Every finding on record at Puget Sound Care

.Based on interviews and record reviews, the facility failed to report an allegation of neglect for 1 of 4 sampled residents (Resident 1) reviewed for neglect. This failure placed residents at risk for ongoing neglect and a diminished quality of life.Findings included.Record review of the facility policy titled, Abuse Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation or Resident Property dated August 2025, showed When allegations that meet the definition of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are received, the center shall:(1) Ensure that all alleged violations are reported immediately. Resident 1 was admitted to the facility on [DATE] for long term care services. The 5-day Minimum data set, an assessment tool, dated 03/14/2026 indicated Resident 1 was moderately cognitively impaired.Review of the facility's incident/accident logging records dated for both March and April 2026, showed no entries regarding an allegation of neglect for Resident 1.Record review of Resident 1's care plan, dated 02/04/2025 showed Resident 1 was incontinent of bowel and bladder and required 2 person assist with all adl's (activities of daily living) care.In an interview with Staff C 04/23/2026 at 2:33 PM, Staff C, Nursing Assistant Certified (NAC) said they came on shift on March 29th, 2026, and found Resident 1's bed saturated with urine. Staff C said the bed was wet enough to cause urine to pool underneath Resident 1 to include 2 pillows up behind her head. Staff C said both pillows had to be replaced due to urine saturation. Staff C said the entire bedding had to be changed due to linen being soaked. Staff C said she notified the nurse and was informed to also notify the Director of Nursing (DNS). Staff C said she sent the DNS a text message of her concerns regarding Resident 1's urine-soaked bed. Staff C said the nurse then asked her to write a statement regarding Resident 1's unkept condition when she found her. Staff C said they then filed an online report as a mandatory reporter because she was concerned the facility would not investigate the potential allegation of neglect.In a joint interview with Staff A, Administrator and Staff B, Director of Nursing and Registered Nurse on 05/08/2026 at 10:23 AM, stated they had heard a concern about care following shift change. Staff A said he thought the nurse addressed the issue in real time, and that neglect was not considered. Staff B said she had received a text from Staff C about a wet bed on Resident 1. Staff C said the NAC failed to do shift change rounds with the off going shift, so there was no way to know how long the bed was wet. Staff B said she did not log the concern as Staff C did not complete shift change rounds. Staff B said they did not treat this as an allegation of neglect because Staff C did not use that terminology. Staff B said she usually logs and reports all concerns about abuse and neglect but did not for this situation. Reference WAC 388-97-0640(5)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (Resident 8, 4 & 25) reviewed for constipation, failed to follow physician's orders for insulin administration and dressing change for a peripherally inserted central catheter (PICC, a flexible tube inserted in the vein, and near the heart for long-term antibiotics administration) for 1 of 1 residents (Resident 25) and failed to obtain weekly weights for 1 of 5 residents (Resident 36) reviewed for quality of care. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . Constipation Record review of the facility policy, titled, Management of Constipation, updated, November 2023, documented: When a resident is identified with No/small Bowel Movement (BM) documented for 64 hrs [hours], the LN [Licensed Nurse] will assess the resident and determine if the bowel protocol will be initiated. -The Clinical Alert will be cleared using the progress note function to document findings and interventions. Standard bowel protocol to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: Miralax [laxative] PO [by mouth] after eight shifts of no BM Compound Laxative, consisting of 17.2 mg [milligrams] of Senna [laxative] and of 10 mg [milligrams] Bisacodyl [laxative] Bisacodyl suppository rectally, if no result from the compound laxative Fleet Enema rectally, if no results from bisacodyl suppository. Resident 8 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS), an assessment tool, dated 12/16/2025, documented Resident 8 was moderately cognitively impaired. Record review of Resident 8's Bowel and Bladder Elimination task sheet, dated January 2026, showed Resident 8 had a BM on 01/03/2026 at 9:04 PM, and did not show another BM until 01/09/2026 at 4:59 PM, over 139 hours (five days) since her previous documented BM.Record review of Resident 8's January 2026 Medication Administration Record (MAR) showed the bowel protocol was not initiated between