MDS dated [DATE] showed Resident #2 required extensive one person assistance for bed mobility and transfers. Resident #2 was not able to walk. Resident #2 did not have a history of pressure injuries. Review of facility Incident Report dated 12/25/18 reflects CNA reported new skin issue on resident's #2's right buttocks. The report describes CNA stating she also told nurse on Saturday (three days before) on day shift about it. 12/25/18 newly formed pressure injury described as maroon, non blanch able area on right buttocks, measuring 6.0cm X 1.5cm X 0cm. On 01/01/19 it was noted that Resident had area red in color on coccyx measuring 4.0cm X 2.5cm X 0cm, right buttocks 2.0cm X .5cm X 0cm red in color, left buttocks 7.0 X 3.0cm X 0cm red in color. On 01-03-18 Resident #2 with unstageable 3.0cm X 4.0cmX 0.2cm pressure injury on coccyx, stage II pressure injury right buttock measures 6.6cm X 3.5cm X 0.2cm. On 01-03-19 air mattress was ordered and Resident #2 was seen by Wound Consultant 01/08/19. In interview on 01/04/19 at 10:38 AM Staff E, Nurse Practitioner (ARNP) reported that Resident #2 was a newly diagnosed [MEDICAL CONDITION] patient and had recently developed a pressure ulcer on her buttocks. Staff E described that there was no reason for Resident #2 to develop pressure ulcers on her buttocks other than she was not getting out of bed as much as before and staff was not ensuring she was repositioned frequently enough. Resident #3 Resident #3 Admission Record reflects admission to the facility on [DATE] [DIAGNOSES REDACTED]. Review of MDS dated [DATE] showed resident #3 required extensive two person assistance for bed mobility and transfers. Resident #3 was not able to walk. Resident had no history of blisters forming on upper thighs. Review of facility Incident Report dated 12/28/2018 reflected that two fluid blisters were found on resident's #3's upper thigh and that dressing around the spra pubic catheter (catheter inserted through a suprapubic incision into the bladder) was soiled and dated for two days prior to the date. The incident report described that More likely than not blisters were formed from catheter tubing laying against resident's thigh and that skin checks and dressing changes were not properly completed and documented. In interview 01/08/2019 at 4:30 PM with Staff B, RN DON she reported that one of the nurses was reprimanded for not completing and documenting skin check. The same nurse was also written up for not providing treatments and falsify documentation that dressing changes were done.

Based on observation, interview, and record review, the facility failed to ensure pain mananagement was provided in a timely manner for 1 of 6 Sampled Residents (#150) reviewed for pain. The facility failed to ensure post [MEDICAL TREATMENT] assessment were completed consistently to identify bleeding, abnormal blood glucose levels, and vital signs for 1 of 1 Sampled Residents (#110) receiving [MEDICAL TREATMENT]. These failures resulted in a delay of treament potentially caused pain, discomfort and unmet health care needs. Finding included: RESIDENT #150 Review of facility's policy entitled Pain Management, dated July 2015, showed the following: -Pain was subjective and the goal was to reduce physical and psychological symptoms associated with pain to be able to assist the resident in achieving their highest practicable level of functioning. -A full evaluation included the pain origin, location, frequency, type, severity, alleviating factors, exacerbating factors, the current treatment and the response to treatment. In addition, verbal and non-verbal expressions and behaviors associated with pain needed to be included. -Licesnsed Staff were expected to initially screen all residents for pain upon admission, quarterly, during any significant change in condition and any time it was suspected a resident was in pain. -Appropriate pain interventions included pharmacological and non-pharmacological interventions. -Licensed Staff were expected to reassess as indicated and screen residents for pain regularly through asking the residents if they have pain, making observations during cares, and observing for signs and symptoms of pain. -The provider was to be notified if interventions were not effective in achieving comfort and/or function goals within 24 hours. Record review of Discharge Minimum Data Set (MDS), an assessment tool, dated 06/06/17, showed Resident #150 was admitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The MDS showed pain limited the resident's day to day activity and pain intensity was at a level of eight out of ten. Resident #150's admission progress note, dated 06/05/17, showed she arrived at the facility at 2:30 p.m., from the hospital with a pain level of nine out of ten. Resident #150 did not receive any pain medication until 7:09 p.m. (four hours and thirty-nine minute) after she arrived at the facility. The facility's form entitled, Pain Data Collection and Assessment was undated and showed the form was not completed or signed. The pain assessment showed during observations and interview of the indicators of pain, Resident #150 was tearful and had a pain intensity of eight out of ten. A medication prescription, dated 06/05/17, showed an order for [REDACTED].#150 upon discharge from hospital. On 06/28/17 at 8:43 a.m., Staff E, License Practical Nurse (LPN), stated she had not provided pain medication to Resident #150 even after knowing the pain level was nine out of ten. When ask if she notified the physician about the resident's nine out of ten pain, Staff E stated, No, it was the end of my shift so I went home. On 06/28/17 at 9:01 a.m., Staff G, Registered Nurse, Resident Care Manager, (RN/RCM), stated it should only take ten to fifteen minutes when a resident admits from the hospital with a narcotic hard script to get the medication out of the emergency kit (this is a supply of medication the pharmacy has provided to facility for emergent usage after authorization). When asked if it is acceptable for the resident to have to wait four and a half hours for pain medication, Staff G, RN/RCM, stated No. On 06/28/17 at 9:17 a.m., Staff C, Registered Nurse, Resident Care Manager, (RN/RCM), stated when a resident was identified in pain, that was a priority and it should not take longer than ten to fifteen minutes to provide the resident pain medication. When asked if it was acceptable for a resident to have to wait four and a half hours for pain medication, Staff C, RN/RCM, stated No, that is too long. On 06/28/17 at 9:30 a.m., Staff B, Registered Nurse/Director of Nursing Services (RN/DNS), stated it was unacceptable for Resident #150 to have had to wait four and half hours for pain medication. On 06/28/17 at 10:08 a.m., Staff A, Administrator, stated it was unacceptable for a resident with pain to wait four and a half hours for pain management. RESIDENT #110-[MEDICAL TREATMENT] The facility's document entitled, Agreement for [MEDICAL TREATMENT] Services, reads, All services shall be provided in a professional, ethical and competent manner and in accordance with all applicable laws, rules, ordinances and regulations and with the policies of the facility. The Admission Record documented Resident #110 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was able to make his own decisions and the recent [DIAGNOSES REDACTED]. Record review of the [MEDICAL TREATMENT] records, for the period 3/8/17 through 6/26/17, showed nine dates (3/10/17, 3/8/17, 3/15/17, 3/31/17, 4/12/17, 4/14/17, 4/26/17, 5/12/17, and 6/16/17) a post [MEDICAL TREATMENT] assessment was not completed. The [MEDICAL TREATMENT] Communication Record, dated 4/18/17, showed the post [MEDICAL TREATMENT] assessment by the nurse included vital signs to include a blood pressure, temperature, pulse and respirations. The shunt site was to be assessed for bleeding, thrill palpated and bruit of site. On 06/26/17 at 9:24 a.m., Staff C, RN/RCM said nurses were to assess the resident when she returned from [MEDICAL TREATMENT]. Staff C stated, I can't explain why it was not done. I did not know it wasn't. Staff C said the resident was being followed by the Endocrinologist related to a recent [DIAGNOSES REDACTED]. On 06/28/17 at 9:09 a.m., Resident #110 said [MEDICAL TREATMENT] was going well and she had no problems. The facility failed to complete post [MEDICAL TREATMENT] assessments to ensure the resident did not have any unidentified and untreated medical needs. WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to monitor to ensure avoidable pressure ulcers were not acquired for 1 of 3 sampled residents (#103) reviewed for pressure ulcers. This failure resulted in recurrent skin breakdown with Stage 2 pressure injury that developed into an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is completely covered by slough 'dead tissue' in the wound bed) on the buttock area. This failure caused pressure injury resulting in harm to the resident. Findings included: Refer to F 285 for history and resident information. Resident #103 was admitted to the facility on [DATE] following a nine month hospitalization . The discharge summary recorded the residents skin was intact on discharge. A Skin Assessment, dated 9/29/16, showed on the day of admission to the facility, the resident did not have any skin impairment. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 04/02/17, documented the resident had one Stage 2 pressure ulcer acquired 02/01/17. The Skin Grid-Pressure/[MEDICAL CONDITION] Ulcer/Other Form, dated 1/28/17, recorded a Stage 2 pressure injury in the upper inner gluteal fold. The size was 2 x 0.4 x 0.1 cm (centimeters). The skin assessment indicated a moderate risk for pressure injury. An entry, dated 03/07/17, documented resolution of the pressure area with fragile skin with no open areas. The provider note, dated 1/17/17, recorded resident was uncooperative during attempt to assess. The provider stated, According to staff his behaviors have improved, although when he is having pain his behaviors, yelling out and aggression seems to increase. Staff is requesting that we schedule pain mediation while we investigate the source of his pain. The Nursing-Therapy Communication Form, dated 02/02/17, regarding change of condition showed a handwritten note that read, Stage 2 to right upper inner gluteal fold. Resident will be encouraged to get up and attend activities. Need wheelchair. The request was signed received by physical therapy, dated 03/02/17. A nurses note, dated 1/17/17, noted the start of administering [MEDICATION NAME] through 1/28/17 after open area on coccyx was found, record only medication responses, and not positioning resident in bed and getting resident out of bed into chair. The Skin Assessment Prevention and Treatment Care Plan, dated 1/17/17, noted to turn and reposition every two hours, therapy referral for wheelchair, bilateral mini mobility bars. A Fax Communication Form, dated 05/02/17, was sent to the provider regarding a superficial open area 1.5 cm x 0.2 cm to the coccyx area. The provider replied to place resident on alert monitor and for wound specialists to see the resident. A Fax Communication Form, dated 06/13/17, was sent regarding the open fragile skin to coccyx and request for update due to increased slough over most of wound bed measuring 2 x 2 cm. The provider replied for wound specialists consultation. Nurses Notes, for the month of May, recorded the area open from 05/02/17 through 05/08/17 and on 05/31/17. On 06/26/17 at 8:58 a.m., when asked if the resident had been seen in May by the wound specialists, Staff C said he had not because the area closed quickly. She explained the area opened again and that was why there was a second fax sent and the resident had been seen by the wound specialists on 6/23/17. On 06/26/17 at 2:20 p.m., Staff B, DNS said the wound specialists had been providing wound care in the facility since January in the facility. They manage all wounds to include surgical. Stage 2 pressure injury (PI) that are healing well are not covered as part of the wound specialists services. Staff B said the resident's wound started as maceration and the provider referred him to wound specialists but was resolved in May 2017. Staff B said on 05/31/17 the area had reopened. The area became a pressure injury when reopened. Resident #103 was being followed by the wound specialists and the provider saw him on Friday. This was his first appointment. On 06/26/17 at 2:42 p.m., Staff B provided the report from wound specialists for the visit, dated 6/23/17. The wound specialists Visit Report, dated 6/23/17, showed the wound was recorded as acquired on 05/02/17, not healed, an unstageable pressure injury obscured full thickness skin and tissue loss (76-100%) measuring 3.5 x 2.5 x 0 cm (an increase in size 2 x 2 cm measured on 6/13/17). This was the initial wound encounter by the wound specialists for the resident. The report noted there were signs of inadequate nutrition, decreased perfusion, moderate drainage and a mild odor to the wound. On 6/26/17 and 6/27/17, unsuccessful attempts were made to observe the wound. On 6/28/27, it was learned the resident had been taken to the hospital the previous evening. Resident #103 presented to the facility without skin breakdown and experienced skin breakdown with open areas progressing from Stage 2 to unstageable with an increase in size. The facility's lack of monitoring resulted in an avoidable skin breakdown and harm to Resident #103.

Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision and timely, consistent interventions after suicidal attempts and statements were demonstrated, and timely removed all potential hazards for suicide prevention for 1 of 5 Sampled Residents (#1) reviewed for psychological harm. Facility staff failed to recognize signs and symptoms of suicidal ideation, that included multiple falls related to the resident's paranoid behavior, implement all interventions necessary to ensure resident safety, or remove potentially dangerous objects used by the resident during suicide attempts. These failures allowed Resident #1 to have continued access to objects previously used during attempts, resulting in Immediate Jeopardy to this resident at the time risks were present. The facility also failed to prevent use of electronic cigarettes inside the facility for 4 of 9 Sampled Residents (#s 2, 3, 4 & 5) reviewed for independent smoking. This failure had the potential to create a safety hazard in the event of electronic cigarette battery malfunction. Finding include: SUICIDAL IDEATION In the course of conducting an investigation by a complainant, it was discovered Resident #1 made several suicide attempts, which were not reported to the Department. Upon further investigation, the following facts were discovered. During review of facility procedure titled Suicide Prevention, dated 7/2015, the document showed staff will observe for psychosocial functioning, which allows staff to detect early warning signs of major mood changes and /or possible suicidal ideation and obtain and provide appropriate interventions. A suicidal resident will be reviewed at the next appropriate daily Clinical Meeting. Staff should report any of the following warning signs immediately to the supervisor: a) Resident expresses feelings of worthlessness, hopelessness or helplessness b) outbursts of anger, mood swings and drastic changes in behavior c) experienced a recent significant loss d) Direct and indirect statements such as I wish I were dead, I'm going to kill myself, I'm useless, I can't go on living like this The procedure identified the resident's environment should be assessed for safety and to remove and store objects which could be used for self-harm. The procedure included a form called suicidality screener. When a resident had suicidal thoughts, the assessment was to be filled out, and given to a supervisor for evaluation and interventions. Resident #1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS also revealed the resident had moderate cognitive status and reported feeling down, depressed, hopeless, tired, and little or no energy, poor appetite, feeling bad about self, and trouble concentrating. According to the MDS, the resident also had hallucinations and delusions. Most activities of daily living, such as transfers and dressing were done with total assistance by one to two staff members. Review of the facility state reporting log referenced seven times, the resident fell out of bed or the wheelchair between the dates of 12/1/16 to 1/1/17. The facility investigation revealed root cause with all of the falls were based on a paranoid type of behavior where the resident was trying to avoid delusions of law enforcement authorities trying to detain him/her. Incident #1 During record review, nursing progress notes dated 12/1/16, at 9:45 p.m., showed the resident's roommate reported to nursing, Resident #1 attempted to put a plastic bag over his/her head. When asked, the resident stated he/she wanted to die per nursing progress notes. A small plastic bag (one placed on the bedside table for trash) was found on the floor and placed in the trash can by the nurse. The room was reviewed for other hazards, but none were removed at that time. At 10:00 p.m., Resident #1 told a nurse's aide to put a bullet between his eyes because he/she wanted to commit suicide. At 10:05 p.m., when the nurse came to speak with the resident, he/she stated he/she wanted to die. Urinalysis and ammonia level labs were to be done, and the resident was to be checked by staff every 15 minutes. At 10:40 p.m., the nurse on duty charted If the resident has a plan to commit suicide, call 911. There was no follow up with the resident to ask if he/she had a plan to commit suicide, although the resident was checked every 15 minutes. A referral to mental health was made. During an interview on 1/19/17 at 10:35 a.m., Resident #1 stated he/she had been threatened with a gun by a nurses aide, and I've told everyone. The resident went on to say he/she calls the facility Bummer Town because the police keep coming. The resident looked up at the ceiling and stated the guns were all up by the wall against the ceiling, and in a concurrent observation, the resident's eyes kept darting out of his room door, and verified, he/she was checking to to see if someone was there. During an interview on 1/31/17 at 10:40 a.m., Staff A stated no reports had been made regarding the plastic bag over the resident's head on 12/1/16, and staff did not alert him/her about it until 1/3/17. Staff A added, such an event should have been on the 24 hour report and the report was usually reviewed by Staff A, but was not aware at the time of the incident, and did not become aware until weeks later. Per nursing progress notes, written 12/8/16, Resident #1 remained on 15 minute checks until 12/8/16. The record did not contain further documentation staff continued to check the resident and no notes identified why the resident came off frequent checks. On 12/8/17, the facility interdisciplinary team met, and discussed all labs that came back in range (within normal limits) and noted the resident continued to cry, be tearful and very emotional. Again, the resident was referred to mental health. In a nursing progress note on 12/9/16 at 3:00 p.m., the resident stated I can only feel anger, I am afraid I might hurt someone. Per the nurses' note, the resident was very emotional. Later in the evening, at 10:00 p.m., the resident was found on the floor kneeling by his bed and stated he wanted to jump out of the window because the police were coming. The facility did not address the statements made by the resident that he/she may hurt others, and all he/she could feel was anger or implement further interventions. During an interview on 1/26/17 at 10:55 a.m., Staff B stated Resident #1 does not have quality of life, and the resident was very delusional. During an interview on 1/31/17 at 10:40 a.m., Staff A stated if Resident #1 wanted to harm others, he/she absolutely should have been hospitalized . According to nursing progress notes, the resident had daily falls on 12/12/16, 12/13/16, 12/14/16, and 12/15/16. At this time, according to progress notes, the resident was being monitored every shift without increasing supervision by staff. Incident #2 On 12/16/16 a nursing progress note documented a nurse's aide reported to the nurse, that she witnessed a call light wrapped around the resident's neck and took the call light away from the resident. When the Licensed Nurse (LN) went to ask the resident what the issue was, the resident stated I'd rather not say. The bed control was also removed at that time, and the resident was placed on every 15 minute checks. In the afternoon, the resident was seen by the facility Advanced Registered Nurse Practitioner (ARNP), who asked the resident if he/she was trying to hurt himself. The resident looked away from the ANRP and shook his head yes. At this time, the ANRP sent the resident to the Emergency Department (ED). The resident readmitted to the facility on [DATE] at 6:00 p.m. The call light and bed controls remained in the room where staff admitted the resident to, which left items accessible to the resident used during previous suicide attempted. Staff placed Resident #1 on frequent checks every 15 minutes. Incident #3 Per nursing progress notes, on 12/18/16 at 5:00 a.m., the resident remained on checks every 15 minutes, and had one episode stating he/she was going to jump, referring to the window. Nursing progress notes stated, a nurse's aide told the LN, she caught the resident attempting to put the call cord, again, around his/her neck. The resident should not have had a call cord in his/her room at the time of readmission due to the previous suicidal attempt with a call light cord just 2 days previously. In addition, the same nurse that took the call light away at the time of the second suicidal attempt with the cord, left the call light within reach at the residents table. The LN explained to the resident why the call light was not in bed with him/her (as he could put the cord around his neck), and left the call cord in the room with the resident. Staff continued checks every 15 minutes. In an interview on 1/26/17, at 11:30 Staff C stated education with all nurses took place after the second attempt at suicide with the call light cord. When asked about leaving the cord in the room when readmitted back to the facility on [DATE], and leaving the call light cord within the resident's reach after knowing the resident just used it to choke his/her self, Staff C stated That is not what should have been done. When asked if the resident would have been successful in a suicide attempt the second time with a call light cord, Staff C stated he/she would not want to cross that bridge. In a follow up interview on 1/31/17 at 12:05 p.m., Staff C stated he/she admitted the resident back into the facility on [DATE] and did not think about the call light cord being a means to commit suicide. In an interview on 1/31/17 at 10:40 a.m., Staff A stated the call light cord being left in Resident #1's room was discovered after the fact, and no one questioned it. Nursing progress notes showed on 12/19/17, during an Interdisciplinary Team (IDT) meeting, the call light was taken away, and a bell was given to the resident in its place, and the resident was placed on a one to one monitoring (1:1, one staff with resident at all times.) The first mental health follow up was done on this date, 19 days following the first suicide attempt. Per nursing progress notes, on 12/26/16, the resident was taken off of the 1:1 status and went back to checks every 15 minutes, as no suicidal ideation presented during the past week. The day before, the resident was diagnosed with [REDACTED].[DIAGNOSES REDACTED] was a condition which has the potential to cause delirium and dehydration related to frequent watery stools. On 1/2/17 at 12:00 p.m., the resident was found on the floor, fall #8, from the bed. The resident had a 1.0 x 5.0 cm. skin tear to the nose. The Medical Director (MD) gave an order at that time for an emergency department (ED) visit, a Computerized Tomography (CT) scan and psychiatric evaluation. In the nursing progress notes dated 1/2/17, the facility nurse reported to the ED the resident threw himself out of bed in an attempt to hurt himself/herself. ED notes dated 1/4/17 showed suicidal ideation as a diagnosis, and added Patient is having thoughts of not wanting to live, but no active suicidal thoughts. Patient is tearful. In an interview on 1/17/17 at 2:31 p.m., when Staff A was asked what was done for the resident during suicide attempts, Staff A stated the facility checked labs, ammonia levels, and the resident was in the hospital for a week and mental health professional stated he had delirium, due to a urinary tract infection. When asked about the facility policy related to suicide precautions, Staff A stated the facility does 15 minute checks, talks to the resident and ask if they have a plan, and call with physician, and send the resident out to the ED if appropriate. When asked why the resident had access to the call light cord during the second suicide attempt, Staff A stated the staff thought the cord issue was resolved. During an interview on 1/31/17 at 11:00 a.m., Staff A stated at no time in December 2016, a suicidality screener was done, per the facility policy. The facility failed to assess, recognize signs of suicidal ideation, implement their policy and procedure to conduct a suicidality screen following suicide attempts, or keep the resident safe by removing all means of harming him/her self during the resident's stay in the facility. the facility also failed to keep the resident safe from multiple falls. SMOKING ELECTRONIC CIGARETTES: During the 6/7/16 meeting of the Kitsap Health Board, the Board approved the Kitsap Public Health Board Ordinance 2016-1: Regulations Restricting Vaping In Indoor Public Spaces. The revised ordinance prohibits the use of vapor products in indoor public places, including the presumptively reasonable minimum distance of 25 feet from doors, windows that open, and to intake vents of indoor public places where vaping is prohibited. During an interview on 1/17/17 at 2:31 p.m., Staff A stated the residents currently can smoke electronic cigarette in bed or in the building, but in the near future it will change, as the law in Kitsap County was changed. During an observation on 1/19/17 at 10:10 a.m., Resident #2 was noted to have an e-cigarette at the bedside. During a concurrent interview, the resident stated he/she was allowed to smoke electronic cigarettes in bed/in building. During an interview on 1/26/17 at 1:55 p.m., Resident #4 stated he/she was allowed to smoke electronic cigarettes in bed and revealed he/she knew about plans to no longer smoke in the building. The resident stated They (the facility) told me about it, I'm going to go outside . after the new rule was in place. During a concurrent observation, it was noted the resident had two of the same smoking devices, with one charge cord. During an interview on 1/26/17 at 2:00 p.m., Resident #5 stated he/she was allowed to electronically smoke in bed/building, and the charger to the device was the same one which came with the device. It was noted the resident was also on oxygen therapy. Potential risks for a safety problem in the smoking device may occur, such as a spark.