the dates of 01/03/2026 and 01/09/2026.In an interview on 01/23/2026 at 10:05 AM, Staff D, Unit Manager (UM)/Licensed Practical Nurse (LPN), said bowel protocol should be initiated and addressed on day two of no BM. Staff D was unable to produce documentation showing bowel protocol was started and documented for Resident 8. Staff D stated, There should be documentation follow up, but nothing is there. Staff D said he would expect for something to be given to Resident 8 around the 6th.In an interview on 01/23/2026 at 10:47 AM, Staff B, Director of Nursing Services/Registered Nurse (RN), said the bowel protocol should have been initiated and documented per facility policy. Staff B said Resident 8 has had consistent BMs and the time period in question was a matter of insufficient documentation. Resident 4 was admitted to the facility on [DATE]. The 5-Day MDS, dated [DATE], showed Resident 4 was alert and oriented. Review of Resident 4's BM task sheet, dated 12/24/2025 to 01/22/2026, documented Resident 4 had a BM on 12/28/2025 at 5:59 AM. Resident 24's next BM was on 01/01/2026 at 5:50 AM, over 95 hours since the last BM. Review of Resident 4's December 2025 and January 2026 Medication Administration Records did not show documentation Resident 4 received any bowel interventions between 12/28/2025 and 1/01/2026. Resident 25 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 25 was alert and oriented. Review of Resident 25's BM task sheet, dated 12/25/2025 to 01/23/2026, documented Resident 25 had a BM on 01/09/2026 at 1:59 PM. Resident 25's next BM was on 01/15/2026 at 9:39 PM, over 151 hours since the last BM. Review of Resident 25's January 2026 MAR did not show documentation Resident 25 received any bowel interventions between 01/09/2026 and 01/15/2026. During an interview on 01/23/2026 at 10:55 AM, Staff B said she believed Resident 4 and Resident 25 were incontinent of bowel and that the missing documentation was a matter of the staff not documenting BMs. During an interview on 01/23/2026 at 1:41 PM, Staff B said she tried to find some documentation to show they were tracking Resident 4 and Resident 25 for norovirus. Staff B said there should have been some documentation of their BMs but she could not find any. PICC dressing change Record review of facility policy, titled, Infusion Therapy Policy & Procedure Manual, undated, documented, Measure external length of PICC .at insertion, with each dressing change and when clinically indicated if catheter dislodgment is suspected. Compare to measurement obtained at insertion. Resident 36 was admitted to the facility on [DATE] with multiple diagnoses to include Type 2 Diabetes (high blood sugar levels) and Congestive Heart Failure (hearts inability to effectively pump blood). The admission MDS, dated [DATE], showed Resident 36 was moderately cognitively impaired. Record review of Resident 36's physician's order, dated 01/06/2026, documented, IV [intravenous, in the vein] Catheter [tube] - Location: LUE [left upper extremity/arm] Type: PICC Lumens [extensions]: 2. Record review of Resident 36's physician's order, dated 01/06/2026, documented, IV Dressing Change - PICC every day shift every Sun [Sunday] for PICC Maintenance Measure upper arm circumference and external catheter length on admission and with each dressing change. Record review of Resident 36's EHR did not show documentation of left upper extremity measurements or external catheter length was documented on admission or with the dressing change that was documented on Sunday 01/11/2026. Record review of Resident 36's EHR did not show documentation of dressing change completion that was scheduled for Sunday 01/18/2026. In an interview on, 01/22/2026 at 2:42 PM, Staff F, UM/LPN, said it was the expectation that Resident 36's PICC line dressing change would have been completed and documented per physicians' orders. Staff F reviewed Resident 36's Treatment Administration Record and stated, shows it was not documented on the 18th. When asked when Resident 36's PICC line dressing was last changed Staff F stated, it was documented on 01/11/2026. Staff F reviewed Resident 36's EHR but was unable to find documentation of PICC line catheter or left upper arm measurements on admission [DATE] or scheduled dressing changes on 01/11/2026, and 01/18/2026. Insulin orders Record review of Resident 36's physician's order, dated 01/06/2026, documented, Check Blood Sugar. Notify physician if CBG [Capillary Blood Glucose, blood glucose level] results is less than 70 or more than 400. before meals and at bedtime. Record review of Resident 36's physician's order, dated 01/06/2026, documented, If CBG is below 70 and resident is able to swallow: administer 15-20 grams of fast acting carbohydrates: 1/2 cup or 4 ounces Juice. 