Based on interview and record review, the facility failed to timely report, register incidents on the State Reporting Log or investigate three suicide attempts for 1 of 2 Sampled Residents (R#1) reviewed for psychological harm related to events regarding alleged potential abuse. This failure placed other residents at risk for psychological harm and resulted in actual psychological harm for R#1. Findings Include: Refer to 323 for additional details related to multiple suicide attempts and resulting harm for Resident #1. During record review on 1/19/17 of progress notes identified Resident #1's made three suicide attempts on the following dates: 12/1/16, 1/16/17 and 1/18/17. When reviewing the state reporting log, no entries were made for the suicide attempts for Resident #1. In an interview on 1/31/17 at 10:30 a.m., Staff A stated no investigation was done with the plastic bag or call light cord used during suicidal attempts made on 12/1/16, 12/16/16, and 12/18/16. Facility staff did not alert Staff A to the 12/1/16 event. Staff A also added any future suicide attempts will be reported to the department, and investigated. During an interview on 1/31/17 at 10:40 a.m., Staff A stated no reports had been made regarding the plastic bag over the resident's head on 12/1/16, and staff did not alert him/her until 1/3/17. Staff A added, such an event should have been on the 24 hour report and the report was usually reviewed by Staff A, but was not aware at the time of the incident. During an interview on 1/31/17 at 1:18 p.m., Staff D stated Clearly, we should have called the suicide attempts in and investigated.

Based on observation, interview and record review, the facility failed to identify and intervene when symptoms of psychological harm were evident in 1 of 5 Sampled Residents (#6), reviewed for psychological harm by medical social services following an allegation of staff verbal abuse. This failure caused Resident #6 to have lasting psychological harm and placed all residents at risk for psychological harm following future allegations of abuse. Findings include: PSYCHOLOGICAL HARM During a record review of a facility investigation on 1/17/17, it was revealed a facility employee allegedly verbally abused Resident #6 on 12/28/16. During the course of the investigation, the facility found two residents speaking to each other. Resident #6 initiated a religious conversation with Resident #7, who did not understand the conversation and became increasingly agitated and confused. Staff E intervened, and asked Resident #6 to stop talking to Resident #7, which Resident #6 took great offense to. Witness statements written 12/29/16 in the investigation stated, the resident was up all night crying and from now on the resident was going to stay in his/her room. In addition, the resident told a nurse (he/she) had a bad night, and was crying while the nurse was passing her medications. The resident was then put on alert charting to monitor for psychological harm. In the investigation, a note was written by Staff B on 12/29/16, noted the resident was going to stay in (his/her)room, no longer wanted to run religious services in the facility, and stated Well, I guess it's time for me to move elsewhere!. Staff B also noted the resident was clearly defensive while speaking to a nurse, and was something he had never seen the resident do. In a follow up report written by Staff A, the facility stated Resident #6 had definite signs of being mad at staff, but no signs of psychological harm. During further record review, progress notes revealed the resident was affected by the facility asking him/her to stop talking to the resident. On 12/29/16, nurses notes stated the resident had not come out of his/her room this shift and appeared withdrawn. On 12/30/16 at 12:00 a.m., the resident appears sad and upset about the situation. On 12/31/17,noted indicated the resident appears sad and quieter than usual. On 1/3/17, the Interdisciplinary Team (IDT) was aware that resident remains upset with staff related to the incident. During an interview on 1/26/17 at 2:30 p.m., R#6 stated he/she was still affected by the 12/28/16 incident and is somewhat fearful of Staff E. Resident #6 stated, I cried for 2 days and 2 nights and it's still a big deal to him/her. In an interview on 1/26/17 at 2:40 p.m., Staff C stated the signs and symptoms of psychological harm are sadness, crying, decreased appetite, changes from baseline mood/behaviors and the progress notes on Resident #6 showed those signs. When asked what was done to follow up with these changes in baseline for Resident #6, Staff C stated he/she did not know, but the information was usually passed on to the social worker. During record review, social worker notes revealed there were minimal interventions done with the event of psychological harm to Resident #6. In a social worker note written 1/31/17, in a conversation with the resident, read the resident would prefer not to see mental health and was quoted as saying What good would that do? There were no other notes written in which social services followed up with the resident in addition to the one time offer of mental health visit. The care plan, written 1/3/17, revealed the social worker was to follow up with psychosocial harm and mood changes, and provide 1:1 with resident as needed for support. Resident #6's record did not contain evidence social service staff provided consistent and ongoing support for signs of psychological harm the resident demonstrated in response to a verbal statement made by Staff E, following an incident on 12/28/16. .

ELOPEMENT Based on observation, interview and record review, the facility failed to ensure a safe environment to prevent an avoidable elopement when 1 of 1 residents sampled for elopement (R#1) exited the facility, was lost outdoors and died shortly after. The facility failed to take immediate relevant corrective actions to prevent a similar accident, and protect other vulnerable residents from harm. In addition, the facility failed to protect residents from hazardous objects that were left in an unsecured construction area. These failed practices by the facility put all vulnerable, cognitively impaired, and delirious residents at risk of injury and the potential of death. This failure resulted in an Immediate Jepordy situation when R#1 was found outside on the ground approximately 2:00 a.m., after the resident eloped from the facility during the night. Findings include: Per state operations manual dated ¿¿¿¿¿2016, the definition of unsafe wandering and elopement occurs when a resident leaves the premises without authorization and/or necessary supervision to do so. A resident who leaves a safe area may be at risk to experience heat or cold exposure and or other medical complications, drowning, or being struck by a motor vehicle. Unsafe wandering and elopement can be associated with falls and related injuries. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, the resident needed supervision for locomotion on and off the unit, and walking in the corridor. The assessment stated R#1 was moderately cognitively impaired, and had hallucinations and delusions. According to the resident's admission record, the following additional [DIAGNOSES REDACTED]. On a physician's note dated [DATE], the resident had a [DIAGNOSES REDACTED]. A monthly note dated [DATE] included a [DIAGNOSES REDACTED]. During record review, a facility investigation report, closed on [DATE], was reviewed. In an incident on [DATE], it was revealed R#1 was last seen in the facility by the front door lobby at 12:30 am. At 2:25 a.m., pharmacy employee found the resident lying on his back outdoors in a parking lot with his head on the curb. At the time, R#1 had a wet productive cough, and had mental status changes. Emergency services were then called via 911, and the resident was taken to the emergency room (ER) and returned to the facility at approximately 6 a.m., without new orders. Resident #1 subsequently declined with increased respiratory symptoms, and was actively being treated by the facility Nurse Practitioner (NP) when Resident #1 died at 2 p.m., nearly 12 hours after being found outdoors. In an interview on [DATE] at 1:21 p.m., Staff A stated R#1 always sat out in the front lobby, would go to the front doors, and only look out. At 2:05 p.m., Staff A stated the facility determined the resident was not an elopement risk, however, an elopement plan of care completed by the facility on [DATE] indicated the resident had a desire to leave. Staff A added, he/she was not sure if the front door was locked on the night R #1 left the facility. Staff A was asked if the resident was still alive, what the facility would have done to prevent a recurring incident with R #1, and Staff A answered I don't know, we may have put a wander guard alarm on (R#1) and changed the care plan. During a record review of the elopement book (a log consisting of the names of the residents at risk of elopement), the resident was not listed as an elopement risk. The elopement plan of care dated [DATE] included: assessment, preventions, and management of residents at risk of elopement. Resident #1's elopement risk factors included: expresses a desire to leave, impaired cognition, independently mobile, a history of alcohol abuse, anxious, and paranoid behavior. A goal listed on the elopement care plan was to allow the resident at risk, to safely wander in the facility and to be free from elopement. A conclusion was made that R#1 was not at risk for elopement at this time, as he was not showing signs or symptoms of wanting to leave. In an interview on [DATE] at 2:05 p.m., when asked to explain R #1's desire to leave the facility, as indicated on the [DATE] elopement assessment, Staff A said the resident wanted to go to an assisted living facility instead of a nursing home. In an interview on [DATE] at 4:30 a.m., Staff B stated when fire exit doors were locked, the residents were able to leave freely, and no one could enter the building. In a concurrent demonstration, the front door was locked, and the bar could still be pushed open without a delay, to allow someone to leave the building. During an interview on [DATE] at 12:18 p.m., Staff E and Staff F said R#1's temperature was found to be 97.5 degrees Fahrenheit in the ER. Staff F stated that it was a point down from being considered normal, and added It is unlikely to have a respiratory infection when the chest x-ray is within normal limits a few hours ago. In an interview on [DATE] at 9:15 a.m., Collateral Contact (CC) #1 stated (R#1) was not ready to die and added, the resident was not in bad shape and the event that happened was not right. In an interview on [DATE] at 1:21 p.m., R#2 stated he/she did not know how to get into the building at night and he/she would break windows to get in. The resident was not aware there was a doorbell at the front door that could be rung to get back into the facility. During an interview on [DATE] at 1:30 p.m., R#3 stated he/she did not know how to get into the building at night, and would pound at the front door to get back in. The resident was not aware there was a doorbell at the front door that could be rung to get back in the facility. In an interview on [DATE] at 1:37 p.m., R#4 did not know there was a door bell and if he/she was out there, he/she would dial a cellphone and call the facility, and added if his/her blood sugar dropped, the resident would not be able to use the cell phone. I wouldn't even know how to call. This resident recognized if he/she was compromised, it would be difficult to get back into the facility. During an interview on [DATE] at 10:52 a.m., CC #2 stated the elopement and laying on the ground for an undetermined amount of time very well could have contributed to the resident's death. In an interview on [DATE] at 1:45 p.m., Staff C stated he/she saw the resident sitting out in the lobby area at 12:00 a.m., and when R#1 was not present in the lobby, he/she assumed the resident went to sleep. Staff C added the resident was outside for a possible two hours, and when found the resident was cold and shaking as it was approximately 40 degrees outside. The doors were generally locked between 10:30 p.m. and 11:00 p.m. for resident safety to keep unwanted intruders from coming in the building. Staff C stated when exit doors are locked, no one could get back in and added I have concerns .we have nothing to indicate if someone leaves, and no camera systems to monitor. During an observation on [DATE] at 4:26 a.m., the service door was unlocked and open to the public, as investigators walked into the building and in a concurrent interview Staff F stated This door is always open. The service door leads to a service hall in which the opposite end of the hall had two double doors that swung open into B hallway where residents lived. During an observation on [DATE] at 4:29 a.m.the fenced in court yard gate was not locked and the smoking door that leads into B hallway was open where residents lived, which gave the unwanted intruders public access to the facility. During an observation on [DATE] at 4:35 a.m. the front door was not locked, which gave unwanted intruders public access to the facility. The doorbell was not visible, as it was white as well as the trim it was mounted on, and there was no signage directing to ring the doorbell, in order to gain access to the building after hours. In an an observation and concurrent interview on [DATE] at 4:35 a.m, Staff G stated if he/she was at the end of A hallway, s/he could not hear the front doorbell when it rang. A hallway had a door that leads to outdoors, and when tested , it was also unlocked, there was no doorbell to get back into the facility as well. In an interview on [DATE] at 4:38 a.m., Staff D stated sometimes we forget to lock the doors. During an observation on [DATE] at 4:50 a.m., in the lobby by the front door and nurse's station, it was noted 3 staff were behind the nurse's station and a resident with a wandergaurd (a device that is warn on a person or mobility device which alarms and prevents residents from exiting the building by locking the door from the inside) was noted to try to exit the building when the wandergaurd alarm went off. There were also 3 other residents in the area, drinking coffee. During an interview on [DATE] at 7:35 a.m., Staff A stated the doors were locked at night because there were homeless people that came in and all doors could be locked. Staff A added there was a history of homeless people coming into the facility and staff finding them sleeping on the couches, and twice this year there have been incidences of inappropriate family members entering the facility. None of our residents sleep through the night. Staff A added, night shift locks the doors between 10:30 p.m. and 11:00 p.m., until 6 a.m. to 7 a.m. Staff A stated Staff B trained nurses last week how to lock the special side door which opens into a unsecured fence area where residents gather. The door was not previously working. During an interview on [DATE] at 8:30 a.m., Staff I stated I do not know how to lock the special side door. In an interview on [DATE] at 8:47 a.m., Staff J stated the doors should be locked every night. When Staff J was asked why the doors were open this morning, he/she stated the nurses will be disciplined. In a concurrent interview with Staff A, he/she stated Staff B only trained me, and indicated he/she had not trained all of the nurses. At 2:30 p.m., Staff J stated R#1 had dementia, but knew where he/she was and would read the newspaper and come and visit in the office. Staff J added, No interventions were put in place regarding elopement. During an interview on [DATE] at 1:44 p.m., Staff J stated the facility treated the event as an unexpected death and not an elopement, and adding alarms were not a substitute for supervision. Staff J added if the resident didn't die, the facility would have done an elopement assessment on R#1. Staff J stated documents for trainings on elopements of the staff were not available. The facility did not recognize environmental hazards included the outside doorbell was not audible in the hallways or visible outside. The facility did not minimize the environmental hazards by not ensuring the residents were aware there were only two door bells that could be accessed outside, one in the smoking area, and one by the main door, and there were a total of 5 exit doors in the facility. The facility did not consistently secure the doors per facility rules. The facility did not place alarm sensors on all exit doors, alerting staff to an outgoing resident. The facility also did not educate the staff regarding elopement. The facility failed to protect residents' space, as intruders were not prevented from entering the building and residents were not prevented from being lost, as residents could get out of the doors, but not back in. UNSECURED CONSTRUCTION SITE According to the state operations manual, dated 2016, Adequate supervision to prevent accidents is enhanced when the resident environment may contain temporary hazards (examples .construction, painting, housekeeping, activities, ect .) that warrant additional supervision or alternative measures such as barriers to prevent access to affected areas of the resident environment. During an observation on [DATE] at 9:25 a.m., room 21 did not have a lock to the door and a do not enter, under construction sign was posted on the door. Upon entering the room, it was noted to be under construction with no one in the room. Inside the remodeling of a resident room and bathroom was being completed. There was exposed wire, chains for fans, loose screws, a hammer, paint buckets, a wooden paint extender (for paint rollers), and a ladder. During an interview on [DATE] at 9:30 a.m., Staff B stated, I do not have a lock, as I just used the last one on a resident shower room. Staff B added, he/she would be done with the room at the end of the day, and did not see urgency in the room being unsecured. During an interview at [DATE] at 9:53 p.m., Staff J stated he/she understood the urgency and a safety plan was requested. During an observation on [DATE] at 11:30 p.m., the door was secured to room 21. The facility failed to secure a construction door, leaving vulnerable residents access to hazards in a construction site, and placing residents at a potential risk of a serious injury or a potential death. .

Based on interview, and record review, the facility failed to ensure licensed staff utilized correct technique when providing specialty care for 1 of 3 Sample Residents (#1). The failure included unsafe oxygen and intravenous (IV) fluid administration. The IV fluids were administered in large quantity and rapidly, contributing to the development of [MEDICAL CONDITIONS]. Low flow of oxygen was administered through a simple mask allowing the resident to retain carbon [MEDICATION NAME] (CO2) which alters blood chemistry and causes damage to organs The combination of two inappropriately administered treatments resulted in [MEDICAL CONDITIONS]. The facility disregarded the resident's risks of congested heart failure ([MEDICAL CONDITION]) and [MEDICAL CONDITIONS] and used inappropriate methods of treatment delivery constituting actual harm. Findings include: Resident #1's [DIAGNOSES REDACTED]. OXYGEN ADMINISTRATION On 10/10/16, Resident #1 was sent to the ER (emergency room ) after being found laying on the ground outside of the facility round 2:00 a.m. by a delivery personnel. Resident #1 returned to the facility from theER on the same day around 6:30 a.m. according to nursing notes dated 10/10/10. Shortly after arrival, Resident #1 went into acute [MEDICAL CONDITION], with noted changes in mental status and [MEDICAL CONDITION] (low oxygen blood levels) according to the assessment documented by healthcare practitioner Staff F on 10/10/16. Staff F also documented Resident #1 had treatment of [REDACTED].C. (nasal cannula). Review of written prescribed orders dated 10/10/16 instructed licensed staff to administer oxygen at 4L/min. Resident #1's oxygen saturation was 87% (measurement for blood oxygen levels, normal is >90% and up to 100%). Facility staff administered 2 L of oxygen through a simple face mask as according to documentation by nurses on 10/10/16 at 11:30 a.m. The nurses administered 2 L of oxygen instead of the ordered 4 L. During interview on 12/12/16 at 1:25 p.m., Staff M confirmed oxygen was delivered by a simple face mask. Staff M said Resident #1's oxygen rate was increased to 3L through face mask when the resident had respiratory problems. It is a common knowledge among healthcare professionals when using a simple face mask the oxygen flow must be at least at 5L to flush CO2 (carbon [MEDICATION NAME]) out keeping CO2 blood levels down. Observations on 12/6/16 at 12:50 p.m. in the central supply room with Staff K revealed that facility had simple masks on hand and utilized those. Staff K was asked about parameters of acceptable flow through face mask. Staff K said one could administer up to 2 L per simple mask. On 12/6/16 at 1:58 p.m., Staff A was asked about parameters of oxygen flow through simple face mask. Staff A indicated 4-5 liters could be given through a simple mask in order to provide right amount of concentrate. In Interview on 12//7/16 at 12:54 p.m. with CC#3(Collateral Contact) who specialized in respiratory therapy, CC#3 explained that the standard is to administer at least 5 L per simple face mask otherwise a person retains CO2, condition known as hypercapnea. CC#3 stated This causes changes and imbalances in the blood chemistry and ultimately poisons organs. INTRAVENOUS FLUID When Resident #1 returned from the emergency room around 6:30 a.m. on 10/10/16, he was in respiratory distress as evidenced by increased respiratory rate and abnormal lung sound as documented in nursing and medical provider notes dated 10/10/16. Despite Resident #1 being at risk for fluid overload given [DIAGNOSES REDACTED]. Order dated 10/10/16 instructed to administer Normal Saline at 250 ml/hr x 4 hours. Infusing large amount of intravenous fluids quickly into Resident #1 who had compromised heart and lungs resulted in [MEDICAL CONDITIONS] (fluid in lungs) worsening resident's ability to breathe. Nursing assessment documented on 10/10/16 at 8:00 a.m. revealed Resident #1's lungs sounded abnormal without a stethoscope. Resident #1 had wet crackles (rattling sounds in lungs, usually due to presence of fluid). Despite acknowledging this abnormality Normal Saline was infused at 250 ml per hour through IV line as documented in nursing notes on 10/10/16 11:00 a.m. The Medication Administration Record [REDACTED]. There was no flow sheet showing that IV fluid administration was monitored for safety. Resident #1 continued with wet cough and required suctioning according to nurses notes dated 10/10/16 at 2:30 p.m. Nursing notes on this same day indicated [MEDICATION NAME] (diuretic) was administered IV around 1:30 p.m. The resident was foaming at the mouth, according to the same note. Staff L on 12/6/16 at 12:09 p.m. said Resident #1 went into severe [MEDICAL CONDITIONS] and it came on suddenly. Staff E on 12/6/16 at 12:18 p.m. was asked about intravenous fluids administered at a rate of 250 ml/hr in to Resident #1 who had [DIAGNOSES REDACTED]. Staff E indicated this intervention can push into [MEDICAL CONDITIONS]. On 12/12/16 at 12:26 p.m. Staff L said if she knew Resident #1 had wet lung sounds she would not order IV fluids. Staff L indicated she should have asked about resident's respiratory status before giving orders for IV fluids, but did not. Staff I on 12/12/16 at 1:15 p.m. said she would question an IV infusion rate of 250 ml/hr for someone with [DIAGNOSES REDACTED]. It is common knowledge among healthcare professionals not to administer fluids rapidly and at a high rate into people with [DIAGNOSES REDACTED].

Refer to F 323 and F 328 Based on interview and record review, the facility failed to immediately protect vulnerable residents pending the results of an investigation. The facility failed to conduct a thorough investigation related to the elopement of R#1, for 1 of 3 facility investigations reviewed for ruling out neglect and abuse. The facility failed to conduct a timely investigation, thoroughly investigate following the elopement of R#1, preventing staff from determining what additional elopement interventions were required to prevent elopements of residents who were cognitively impaired or had altered mental status and did not wear a wandergaurd (a device worn on the resident or mobility equipment). This failure placed all residents at risk for neglect and abuse, and resulted in harm to R#1, and ultimately, death. Findings include: During a record review of the facility investigation dated [DATE], revealed the resident died on [DATE], and the investigation was closed on [DATE], ten days late. The document stated abuse ruled out, however, the investigation did not state why and how this conclusion was determined. The facility failed to address neglect related to R #1's elopement, and unsafe delivery of treatments pertaining to administration of oxygen and intravenous fluids (IV) after an elopement incident. The investigation was conducted for an unexpected death, and not for and elopement incident. The inappropriate and unsafe treatments were not investigated, and were not viewed as incidents related to neglect. The investigation had no witness statements attached, and under the title witness statement regarding the incident, the document stated N/A. Under oxygen saturations, the document read N/A. Under location of the incident, the document reads resident room and under activity the document stated in bed when the elopement incident occurred outdoors and the resident was laying on the road outside the facility. The facility failed to identify a root cause to the event, which was an elopement by R#1. During an interview on [DATE] at 1:21 p.m., when asked how abuse and neglect was ruled out, Staff A stated Staff C was responsible for ruling out abuse as Staff C was the licensed nurse on duty when the incident occurred. (Again, neglect was not mentioned). No staff suspensions took place, pending the investigation. During an interview on [DATE] at 2:05 p.m., Staff A stated there were no statements from staff for the investigation, and said she (Staff A) came to her own conclusion after interviewing staff. Staff A added he/she was not sure if the doors to the facility were locked the night of [DATE], when R#1 eloped from the facility. In interview on [DATE] at 1:45 p.m., Staff C stated after she saw R#1 at 12:30 a.m., and later did not see him, she assumed the resident went to bed. Staff C said she did not check on him at that time. During an interview on [DATE] at 7:30 a.m., when Staff A was asked why locking the door was not part of the investigation, he/she stated I didn' t think of it. Staff A did not investigate the reason why the resident went out of the facility unsupervised between 12:31 a.m. and 2:00 a.m., and did not address that staff did not check on the resident after he was no longer seen after 12:30 a.m., as this was not a pattern for R#1 to go outside. When Staff A was asked if the door bell was tested on the day of [DATE], she stated I don't know. When Staff A was asked how neglect was ruled out, she stated the Nurse Practitioner (NP) came in to treat R#1; we all treated him. When asked who was in charge of abuse and neglect issues in the building, Staff A stated probably me. When asked why the IV fluids were stopped, Staff A stated I don't know. When asked what was the cause of death of R#1, Staff A stated I do not know what he died from, I guess I would look at the death certificate. During an interview on [DATE] at 2:30 p.m., when asked what she expected facility staff to achieve and accomplish during an investigation, Staff J stated I would expect interviews of pertinent staff, come to a reasonable conclusion and have interventions. When asked what interventions were put in place related to findings of R#1's investigation, Staff J stated None, didn't consider him missing. The facility failed to conduct a thorough investigation into the death of a resident after an elopement incident, and after special treatments were provided pertaining to the care the resident received after the elopement. .