1 cup skim milk, 3 glucose tablets, 4 sugar cubes, 5-8 pieces of hard candy or 15-20 grams of fast acting carbohydrate: Glucose Gel (Instant Gel). If unable to swallow: give glucagon [treats low blood sugar] 1mg [milligram] subQ [subcutaneous, skins fatty layer] or IM [intramuscular, within the muscle]. Re check blood glucose approximately every 15 minutes after giving carb until 90 or above. Notify MD [medical doctor] per orders. Follow up with protein snack. Record review of Resident 36's EHR documented CBG levels of 67 on 01/14/2026 at 12:29 PM. Resident 36's EHR did not show documentation of low blood sugar interventions per physician's order. Next blood sugar was documented at 16:39 PM, four hours later. Record review of Resident 36's EHR documented CBG levels of 67 on 01/15/2026 at 8:49 AM. Resident 36's EHR did not show documentation of low blood sugar interventions per physician's order. Next blood sugar was documented at 12:55 PM, four hours later. In an interview on, 01/22/2026 at 3:13 PM, Staff F said it was the expectation that the licensed nurse should have initiated low blood sugar protocol as ordered and notified the MD of Resident 36's low blood sugars on 01/14/2026 and 01/15/2026. In an interview on, 01/23/2026 at 10:20 AM, Staff B said it was her expectation that the licensed nurse followed physician's orders when checking Resident 36's blood sugar. Weights Record review of facility policy, titled, Weight Monitoring, updated 11/14/2022, documented, CNA Responsibilities 1. Weigh each resident within 24 hours of admission and readmission, preferably on the shift when the admission occurred. 2. Weigh the resident weekly for four weeks and/or until the wight is determined to be stable by the interdisciplinary team following admission and readmission. Licensed Nurse Responsibilities 1. Verify accuracy of the weight by comparing the weight with the most recently recorded weight. Record review of Resident 36's EHR documented a weight obtained on 01/08/2026 of 177.4 Lbs (pounds) two days after admission. Record review of Resident 36's EHR, on 1/22/2026, did not show additional documentation of weights. In an interview on 01/22/2026 at 2:55 PM, Staff F said residents who were new admissions to the facility were weighed weekly up to four weeks. When asked how many times Resident 36 had been weighed since admission, Staff F reviewed the EHR and said Resident 36 was weighed once. In a joint interview on 01/23/2026 at 10:40 AM, with Staff B and Staff H, Assistant Director of Nursing/RN, Staff B said residents who were new admissions were weighed per facility policy. Staff H said residents located on B side (side of the building where Resident 36 was located) were supposed to be weighed weekly. In a joint review of Resident 36's EHR, both Staff B and Staff H said one weight was documented since admission. Reference WAC 388-97-1060(1)(3)(c)

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for 2 of 3 sampled residents (Resident 36 & 78) reviewed for bed rails. This failure placed residents at risk for injury and a diminished quality of life.Findings included.Record review of facility policy, titled, Safety Device Application, date revised 04/07/2023, documented, 1. Verify the following: . d. Safety device is documented on the Safety Device Care Plan.Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 01/10/2026, showed Resident 36 was moderately cognitively impaired. In an observation on 01/20/2026 at 9:44 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed. In an observation on 01/21/2026 at 11:04 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed. Record Review of Resident 36's Comprehensive Care Plans, initiation date 01/06/2026, did not show a Focus, Goal, or Intervention documenting Resident 36's use of bed rails.Resident 78 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 78 was moderately cognitively impaired. In an observation on 01/20/2026 at 9:16 AM, Resident 78's bed was observed with quarter length bed rails on the upper left and right sides of bed.In an observation on 01/21/2026 at 2:08 PM, Resident 78's bed was observed with quarter length bed rail on the upper left and right side of bed.Record Review of Resident 78's Comprehensive Care Plans, initiation date 01/06/2026, did not show a Focus, Goal, or Intervention documenting Resident 78's use of bed rails.In an interview on 01/21/2026 at 2:37 PM, Staff F, Unit Manager/Licensed Practical Nurse, reviewed Resident 36's and Resident 78's electronic health record and said both Resident 36 and Resident 78 did not have care plans for bed rails and there should have been.In an interview on 01/23/2026 at 10:16 AM, Staff B, Director of Nursing/Registered Nurse, said the bed rails on Resident 36's and Resident 78's bed should have been addressed in their respective care plans. Reference WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to provide oxygen humidification (providing warm and moistened oxygen with water vapor preventing dryness, sore throats, and thickened mucus caused by long-term use of dry