Based on observation, interview and record review, the facility failed to provide an individualized meaningful activity in accordance to a personal preference for 1 of 1 sampled residents (R#7) reviewed for psycho social well-being. This failure placed all residents at risk for a diminished quality of life and prevented R#7 from attaining his/her highest practical psycho-social well-being and caused actual psycho-social harm. Findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS stated the resident needed to be supervised for most activities of daily living, and it was very important to do his/her favorite activities. During a record review of a facility investigation dated 11/20/2016, Resident #7 was in an altercation with another resident over putting puzzles together. The residents were separated and the puzzles were removed as it was the second altercation over the puzzles. Life Enrichment (Activities Department) removed all puzzles and replaced them with free time coloring books. During an interview on 12/2/16 at 9:45 a.m., R#7 stated the other resident involved came to him twice while he was working on the puzzle and said Quit that! Quit that! And then hit me. When asked what happened next, R#7 stated a lady (who he could not recall) told him that the puzzles needed to be taken away, and that the activity caused too much trouble. R#7 added, the puzzles were no longer there, and there were no more puzzles. During a concurrent observation it was noted the resident leaned back in his bed, and had tears well up in his eyes. R#7 stated no one came into his room to set up a puzzle, and if that resident was not in the facility, he would like to do puzzles again. In an observation on 12/2/16 at 11:30 a.m., R#7 was sitting in a wheel chair rocking it back and forth staring out a window. In an observation on 12/6/16 at 11:50 a.m., R#7 was sitting in a wheel chair by the entrance looking around, hands in his lap, and smiled when he was greeted. During an interview on 12/6/16 at 2:30 p.m., Staff O stated administration said to remove the puzzles. Staff O stated it was not worth the residents fighting over them. Staff O added They both liked to do puzzles. During a record review of the resident's care plan, it was revealed under interventions for mood/behavior the puzzle was removed. In the activity care plan, it revealed under goals the resident will continue to make daily preferences/choices that are important to them in the area of watching tv, working on jigsaw puzzles in Olympic room. Puzzles are mentioned 2 more times as interventions and goals for R#7. During further record review of the resident's nursing progress notes dated 11/21/16, it was revealed the interdisciplinary team was aware of the altercation and puzzle removal from the front room. During an interview on 12/12/16 at 3:00 p.m., Staff J stated he/she was not the one who made the directive to take the puzzles away, and did not recall the interventions that were put in place related to the resident to resident altercations with R#7, and the puzzles. Staff J added the staff will try to set up puzzles in his room or speak to the resident to see what he wants to do. The facility caused resident #7 psychosocial harm by taking away an activity the resident was very interested in doing for a personal preference past time activity. .

Based on observation, interview, and record review, the Administrator failed to effectively and efficiently manage resources to ensure facility compliance with federal regulatory requirements. Failure to ensure compliance related to elopements, special treatments, investigations, and activities, resulted in harm to Resident #1 as referenced in F 323, 328, and 225, and harm to Resident #7 as referenced in F 248, and Immediate Jeopardy in F 323. Findings include: 1. Refer to 42CFR 483.25(h)(1)(2)-F323 All residents in the facility were placed in an immediate jeopardy situation when a resident requiring supervision exited the facility unsupervised during the night, and was missing. The Administrator failed to ensure staff adequately supervised the resident to prevent an elopement incident. 2. Refer to 42CFR 483.13(c)(3)-F225 The Administrator failed to ensure thorough investigations were conducted to rule out abuse and neglect related to an unexpected death of a resident, after an elopement incident, and related to special treatments pertaining to safe oxygen delivery and fluid resuscitation. These failures resulted in not recognizing when inappropriate and unsafe special treatments were provided in the care of R #1 after the elopement incident, and not identifying inconsistencies in securing entrances and exits to decrease the likelihood of repeat elopement incidents. 3. Refer to 42CFR 483.15(f)(1)-F248 The Administrator failed to ensure staff provided appropriate interventions related to activities to prevent resident altercations, and to maintain or improve a resident's quality of life. This failure resulted in psychological harm to Resident #7. 4. Refer to 42CFR 483.25(k)((2)(6)-F328 The Administrator failed to ensure residents received proper treatment and care when staff delivered oxygen and fluid resuscitation, resulting in the inappropriate and unsafe administration of oxygen and fluid resuscitation to a resident who subsequently died .

Based on observation, interview, and record review, the facility failed to recognize indivividual preferences for pain relief, failed to revise interventions for effective pain management, assesss/reassess, adequately treat pain, and address underlying causes of pain for 3 of 5 sampled residents (#s 2, #65, # 81), reviewed for pain management. This failure resulted in harm for two residents, and placed on resident at risk for unrecognized sources of pain, worsening and prolonged pain, discomfort and delay in medical treatment for [REDACTED]. Additionally, the facility failed to ensure medications were provided as ordered when a resident went out of the facility to the [MEDICAL TREATMENT] center, for 1 of 1 resident (#s 68) reviewed for [MEDICAL TREATMENT] and failed to administer a medicaiton in a timely manner to 1 of 1 sampled residents (# 145) reviwed for quality of care. These failures placed the residents at risk for imbalances in laboratory values and ineffectiveness of medication and decreased quality of life. Findings include: Review of the facility policy titled Pain Management Program, dated July 2015, revealed pain was subjective and individual and the goal of pain management was to reduce physical and psychological symptoms associated with pain and assist the resident in achieving the highest practicable level of functioning. According to the policy, a full evaluation included origin, location, frequency, type, severity, alleviating factors, exacerbating factors, current treatment and response to treatment. The evaluation included verbal and non-verbal expressions and behaviors associated with pain. All residents were initially screened for pain upon admission, quarterly, significant change in condition, and any time it was suspected a resident was in pain. The resident, family and interdisciplinary team (IDT) was included in the assessment of pain, interventions and goals. Appropriate interventions included pharmacological and non-pharmacological interventions. Staff were directed to reassess as indicated and screen residents for pain regularly through asking the residents if they had pain, observe during cares, and observing for signs and symptoms of pain. Staff were to notify the provider if interventions were not effective in achieving comfort and/or function goals within 24 hours. RESIDENT #2 Record review of the 3/10/16 annual Minimum Data Set (MDS, an assessment tool), revealed Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was dependent on staff for bed mobility, transfers, toileting, dressing, bathing and grooming. Set up assistance was required for meals. Resident #2 had short and long term memory loss with impaired problem solving skills. Record review of 3/10/16 Care Area Assessments (CAA) revealed Resident #2 triggered for cognitive loss, communication, activities of daily living (ADL's), and pain. The resident exhibited decreased ability to make him/herself understood and understand others, exhibited behaviors such as yelling out, identified as having the potential for more independence with ADL performance with adaptations or accommodations, was hard of hearing, had vision problems, was at risk for functional decline related to relying on staff for all mobility, complications of immobility and depression. Review of the 3/10/16 pain CAA revealed Resident #2 received [MEDICATION NAME] routinely and as needed. S/he would cry out in pain with position changes and transfers. At times pain would interfere with sleep due to every two hour check and change. The resident usually rested comfortably after receiving pain medication. Characteristics of the resident's pain were not identified (location, what made it better, type, triggers, frequency. Non-verbal indicators and associated signs and symptoms of pain were not identified, though the resident had memory impairment and behaviors such as yelling out. It was identified Resident #2 remained at risk for ineffective pain management. Facility staff were to assess for pain, medicate as ordered, assess for effectiveness and adverse side effects. Staff were to offer alternate pain relief measures as needed. Record review of the 3/10/16 document titled, Quarterly Nursing Data Collection and Assessment, revealed Resident #2 exhibited pain in the past several months, deformities and impaired range of motion located in bilateral ankles/legs, and weakness. Record review of May 2016 Medication Administration Record [REDACTED]. Documentation revealed that when staff were asking the resident if his/her pain medication was effective, the resident was responding yes. However it was unclear the timing of the question, what the resident was doing at the time of the question, if the resident heard, understood or recalled adequate information to appropriately answer the question despite hearing difficulties and cognitive impairments. For the survey ending on 5/27/16, record review of the May 2016 MAR indicated [REDACTED]. Of those 22 times, 11 of them were in the early morning hours between 12:05 a.m. and 8:30 a.m., 8 were between the hours of 5:45 p.m. and 11:30 p.m., and 3 were given between 11:40 a.m. and 12:30 p.m. Record review of the pain flow sheets for February, March, April and May 2016 revealed there did not appear to be a pattern of usage as one month Resident #2 used 26, 19 another month, 13 another month and 25 doses in May 2016. Review of the most recent document titled, Pain Data Collection and Assessment dated 3/10/16 revealed the [DIAGNOSES REDACTED]. The assessment did not identify other possible factors, [DIAGNOSES REDACTED]. No non-pharmacologic approaches were identified nor effectiveness. According to the 3/10/16 assessment, the resident was unable to answer or complete the questions, and observations included relaxed, making eye contact, calm and pleasant. Signs and symptoms of pain the resident exhibited at the time included occasional moaning. The family was not included in the interview to obtain additional information. The answers were based on feedback from the resident and staff, to conclude the current pain management regime was effective. The 3/10/16 pain assessment data conflicted with observations, interviews and record reviews and appeared to not reflect an accurate depiction of Resident #2's actual non-verbal signs and symptoms of pain to include frequency, severity, type, location, patterns and potential causes. The resident was not reassessed at another date or time when s/he was able to answer the questions, when family was involved, or when the resident was actually experiencing pain. Record review of the pain management care plan dated 3/24/16 revealed Resident #2 had persistent chronic pain related to arthritis and [MEDICAL CONDITION]. The goal for the resident was identified to decrease persistent pain to a tolerated level so the resident could function in daily life, with no decline in activity, and to be able to attend recreational activities, have no non-verbal signs of pain, and no complaints of pain when questioned. Interventions included monitoring, assess verbal and non-verbal signs and symptoms of distress unrelieved by ordered treatments or medications, and observe during rest and during movement for pain. Staff were to provide alternate comfort measures to include position change, smooth linens, encourage mobility, physical activity as tolerated to prevent stiffness and contracture. The 3/2016 care plan did not include heat packs per resident preference. The facility did not demonstrate encouragement of mobility and activity to prevent stiffness or contractures, or identify movement as a potential cause of pain. Record review of the cognitive assessment and plan of care dated 3/14/16, identified as Resident #2 with moderate cognitive impairment with memory loss and impaired judgement. Mental function varied throughout the day, and staff would anticipate the resident's needs 100% of the time. Record review of restorative program notes dated 1/8/16 revealed participation with the program depended on the resident's mood, thus intermittent. According to the 3/2016 mood care plan, mood indicators included repetitive verbalizations, yelling out, combative and refusals, all potentially related to unidentified pain. Record review of Optum Monthly Note dated 4/12/16 revealed Resident #2 had a history of [REDACTED]. Observation on 5/18/16 at 10:30 a.m. upon arrival to the facility, a female voice was heard yelling Ow, ow, it hurts! repeatedly. Upon entrance to the facility, the yelling Ow, I can't move was heard louder, coming from the A hall. The source of the yelling and crying was Resident #2 in his/her room with staff. When one staff exited the room, the other staff member was repositioning the resident's feet in bed with blue padded boots and the resident was lying flat on his/her back. The resident said, Ow! I can't move my legs! My foot is twisted! The resident's affect was pained, breathing strenuous. The nursing assistant (NA) replied to the resident, You haven't moved them in a long time. The resident was wearing a hospital gown and continued to moan in pain after the staff member left the room. After several minutes, Staff N entered the room and removed the boots per the resident's direction and informed the resident and other staff that the boots would stay off until the pain medication kicked in. The resident stopped yelling out and gradually quieted down after several minutes. On 5/19/16 at 9:49 a.m., Resident #2 was observed wearing a hospital gown, lying in bed moaning, rocking her head from side to side, saying Ow, while staff were performing cares. At 10:44 a.m., staff had completed cares and were out of the room, but the resident continued to moan in pain for several minutes afterward. In interview on 5/19/16 at 10:50 a.m., Staff N reviewed the resident's pain medication regime and stated changes were recently made to include an increase in [MEDICATION NAME], even though the date of the order was 11/13/15, and Resident #2 had shown an improvement in his/her pain level since last year. In interview on 5/19/16 at 2:41 p.m., Resident #2's family member stated the resident had experienced pain with no relief that began prior to admission at the facility. The pain was from arthritis in his/her shoulder that caused a constant ache, and was painful when moving him/her. Observations on 5/20/16, 5/23/16 and 5/25/16 revealed at various times throughout the morning and afternoon, Resident #2 was sleeping in bed, television on, and not easily aroused by voice. Observation on 5/24/16 at approximately 8:30 a.m., revealed Resident #2 was heard crying out, yelling Ow! Oh, it hurts! The resident complained of pain in his/her hips, back and legs. Staff S opened the door to exit the room, and an odor was present from staff having just changed the resident. In addition, the resident was wearing a hospital gown and the breakfast tray was on the bedside table, untouched. In interview, Staff S stated Resident #2 had been changed approximately 10 minutes prior, and stated the resident had been goodthe last two days, but woke up like this, this morning. The resident then yelled out and wanted the head of the bed in the up position. At 8:36 a.m., six minutes later, Resident #2 was still moaning out. In interview 5/24/16 at 9:42 a.m., Staff P stated most of theresidents were cognitively intact and made pain assessments easy. The therapy staff communicated well to provide pain medication prior to therapy. Only a few residents assigned to Staff P were cognitively impaired, which required investigative work to determine what was effective and not effective, such as repositioning or a heat pack. Staff P had worked with Resident #2 for two years and complained of pain mostly in his/her hips and during repositioning. Staff P further stated Resident #2 was difficult to assess. The resident received routine [MEDICATION NAME], twice daily and routine [MEDICATION NAME]. The resident was sometimes happy and pleasant, sometimes called out, possibly related to behaviors. Behaviors were documented when it was out of the norm for the resident. The resident's physician order for [REDACTED]. The [MEDICATION NAME] was assessed 30 minutes after administration and was usually effective. At that time, cares were completed and the resident was lying in bed. Observation on 5/26/16 at 9:39 a.m., revealed Resident #2 was sitting up in bed, wearing a hospital gown, television was on and was looking at her nails, and appeared in a good mood. In interview on 5/26/16 at 9:39 a.m., Resident #2 stated s/he was feeling great. When asked about pain, the resident stated s/he had arthritis in his/her knees all the time. The resident stated heat was the most effective intervention for the pain, but the facility did not provide the intervention. Observation on 5/26/16 at 10:34 a.m., revealed crying and yelling out, Ow, my hips! came from the room of Resident #2. Staff Q was changing the resident, and the sheets on the bed. When asked if the resident had medication for pain, Staff Q stated the nurse usually medicated the resident at set times. In further observation at 10:34 a.m., Staff R entered the room to assist with cares. Each time the resident was turned on his/her side, the resident cried, and yelled out louder in pain, Ow! My hips! My toes! Resident #2 was still complaining of pain, but stated s/he wanted to get dressed, get up in his/her chair and get his/her nails done. The resident's nurse was notified to request pain medication. Staff assisted dressing the resident. Resident #2 complained of pain in the hips, lower back, and toes each time s/he was moved side to side and legs moved. The resident was tearful and moaning in pain. Staff R asked the resident if s/he wanted to get up or wait until the pain medication was effective. Resident #2 continued to state s/he wanted to get up. At 10:50 a.m., Resident #2 still complained of pain and was tearful. The licensed nurse, Staff K arrived with medication. When Staff K asked the resident on a scale from zero to ten (zero being no pain), what was the current pain level, Resident #2 stated A 10! My hips! Staff R asked Resident #2 if s/he wanted to wait for the pain medication to work or continue to get up, the resident expressed s/he wanted to continue to get up. At 10:54 a.m., staff started the hoyer transfer lift. As soon as the lift raised the resident in the air, the resident's volume level grew louder as s/he cried in pain. Due to the visual and audible intensity of Resident #2's pain, staff stopped the transfer and put the resident back to bed. At 11:04 a.m., staff repositioned the resident and removed the sling and replaced the padded boots. Each time the resident was moved, the resident continued to complain of back, toe and hip pain. The resident stated, I have never been in so much pain in my life! Due to pain, Resident #2 was not able to participate in desired meaningful activities. In interview on 5/26/16 at 11:09 a.m., Staff K stated the medication that was given to Resident #2 at 10:50 a.m. was [MEDICATION NAME] (an antianxiety medication), not a pain medication. The resident had already taken all his/her routine and as needed prescribed medication for pain, at 8:00 a.m. and was not due for the next [MEDICATION NAME] (narcotic) until 12:00 p.m. Staff K stated what s/he observed earlier was pain and what the resident was prescribed and taking was not effective. Record review of a written statement from Staff K, revealed conflicting information provided by Staff K in comparison to the initial interview performed 5/26/16 at 11:09 a.m., to include time Resident #2 received the medication, medication provided (identified as pain mediation), pain level the resident had reported, statement related to effectiveness of pain medication regime. The facility did not comprehensively assess Resident #2's pain to include adequately premedicating prior to cares, utilize and re-evaluate non-pharmacological interventions, rule out pain as a potential trigger to behaviors exhibited, anticipate the resident's needs, meet resident-centered activity and pain goals to determine effectiveness of the current pain management program. RESIDENT #65 Record review of 4/16/16 quarterly review MDS revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required total physical assistance for bed mobility, transfers, mobility and activities of daily living (ADL's) to include eating. Resident #2 had impaired cognitive status related to memory, judgment and insight. The resident did not complete the cognitive assessment, thus severity of deficit was unclear. The resident exhibited mood indicators including feeling down, tired and difficulty sleeping at times. The resident demonstrated verbal abuse and socially inappropriate behaviors that significantly impact care and participation in activities 4-6 days a week. Record review of the May 2016 Physician's orders revealed an order for [REDACTED]. Further review of physician's orders revealed the resident was to wear a splint on his/her right hand for a maximum of eight hours, splint on left hand for four hours, splint on left elbow for six hours (splint to be off when laying on left side). Pain In interview on 5/19/16 at 3:27 p.m., Resident #65 stated s/he required splints on both arms and were painful even after medications. The resident's affect was agitated, was lying in bed with bedside curtains drawn. In interview on 5/20/16 at 9:35 a.m., Resident #65 stated s/he had unrelieved pain and discomfort in his/her buttocks. It feels like a metal pan under my butt, my left side. I cannot move myself and staff reposition me when they change me. In interview on 5/24/16 at 12:16 p.m., Resident #65 spoke in a raised voice, not easily redirectable. The resident stated s/he was in pain and had pain all the time, but didn't verbalize it because s/he was tough. The pain resided in his/her legs, back and buttocks. When s/he participated in restorative therapy and put splints on, It hurts like hell! When asked what they were doing for the pain, the resident responded, Not much. They give me some pills, but they don't work. Maybe that is why I get so cranky in the afternoons. Resident #65 stated he used to get up out of bed and in his power chair and drive around outside, but it had been at least six months since s/he had been up in it. The resident could no longer get up and drive it due to not being able to move his/her arms, also related to pain. Record review May 2016 physician's orders revealed there were no available medications as needed for pain relief. Telephone orders revealed [MEDICATION NAME] discontinued 3/4/15, and [MEDICATION NAME] discontinued 6/3/15 for non-use. Record review of the pain management care plan dated 4/23/16 revealed Resident #65's potential altercation in comfort was identified secondary to tetraplegia, spasms, contractures, [MEDICAL CONDITION] skin. Interventions included cold packs, position changes, massage, smooth linens, encourage mobility and physical activity as tolerated to prevent stiffness or contracture. However, interventions did not include identification of precipitating factors of pain and pre-medicate for pain prior to activity to optimize participation. Review of the cognitive assessment care plan dated 4/20/16 revealed severity was uncertain because Resident #2 did not respond if s/he did not answer, such as the day, month or year for the quarterly cognitive assessment. The resident also made statements such as s/he did not pay attention to time. Record review of Resident #65's pain assessment dated [DATE] revealed [DIAGNOSES REDACTED]. The assessment did not include [DIAGNOSES REDACTED]. The resident was unable to answer if pain had limited his/her ability to move or participate in activities, in addition to interventions attempted in the past which did not relieve the pain or were unable to tolerate. The risk factors associated with of the [DIAGNOSES REDACTED]. The location of the pain and severity was verbalized at a four on a scale of 1-10, with ten being worst pain, located in the elbow. In addition, the resident stated if staff repositioned him/her, the steel on my back would be gone. Staff responded that they were not able to locate any steel on his/her back. No further information of what was done to relieve the discomfort, what the discomfort might have been or caused from, was not described. The list of pain medication that was identified on the assessment included current medications, and did not include [MEDICATION NAME] or [MEDICATION NAME], and did not include effectiveness as instructed. Non-pharmacologic approaches included splinting, though it did not address that the splinting process was painful. According to the assessment, the interviewer's observations of indicators of pain included the resident being conversant, pleasant and smiling. The resident demonstrated behaviors (did not describe) occasionally, but it was concluded not related to pain, however was not further explained why. Record review of the Optum physician progress notes [REDACTED]. Resident #65 was positive for anxious, agitation, compulsive behavior delusion, denial, depressed affect, hallucinations, obsessive thought, poor insight and poor judgment. The physician reported nursing had no concerns about the resident at that time. Further review of the progress note, the physician documented Resident #65 was severely disabled, had a lot of anger and anxiety surrounding care, was resistive to care and stated s/he did not receive it. Consistent staff assignments seemed to benefit the resident. Record review of nursing progress notes dated 5/22/16 and 5/23/16, revealed the licensed nurse (LN) documented Resident #65 was verbally abusive to staff on both occasions, in the afternoon, as medications were due. Pain was not assessed or documented at that time and no medications were given until later. In interview on 5/24/16 at 1:00 p.m., Staff N stated the pain assessment performed on 4/15/16 was completed in the morning while in bed. Staff N did not re-assess or provide additional information to provide the resident's status in the afternoon or when attempting to get up in the wheelchair. In interview on 5/24/16 at 1:15 p.m., Staff N reviewed the nursing progress notes dated 5/22/16 and 5/23/16 that documented Resident #65's verbally abusive behaviors. Staff N stated it was the expectation pain was to be reviewed as a potential cause to behaviors and was unclear why the licensed nurse did not assess or address pain in the notes. RESIDENT #68 According to the annual Minimum Data Set ((MDS) dated [DATE], Resident #68 was admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment revealed s/he was alert and oriented, required extensive assistance with most of activities of daily living (ADL), was totally dependent on transfers and needed supervision with eating. Review of the physician order (PO) dated 