oxygen) for 1 of 2 residents (Resident 78) reviewed for respiratory care. This failure placed residents at risk of respiratory complications and a diminished quality of life. Findings included.Resident 78 was admitted to the facility on [DATE] with diagnosis including malignant pleural effusion (excessive fluid build up in the lungs caused by cancer cells). The admission Minimum Data Set, an assessment tool, dated 01/11/2026, showed resident 78 was moderately cognitively impaired. Record review of Resident 78's physician's order, dated 01/09/2026, documented, O2 [oxygen] @[at] 2 Liters via Nasal Cannula w[with]/ humidification to keep O2 sats >[greater then] 90%[percent] and/or SOB[shortness of breath]/Comfort every shift for Respiratory failure w/hypoxia [low oxygen].Record Review of Resident 78's January 2026 electronic treatment record showed licensed nurses documented oxygen was administered with humidification.In an observation on 01/20/2026 at 9:16 AM, Resident 78 was observed lying in bed with oxygen via nasal cannula delivered through an oxygen concentrator (machine that delivers oxygen) which did not have a humidifier connected to it. In an observation on 01/21/2026 at 2:08 PM, Resident 78 was lying in bed with oxygen via nasal cannula delivered through an oxygen concentrator which did not have a humidifier connected to it.In an interview on 01/21/2026 at 2:30 PM, Staff F, Unit Manager/Licensed Practical Nurse reviewed Resident 78's physician orders for oxygen use. Staff F said Resident 78's oxygen concentrator should have had humidification per the physician's order. Reference WAC 388-97-1060 (1)(3)(vi)

Based on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices when a resident ingested a medication that fell on the floor for 1 of 2 staff observed (Staff G) for medication administration; and failed to ensure staff properly donned (putting on) personal protective equipment (PPE) for 1 of 5 sampled resident rooms (Room B33) reviewed for infection prevention and control. This failure placed residents at risk for the spread of infection transmission in the facility and a diminished quality of life.Findings Included. In an observation and interview on 01/22/2026 at 9:46 AM, Staff G, Registered Nurse (RN), was observed standing at the A wing nurse's station beside the medication cart. A resident was sitting in her wheelchair next to the nurse's station counter. Staff G was observed to set a cup of pills and a cup of water on the counter beside the resident. The resident took pills out of the cup and started to swallow them. One white pill dropped onto the floor when the resident was taking the pills. Staff G was observed to pick up the white pill off the floor and set it down on the counter one inch away from the cup of pills. The resident picked up the white pill that dropped onto the floor and swallowed it. Staff G was observed to watch the resident swallow the pill and did not say anything to the resident. When asked Staff G what the procedure was if a medication dropped onto the floor, Staff G said dropped medication should be put in the sharps container (a puncture resistant container designed for the safe disposal of needles, syringes, and other medical waste). Staff G stated, I should have put it in the sharps. In an interview on 01/22/2026 at 12:49 PM, Staff D, Unit Manager/Licensed Practical Nurse (LPN), said if a medication dropped on the floor, the nurse should destroy it and get a new one. In an interview on 01/22/2026 at 2:13 PM, Staff B, Director of Nursing/RN said she expected a medication was thrown away that fell on the floor. Review of the infection control sign titled, Contact Enteric Precaution, dated 08/03/2023, indicated, Prior to entering – wash or gel hands prior to entry. – Use SOAP AND WATER upon leaving the room. Wear a gown and gloves. During an observation on 01/22/2026 at 1:02 PM Staff J, Restorative Aide/Nursing Assistant, went into room B 33 with a lunch tray. Outside the room next to the door was a sign Contact Enteric Precaution. Staff J went into the room but did not don PPE. As Staff J left the room, Staff J used gel to sanitize his hands. During an interview on 01/22/2026 at 1:11 PM, Staff J said he only had to wear PPE if he was providing care. Staff J said he only had to sanitize his hands when leaving the room because no care was provided. Staff J said he went into the room to deliver a lunch tray to the resident in bed 1. During an interview on 01/22/2026 at 1:16 PM, Staff K, Infection Preventionist/LPN, said the expectation for staff entering rooms with the Contact Enteric Precaution signs to perform hand hygiene and don PPE. Staff K said when staff exited the room, they were supposed to wash their hands with soap and water. Reference WAC 388-97-1320 (1)(a)