5/9/15, revealed an order for [REDACTED]. A communication report of laboratory values for Resident #68 from the [MEDICAL TREATMENT] center dated March 2016, revealed Phosphorus level was high at 6.1 and a reminder not to forget to take binder with meals and snacks. Review of the consultation report from the pharmacist dated 3/17/16, revealed Resident #68's serum phosphorus was high at 6.1. The pharmacist recommended [MEDICATION NAME] to be taken with meals for optimal [MEDICATION NAME] binding. Staff reviewed the report on 3/23/16. Review of the May 2016 Medication Administration Record [REDACTED]. In interview on 5/24/16 at 11:02 a.m., Staff K stated Resident #68 went to [MEDICAL TREATMENT] on Monday, Wednesday and Friday at 10:00 a.m. and returned to the facility at 5:00 p.m. A communication sheet which included vital signs, list of medications taken 6 hours prior to sending resident to [MEDICAL TREATMENT], skin assessment and [MEDICAL TREATMENT] site assessment was sent with the resident together with his/her lunch and a can of Nepro (nutritional supplement). The communication sheet was sent back to the facility when the resident returned, which included the resident's weight, vital signs, assessment of [MEDICAL TREATMENT] site (shunt) and medication given while at [MEDICAL TREATMENT]. None of the communication sheets for the month of May 2016 indicated [MEDICATION NAME] was given at the [MEDICAL TREATMENT] center. In interview on 5/24/16 at 11:59 a.m., Staff K stated the resident's significant other goes with him/her to [MEDICAL TREATMENT] and was the one who gave the [MEDICATION NAME] medication. No documentation was found in Resident #68's records indicating the significant other was authorized to administer [MEDICATION NAME] while the resident was at [MEDICAL TREATMENT]. In interview on 5/24/16 at 2:58 p.m., Staff L stated the previous order to take [MEDICATION NAME] while at [MEDICAL TREATMENT] was never carried over at readmission. Staff L stated resident #68 carried a bottle of [MEDICATION NAME] in the bag however, the [MEDICAL TREATMENT] center was not responsible for giving the medication. It was the significant other who gave the medication. According to Staff L, s/he spoke to the significant other and was told s/he no longer went to [MEDICAL TREATMENT] with the resident. It was not known how long the significant other stopped going. The facility was unaware how long the resident had not been taking the noon time dose of the [MEDICATION NAME]. On 5/25/16 at 8:12 a.m., Resident #68 was sitting upright in bed trying to eat breakfast. Due to severe hand tremors s/he had difficulty drinking from the cup and spilled some of its content. In interview on 5/25/16 at 8:16 a.m., Resident #68 was able to name [MEDICATION NAME] as the medication taken at [MEDICAL TREATMENT]. S/he stated 4 tablets were given and it had to be taken with meals. Resident #68 stated his significant other gave it before but now no longer cameto [MEDICAL TREATMENT]. In interview on 5/25/16 at 9:00 a.m., Staff B stated the resident carried a bottle of the [MEDICATION NAME] to [MEDICAL TREATMENT] and the significant other was the one giving the medication not the [MEDICAL TREATMENT] center. According to Staff B, the resident was not capable of taking the medication by him/herself because of the severe hand tremors. The facility failed to ensure a system was in place for resident to receive prescribed medication safely and in a timely manner while receiving treatment outside the facility. This failure resulted in resident missing doses of the medication which potentially contributed to imbalance in resident's laboratory values and placed resident at risk for harm. RESIDENT #81 Resident #81 admitted to the facility with [DIAGNOSES REDACTED]. The resident had a document history of continued yelling out and screaming from the time of admission to present wi

Based on observation, interview, and record review it was determined the facility failed to implement interventions that were consistent with the resident's needs, goals, and recognized standard of practice, and failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure caused harm when resident #1 had pressure ulcers that deteriorated and developed infection. Resident #1 admitted from the hospital to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The minimum data set (MDS), an assessment tool, dated 5/30/14, documented the resident required extensive assist of two people for bed mobility and toilet use, and required total assist of two people for transfers. According to the MDS, the resident had a BIMS score of 15, which indicated no cognitive impairment. According to the facility's treatment protocol for Stage II pressure ulcers (partial thickness loss of skin presenting a shallow open ulcer with a red pink wound bed without slough) with revision dates of April 2009 and October 2010 and Stage III pressure ulcers with revision dates of October 2010 and October 2013, documented in part, if a stage II or a stage III ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify interventions is also indicated. On 8/14/14 at 9:45 a.m., during an interview, Resident #1 reported she developed wounds on her toe from the footboard so the facility removed the footboard. The resident stated she [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph - antibiotic resistant bacteria) to the wound on her toe, and stated she had a wound on her buttocks that they are not dressing appropriately. The resident stated she is supposed to have an air alternating mattress, but they took the machine off because she was too tall. On 8/14/14, observation of the resident's wounds from 10:12 a.m. - 10:35 a.m., with the licensed nurse (Staff C) and an unidentified staff member, revealed the resident had a wound to her coccyx (tailbone) coccyx and a wound to her left hallux (base of great toe). The wound to the resident's coccyx measured 2.1 cm length x 1 cm width x 2 cm in depth. Staff C reported the wound was a stage III pressure ulcer or a stage IV pressure sore (deep pressure ulcer with damage to the muscle and bone) with no slough (tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy). The wound to the resident's left hallux measured 2 cm length by 2.3 cm width and was beefy red. Staff A reported the wound was a stage II pressure ulcer (skin blisters or forms an open sore, the area around the sore may be red and irritated). The resident had an air dyne pro mattress in place, with the pump on the railing underneath the bed. The machine/pump to the mattress was on and functioning at the time. The skin integrity assessment prevention and treatment care plan dated 3/14/14, with a last assessment date of 5/28/14, and a next review date of 8/14, did not reveal the care plan had been updated to reflect the residents needs and or goals, and did not reveal the interventions were revised as appropriate when the resident had a noted change of condition to the coccyx pressure ulcer and had noted pain, odor, increased drainage and increased size of the left hallux pressure ulcer. COCCYX The physician telephone order dated 2/12/14, and signed by the physician without a date, documented discontinue air dyne mattress and change to a regular mattress. The documentation on the physician telephone order did not provide a description of the wound or the reason for discontinuing the air dyne mattress. Although the wound had not healed and the resident was placed on an air dyne mattress to promote wound healing, the progress note dated 2/12/14, documented discontinue air dyne mattress and change to a regular mattress related to progression in therapy. According to the skin grid dated 2/12/14, the stage III pressure ulcer to the coccyx measured 1 cm length x 0.2 cm width and 1 cm depth, red in color with no drainage. Documentation revealed the resident continued with the stage III pressure ulcer to the coccyx through 4/25/14. MD Fax dated 4/25/14, documented, coccyx wound noted to have worsened: depth now 1.8 last 0.2 cm, will restart calcium alginate in wound bed, skin prep periwound and cover with coversite. Review of the record revealed the stage III pressure ulcer to the coccyx had further deteriorated after 4/25/14, with noted mild and foul odor and an increase in size. The facility removed the assistive device (air dyne mattress) used to promote healing more than two months prior. Resident #1 continued with the same treatment initiated on 4/25/14, through the date of this investigation without care plan changes or written documentation of why the treatment and interventions remained the same. Review of the skin grid revealed, in part, the following dates and description of the stage III pressure ulcer to the coccyx: 6/26/14 - 2.8 cm length x 1 cm width x 2.5 cm depth, with red wound bed, pink drainage and foul odor. 7/3/14 - 2.9 cm length x 1 cm width x 2 cm depth, with red wound bed, pink drainage and mild odor. 7/11/14 - 2.9 cm length x 1 cm width x 2 cm depth, with red wound bed, pink drainage and mild odor. 7/18/14 - 2.9 cm length x 1 cm width x 2.1 cm depth, with red wound bed, serosanguineous (composed of serum and blood) drainage, and mild odor. On 8/27/14 at 11:45 a.m., the physical therapist (Staff D) stated sometimes the mattresses will have a different firmness so the therapist will modify the bed, and in the case of transfer training or edge of bed training, the therapist would make the bed firmer or use the mat in the therapy room. Staff D stated if the resident is unable to transfer, transfer training will take place in the therapy room. Staff D stated, therapy does not recommend to nursing the type of mattress the residents should have, but that is rather a nursing recommendation. On 8/27/14 at 2:15 p.m., during an interview with the Director of Nursing (Staff B), and the Administrator (Staff A), Staff B stated the air dyne mattress was discontinued, because therapy was working on edge of bed or slide board transfer for possible discharge home. Staff B stated the resident was provided a bariatric mattress which had the capability for the use of the pump, but was not being used. Staff A stated the pump for the air dyne mattress arrived on July 17, 2014, approximately 3 months after the wound became worse. On 8/27/14 at 2:30 p.m., during an interview, the Director of Nursing (Staff B) stated, wound healing is based on the condition of the wound, and if wounds decrease in size. HALLUX Review of the record revealed the resident's left hallux wound had various stages of healing to include deterioration between 1/28/14 and 6/27/14. The resident continued to receive the same ordered treatment initiated on 1/28/14 through 6/27/14. On 6/27/14 the resident began a new treatment, and course of antibiotics for an infected left hallux wound. MD fax dated 4/29/14, documented, left hallux is worse in size. Increased to 1.8 x 1.8 from 1 x 1. Resident stated she has been hitting on foot board on bed- maintenance removed will continue to monitor. Although the footboard was removed, there was not documented evidence the facility evaluated the impact of the treatment interventions, or revised interventions as appropriate. Review of the nursing progress note dated 6/8/14 at 5:40 a.m., documented, resident complain of left hallux pain. Left foot swollen, dressing removed with foul odor noted. Wound measures 2 inches x 2 inches, small amount of necrotic tissue noted in wound. MD fax dated 6/9/14 at 8:30 p.m., documented, left hallux wound noted with increased drainage (serosanguineous), increased swelling, left lower extremity also note as warm to touch. Resident also complains of pain to whole left lower extremity. Treatment order is to cleanse wound with normal saline apply skin prep to peri wound, cover with coversite and change daily. Resident wanted to go to the emergency room for evaluation and treatment, please advise. The undated physician's response documented, doesn't sound like she needs to go to the ER have RCM call me tomorrow. MD fax dated 6/10/14, documented, assessed wound, measures 2 x 2 cm with serosanguineous drainage (moderate amount) slight slough in wound bed no redness no signs or symptoms of infection will continue to monitor. Physician's undated response documented, noted. Review of the skin grid revealed, in part, the following dates and description of the left hallux pressure ulcer: 6/3/14 - 1.8 cm length x 2 cm width with pink wound bed, serosanguineous drainage and no odor. 6/10/14 - 2 cm length x 2 cm width with yellow wound bed, serosanguineous drainage and no odor. 6/20/14 - 1.4 cm length x 1.3 cm width with yellow wound bed, serosanguineous drainage and mild odor with a comment which documented, resident care manager assessed: slight slough, no redness or signs or symptoms of infection, no longer complain of pain. 6/26/14 - 3.5 cm length x 3.8 cm width and 0.4 cm depth with Red Necrotic/slough to the wound bed, foul odor and purulent drainage, with a comment which documented, resident with brown tissue in wound bed, unknown if it's from iodosorb (coloring) or necrotic tissue (dead tissue). On 6/3/14, the wound had a pink wound bed and no odor. On 6/10/14, the wound had slough, on 6/20/14 the wound had slough and odor. Documentation did not reveal the wound had been reevaluated to determine if new treatment interventions were needed. Record review revealed a lab report dated 7/21/14, which documented, in part, [MEDICAL CONDITION] resistant staph aureus (MRSA- antibiotic resistant bacteria). Further review revealed the results of a bone biopsy dated 8/2/14, documented, sections of this bone from the left foot show acute inflammation and abscess formation in association with bone, consistent with acute osteo[DIAGNOSES REDACTED] (infection of the bone). On 8/27/14 at 2:10 p.m., during an interview, Staff B confirmed the resident had slough to the wound bed, and treatment interventions had not been revised. Staff B stated, staff notified the physician of the change in condition of the wound, and confirmed staff did not request from the physician, an alternative treatment plan.