Based on observation interview and record review the facility failed to secure medications in 1 of 1 residents' room (Resident 41) reviewed for medication access and storage. This failure placed residents, staff and visitors at risk for accessing unauthorized medication, injury and a diminished quality of life. Findings included.Resident 41 was admitted to the facility on [DATE] with diagnoses to include urinary tract infection. The admission Minimum Data Set, an assessment tool, dated 12/09/2025, Showed Resident 41 was alert and oriented. In an interview and observation on 01/21/2026 at 9:46 AM, Resident 41 was observed laying in bed. Resident 41 was observed to have three bottles of medication on her bedside table. The labels/names on the on the bottles were Azo Cranberry, Centrum Women's and Azo Urinary Defense. Resident 41 stated she had been taking the medication for some time. When asked Resident 41 if staff knew she had the medications in her room, she stated I keep them there (pointing at her bedside table) so I guess they do.Record review of Resident 41's electronic health records did not show a medication self-administration assessment had been done nor a physicians order for medication self-administration.In an interview and observation on 01/21/2026 at 10:06 AM, Staff M, Registered Nurse, observed the medication bottles on Resident 41's bedside table and said residents who had their own medication would have their medications stored in the nurses medication cart after the provider reviewed the medication, gave the order and if the pharmacy did not have the medication, the resident's own medications would have a pharmacy printed label and administered per physicians order.In an interview on 01/21/2026 at 11:42 AM, Staff F, Unit Manager/Licensed Practical Nurse, stated residents should not have medication at bedside. If they choose to a self-medication assessment is completed, MD [doctor] to review medications and give order for the medication and self-administration.Reference WAC 388-97-1300(2)

Based on observation, interview, and record review, the facility failed to obtain a bed rail physician's order, use of bed rail consent, and evaluation for 2 of 3 sampled residents (Resident 36 & 78) reviewed for accidents. This failure placed residents at risk of injury and a diminished quality of life. Findings included.Record review of facility policy, titled, Safety Device Application, date revised 04/07/2023, documented, 1. Verify the following: a. Safety Device Data Collection completed and evaluated for the need of a safety device.b. Physician's order obtained for safety device.c. Safety Device Data Collection, Evaluation, and Information evaluation completed and reviewed with the resident or resident representative.Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 01/10/2026, showed Resident 36 was moderately cognitively impaired. In an observation on 01/20/2026 at 9:44 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed.In an observation on 01/21/2026 at 11:04 AM, Resident 36's bed was observed with quarter length bed rails on the upper left and right sides of bed.Record review of Resident 36's Electronic Health Record (EHR) did not show a physician's order for bedrails, nor did it show an evaluation and consent for the use of bed rails was completed.Resident 78 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 78 was moderately cognitively impaired.In an observation on 01/20/2026 at 9:16 AM, Resident 78's bed was observed with quarter length bed rails on the upper left and right sides of bed.In an observation on 01/21/2026 at 2:08 PM, Resident 78's bed was observed with quarter length bed rail on the upper left and right side of bed.Record review of Resident 78's EHR did not show a physician's order for bedrails, nor did it show an evaluation and consent for the use of bed rails was completed. In an interview on 01/21/2026 at 2:34 PM, Staff F, Unit Manager/Licensed Practical Nurse, reviewed Resident 36's and Resident 78's EHR and said both Resident 36 and Resident 78 did not have physician's orders, evaluations or consents completed for bed rails and there should have been.In an interview on 01/23/2026 at 10:12 AM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation that Resident 36 and Resident 78 had bed rail evaluations, consents and physician's orders prior to bed rails being used. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to convey the trust account for 1 of 4 residents (Resident 107) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds. Findings included.Resident 107 admitted to the facility on [DATE]. Resident 107 had a trust account while a resident in the facility. Resident 107 expired on [DATE]. Review of the facility's Resident Statement Landscape, from [DATE] to [DATE], indicated Resident 107 had a balance of .03 cents. The account was closed on [DATE], 53 days after Resident 107 expired.During an interview on [DATE] at 10:50 AM, Staff L, Business Office Manager, said trust accounts were supposed to be conveyed no longer than 30 days after discharge or death. Staff L said she just recently closed out Resident 107's account. Reference WAC 388-97-0340 (5)

Based on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 11) reviewed for activities of daily living (ADL). This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Resident 11 was admitted to the facility on [DATE] with multiple diagnosis to include diabetes mellitus (DM, a disease in which the body's ability to produce or respond to the hormone insulin is impaired resulting in elevated blood sugar levels). The Quarterly Minimum Data Set, an assessment tool, dated 11/07/2025, documented Resident 11 was cognitively intact and had diabetes mellitus. Record review of Resident 11's physician orders, dated 08/04/2023, documented, Diabetic Nail Care every day shift every Sat [Saturday] for DM LN [Licensed Nurse] to do nail care.Record review of Resident 11's ADL care plan, revised on 02/20/2025, showed an intervention, Bathing: Clean and trim nails on bath day and as necessary. Trimming to be done by CNA [Certified Nursing Assistant]. Record review of Resident 11's Kardex (a nursing documentation system used to provide a quick summary of patient care needs), dated 01/22/2026, documented, .BATHING: Clean and trim nails on bath day and as necessary. Trimming to be done by CNA .In an interview on 01/22/2026 at 3:08 PM, Staff E, CNA, said they got information on care needs for residents, such as bathing and ADLs, from the Kardex. In an interview on 01/22/2026 at 3:32 PM, Staff D, Unit Manager/Licensed Practical Nurse, said CNAs did not do nail care for diabetic residents, nurses only did diabetic nail care. After looking at Resident 11's care plan, Staff D said Resident 11's ADL care plan should have been updated for the nurse to do nail care.In an interview on 01/23/2026 with Staff C, Regional Administrator, and Staff B, Director of Nursing/Registered Nurse, Staff B said the care plan populated the Kardex. Staff B said Resident 11's care plan should not have had the CNA's do nail care; it should have been the nurse. Reference WAC 388-97-1020 (5)(b)

Based on observations, interviews and record review, the facility failed to ensure food was stored, prepared, and served in a sanitary manner for 1 of 1 kitchen reviewed for kitchen practices. This failure placed residents at risk of foodborne illness, and the potential for experiencing a diminished quality of life. Findings included . Record review of the facility policy, titled, Sanitation, dated January 2018, showed, The Nutrition Services team maintains clean and sanitary kitchen centers and equipment. Walls, floors, ceilings, equipment, and utensils are clean and/or sanitized, and in good working order. The Nutrition Services team will practice good infection prevention and control procedures and habits. Employees will be clean and well-groomed and will handle food properly to prevent contamination. In an observation on 06/16/2025 at 10:46 AM, during a general tour of the kitchen area after the morning meal , food crumbs and dried food were visible on the steam table. The serving bowls and lids were covered with unknown food crumbs. The stove cooking area had visible leftover breakfast debris. The steam table was prepped for lunch service with the surface showing left over food and debris from the previous meal. Kitchen carts used to transport food were observed with crumbs, dried food, and liquid spillage. The plastic cover of the kitchen cart had a dried brown fluid on the back surface of the plastic cover. The floor in front of the stove and steam table was littered with smashed food, chunks of food and debris. The food storage room had a box of potatoes sitting directly on the floor surface with holes in the bottom of the box exposing the potatoes directly to the floor. In an observation on 07/01/2025 at 11:05 AM, the kitchen area showed there was food debris from the previous meals on the lids and bowls used to serve food. Next to the stove area a personal soda bottle was sitting in the food serving area. In an interview on 06/16/2025 at 11:12 AM, Staff C, Dietary Manager, said the kitchen was to be cleaned between meals by the cook. Staff C said she was not sure why the cook had not cleaned the kitchen area after breakfast. Staff C said the storage room should not have food sitting on the floor. Staff C said the boxes should be stored on the shelves in the storage area. In an interview on 06/16/2025 at 11:47 AM, Staff D, Cook, said they were responsible for cleaning the stove, floors and steam table between meals. Staff D said the steam table should have been thoroughly cleaned before placing lunch items into the steam table. Staff D said he was running behind today and was not able to clean the area. In an interview on 07/01/2025 at 11:19 AM, Staff C said kitchen staff should not be drinking personal beverages on the food line. Reference WAC 388-97-1100 (3) and 388-97-2980.