Based on observation, interview, and record review it was determined the facility failed to implement interventions that were consistent with the resident's needs, goals, and recognized standard of practice, and failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate for 1 of 3 residents (#1) reviewed for pressure ulcers. This failure caused harm when resident #1 had pressure ulcers that deteriorated and developed infection. Resident #1 admitted from the hospital to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The minimum data set (MDS), an assessment tool, dated 5/30/14, documented the resident required extensive assist of two people for bed mobility and toilet use, and required total assist of two people for transfers. According to the MDS, the resident had a BIMS score of 15, which indicated no cognitive impairment. According to the facility's treatment protocol for Stage II pressure ulcers (partial thickness loss of skin presenting a shallow open ulcer with a red pink wound bed without slough) with revision dates of April 2009 and October 2010 and Stage III pressure ulcers with revision dates of October 2010 and October 2013, documented in part, if a stage II or a stage III ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the ulcer (including potential complications) and the resident's overall clinical condition should be reassessed. Re-evaluation of the treatment plan including determining whether to continue or modify interventions is also indicated. On 8/14/14 at 9:45 a.m., during an interview, Resident #1 reported she developed wounds on her toe from the footboard so the facility removed the footboard. The resident stated she [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph - antibiotic resistant bacteria) to the wound on her toe, and stated she had a wound on her buttocks that they are not dressing appropriately. The resident stated she is supposed to have an air alternating mattress, but they took the machine off because she was too tall. On 8/14/14, observation of the resident's wounds from 10:12 a.m. - 10:35 a.m., with the licensed nurse (Staff C) and an unidentified staff member, revealed the resident had a wound to her coccyx (tailbone) coccyx and a wound to her left hallux (base of great toe). The wound to the resident's coccyx measured 2.1 cm length x 1 cm width x 2 cm in depth. Staff C reported the wound was a stage III pressure ulcer or a stage IV pressure sore (deep pressure ulcer with damage to the muscle and bone) with no slough (tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy). The wound to the resident's left hallux measured 2 cm length by 2.3 cm width and was beefy red. Staff A reported the wound was a stage II pressure ulcer (skin blisters or forms an open sore, the area around the sore may be red and irritated). The resident had an air dyne pro mattress in place, with the pump on the railing underneath the bed. The machine/pump to the mattress was on and functioning at the time. The skin integrity assessment prevention and treatment care plan dated 3/14/14, with a last assessment date of 5/28/14, and a next review date of 8/14, did not reveal the care plan had been updated to reflect the residents needs and or goals, and did not reveal the interventions were revised as appropriate when the resident had a noted change of condition to the coccyx pressure ulcer and had noted pain, odor, increased drainage and increased size of the left hallux pressure ulcer. COCCYX The physician telephone order dated 2/12/14, and signed by the physician without a date, documented discontinue air dyne mattress and change to a regular mattress. The documentation on the physician telephone order did not provide a description of the wound or the reason for discontinuing the air dyne mattress. Although the wound had not healed and the resident was placed on an air dyne mattress to promote wound healing, the progress note dated 2/12/14, documented discontinue air dyne mattress and change to a regular mattress related to progression in therapy. According to the skin grid dated 2/12/14, the stage III pressure ulcer to the coccyx measured 1 cm length x 0.2 cm width and 1 cm depth, red in color with no drainage. Documentation revealed the resident continued with the stage III pressure ulcer to the coccyx through 4/25/14. MD Fax dated 4/25/14, documented, coccyx wound noted to have worsened: depth now 1.8 last 0.2 cm, will restart calcium alginate in wound bed, skin prep periwound and cover with coversite. Review of the record revealed the stage III pressure ulcer to the coccyx had further deteriorated after 4/25/14, with noted mild and foul odor and an increase in size. The facility removed the assistive device (air dyne mattress) used to promote healing more than two months prior. Resident #1 continued with the same treatment initiated on 4/25/14, through the date of this investigation without care plan changes or written documentation of why the treatment and interventions remained the same. Review of the skin grid revealed, in part, the following dates and description of the stage III pressure ulcer to the coccyx: 6/26/14 - 2.8 cm length x 1 cm width x 2.5 cm depth, with red wound bed, pink drainage and foul odor. 7/3/14 - 2.9 cm length x 1 cm width x 2 cm depth, with red wound bed, pink drainage and mild odor. 7/11/14 - 2.9 cm length x 1 cm width x 2 cm depth, with red wound bed, pink drainage and mild odor. 7/18/14 - 2.9 cm length x 1 cm width x 2.1 cm depth, with red wound bed, serosanguineous (composed of serum and blood) drainage, and mild odor. On 8/27/14 at 11:45 a.m., the physical therapist (Staff D) stated sometimes the mattresses will have a different firmness so the therapist will modify the bed, and in the case of transfer training or edge of bed training, the therapist would make the bed firmer or use the mat in the therapy room. Staff D stated if the resident is unable to transfer, transfer training will take place in the therapy room. Staff D stated, therapy does not recommend to nursing the type of mattress the residents should have, but that is rather a nursing recommendation. On 8/27/14 at 2:15 p.m., during an interview with the Director of Nursing (Staff B), and the Administrator (Staff A), Staff B stated the air dyne mattress was discontinued, because therapy was working on edge of bed or slide board transfer for possible discharge home. Staff B stated the resident was provided a bariatric mattress which had the capability for the use of the pump, but was not being used. Staff A stated the pump for the air dyne mattress arrived on July 17, 2014, approximately 3 months after the wound became worse. On 8/27/14 at 2:30 p.m., during an interview, the Director of Nursing (Staff B) stated, wound healing is based on the condition of the wound, and if wounds decrease in size. HALLUX Review of the record revealed the resident's left hallux wound had various stages of healing to include deterioration between 1/28/14 and 6/27/14. The resident continued to receive the same ordered treatment initiated on 1/28/14 through 6/27/14. On 6/27/14 the resident began a new treatment, and course of antibiotics for an infected left hallux wound. MD fax dated 4/29/14, documented, left hallux is worse in size. Increased to 1.8 x 1.8 from 1 x 1. Resident stated she has been hitting on foot board on bed- maintenance removed will continue to monitor. Although the footboard was removed, there was not documented evidence the facility evaluated the impact of the treatment interventions, or revised interventions as appropriate. Review of the nursing progress note dated 6/8/14 at 5:40 a.m., documented, resident complain of left hallux pain. Left foot swollen, dressing removed with foul odor noted. Wound measures 2 inches x 2 inches, small amount of necrotic tissue noted in wound. MD fax dated 6/9/14 at 8:30 p.m., documented, left hallux wound noted with increased drainage (serosanguineous), increased swelling, left lower extremity also note as warm to touch. Resident also complains of pain to whole left lower extremity. Treatment order is to cleanse wound with normal saline apply skin prep to peri wound, cover with coversite and change daily. Resident wanted to go to the emergency room for evaluation and treatment, please advise. The undated physician's response documented, doesn't sound like she needs to go to the ER have RCM call me tomorrow. MD fax dated 6/10/14, documented, assessed wound, measures 2 x 2 cm with serosanguineous drainage (moderate amount) slight slough in wound bed no redness no signs or symptoms of infection will continue to monitor. Physician's undated response documented, noted. Review of the skin grid revealed, in part, the following dates and description of the left hallux pressure ulcer: 6/3/14 - 1.8 cm length x 2 cm width with pink wound bed, serosanguineous drainage and no odor. 6/10/14 - 2 cm length x 2 cm width with yellow wound bed, serosanguineous drainage and no odor. 6/20/14 - 1.4 cm length x 1.3 cm width with yellow wound bed, serosanguineous drainage and mild odor with a comment which documented, resident care manager assessed: slight slough, no redness or signs or symptoms of infection, no longer complain of pain. 6/26/14 - 3.5 cm length x 3.8 cm width and 0.4 cm depth with Red Necrotic/slough to the wound bed, foul odor and purulent drainage, with a comment which documented, resident with brown tissue in wound bed, unknown if it's from iodosorb (coloring) or necrotic tissue (dead tissue). On 6/3/14, the wound had a pink wound bed and no odor. On 6/10/14, the wound had slough, on 6/20/14 the wound had slough and odor. Documentation did not reveal the wound had been reevaluated to determine if new treatment interventions were needed. Record review revealed a lab report dated 7/21/14, which documented, in part, [MEDICAL CONDITION] resistant staph aureus (MRSA- antibiotic resistant bacteria). Further review revealed the results of a bone biopsy dated 8/2/14, documented, sections of this bone from the left foot show acute inflammation and abscess formation in association with bone, consistent with acute osteo[DIAGNOSES REDACTED] (infection of the bone). On 8/27/14 at 2:10 p.m., during an interview, Staff B confirmed the resident had slough to the wound bed, and treatment interventions had not been revised. Staff B stated, staff notified the physician of the change in condition of the wound, and confirmed staff did not request from the physician, an alternative treatment plan.

Based on observation, interview and record review the facility failed to provide necessary treatment and services to prevent the development or worsening of pressure sores for 1 of 7 Sampled Residents (#1). This failure resulted in harm due to the development of pressure ulcer in the facility. A pressure sore is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue and usually occurs over boney prominences. The severity of pressure sores is described by stages as follows: Stage I: A persistent area of skin redness (without an opening in the integrity of the skin) that does not disappear when pressure is relieved and may appear with persistent red, blue or purple hues. Stage II: A partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Stage III: A full thickness loss involving damage to, or necrosis (dead, non-viable tissue) of, subcutaneous tissue that may extend down to but not through underlying fascia (tissue binding muscles and organs). The pressure sore presents as a deep crater with or without undermining (separation of the skin from the wound) of adjacent tissue. Stage IV: A full thickness loss of skin with extensive destruction, tissue necrosis and underlying tissue or damage to muscle, bone or supporting structure (i.e. tendon). Findings include: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was totally dependent on others for all care. Interview with Interested Party1 on 10/06/11 at 9:40 a.m. revealed Resident #1 admitted to the facility following PEG tube placement to allow the surgical wound to heal and allow the resident to get used to enteral feeding. The resident has a home to return to but developed a pressure ulcer in the facility that needs to resolve before he can go home. The pressure ulcer has worsened since arriving. Record review of admission skin assessment dated [DATE] revealed Resident #1 admitted for the hospital with 3 x 2 cm reddened area on coccyx, pressure related. The skin on the coccyx was intact and there was no documentation indicating potential for deep tissue injury. The resident also had a reddened area on the left buttocks 3 x 1 cm. The facility skin grid sheets dated 04/19/11 indicated the resident had a Stage I pressure (skin intact) pressure ulcer on his coccyx. On 04/26/11 the facility skin grid sheets indicated the resident received monitoring for Stage II pressure ulcer on coccyx measuring 3 x 2 x 0.1 cm (length x width x depth). On 06/20/11 the wound on the coccyx area increased to Stage III measuring 5 x 4 x 0.8 cm and the wound began undermining (separation of the skin from the wound). Hospital records dated 08/24/11 indicated the resident admitted to the hospital with [REDACTED]. Hospital records indicated the resident was seen by a wound care specialist while hosptalized on [DATE]. The facility readmission orders [REDACTED]. Staff D revealed on 10/06/11 at 11:45 a.m. Resident #1 was completely dependent on staff for all care and the resident was unable to reposition himself independently. Interview with Interested Party 2 on 10/06/11 at 9:25 a.m. revealed on 10/03/11 the dressing on the pressure wound was soiled with yellow, black and green drainage. The dressing was dated 09/30/11. The facility was made aware of the dressing being unchanged. Interview with Interested Party 1 on 10/06/11 at 9:40 a.m. revealed a subsequent observation of the wound on 10/04/11 revealed the dressing remained soiled with drainage and continued to emit a foul odor. The dressing was still dated 09/30/11. The facility was again made aware of the soiled dressing when Interested Party 3 entered the building the next day. The facility indicated the dressing was changed every six days. The Interested Party asked the facility to locate the readmission orders [REDACTED]. Review of TAR (treatment administration record) revealed the previous order for wound care using the bio-step was discontinued on 10/04/11. Interview with Staff A on 10/06/11 at 5:25 p.m. revealed the new TAR with the new treatment for [REDACTED]. The wound care was not done according to the resident's current order because the staff were not aware of the order. Observation of wound care on 10/06/11 at 11:50 a.m. revealed open wound on coccyx area with undermining. Tissue surround the wound was pink in color. A small amount of slough (yellow non-viable tissue) was noted on the left outer area of the tissue surrounding the wound. The wound opening exposed pink muscle. During same observation a bleeding open area was noted on the left ischial tuberosity (area where humans sit when resting) approximately 1 x 1 cm in size. Staff A was not aware of the open area and applied EPC (extra protective cream) to the wound. Review of plan of care for Resident #1 established on 04/19/11 indicated the resident was at high risk for developing pressure sores. Interventions established on 04/19/11 were not changed or updated when the resident's wound worsened to a Stage II, II and ultimately a Stage IV. Resident #1 entered the facility on 04/19/11 without any open pressure sores in his skin. Within a week of admission the resident presented with a on open pressure sore. When hosptalized on [DATE] the wound was found to be a Stage IV wound and a wound care specialist made recommendations for wound care. Upon readmission to the facility the wound care orders were not followed for four days, even after an Interested Party mentioned the wound care on the third day.