Based on observation and interview, the facility failed to ensure proper disinfecting of the food thermometer when taking food temperatures in 1 of 1 kitchens reviewed for sanitation and storage. This failure placed residents at risk of cross-contamination and food borne illness. Findings included . On 11/06/2024 at 11:32 AM, Staff I, Cook, was observed testing the temperature of the food on the tray line with a kitchen thermometer. At 11:34 AM, Staff I was observed placing the thermometer into pan of pureed chicken. After documenting the temperature, Staff I wiped the thermometer with a kitchen cloth. Staff I then placed the same thermometer into another pan to test the temperature of another entree. Staff I did not use a sterilizer after temping the foods with the thermometer. At 11:36 AM, when asked about safe cleaning practices of food preparation equipment, Staff I said, he used a cloth to clean the thermometer, but the facility would prefer if he were to use alcohol wipes. At 11:43 AM, when asked about the expectation to clean the thermometer between checking food temperatures, Staff G, Dietary Manager, stated, We use alcohol wipes. On 11/07/2024 at 10:31 AM, Staff B, Director of Nursing Services and Registered Nurse, said she expected staff to abide by proper cleaning practices to prevent food borne illness. Reference WAC 388-97-1320 (1)(c)

Based on interviews and record reviews, the facility failed to ensure bowel interventions were initiated for 3 of 7 sampled residents (14, 58 & 37) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . Per Facility Bowel Management Policy, entitled Management of Constipation, updated 11/2023: When a resident is identified with No/small Bowel Movement documented for 64 hrs [hours], the LN [Licensed Nurse] will assess the resident and determine if bowel protocol will be initiated. The Clinical Alert will be cleared using the progress note function to document findings and interventions. Standard bowel protocol to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: --Miralax PO after eight shifts of no BM --Compound Laxative, consisting of 17.2 of Senna and of 10 mg Bisacodyl --Bisacodyl suppository rectally, if no results from the compound laxative --Fleet Enema rectally, if no results from Bisacodyl suppository. 1) Resident 14 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment, dated 09/29/2024, documented the resident was alert and oriented. The Bowel and Bladder Elimination task sheet showed Resident 14 had a Bowel Movement (BM) on 10/27/2024 at 2:59 PM, and did not show another BM until 11/02/2024 at 9:30 AM, over 138 hours (more than five and a half days) since her last documented BM. Review of Resident 14's October 2024 and November 2024 Medication Administration Report (MAR) showed the bowel protocol was not initiated between the dates of 10/27/2024 and 11/02/2024. 2) Resident 58 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], documented the resident was moderately cognitively impaired. The Bowel and Bladder Elimination task sheet showed Resident 58 had a BM on 10/21/2024 at 9:59 PM, and did not show another BM until 10/27/2024 at 7:30 PM, over 141 hours (more than five and a half days) since her last documented BM. Review of Resident 58's October 2024 MAR showed the bowel protocol was not initiated between the dates of 10/21/2024 and 10/27/2024. 50416 3) Resident 37 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 37 was severely cognitively impaired, incontinent of bowel and bladder and required total assistance with activities of daily living. Resident 37's care plan, dated 10/20/2019, documented, .Potential for Alteration in bowel elimination constipation r/t [related to] decreased mobility; medication use . Will have a normal bowel movement at least every 1-2 days through the review date . Follow facility protocol for bowel management . The Bowel and Bladder Elimination task sheet showed Resident 37 had a BM on 10/12/2024 and did not have another BM until 10/19/2024, six days between BMs. Review of Resident 37's MAR did not show the bowel protocol was initiated from 10/13/2024 to 10/18/2024. On 11/06/24 at 9:13 AM, Staff F, Unit Manager (UM) and Licensed Practical Nurse (LPN), said bowel reports on the Electronic Health Record (EHR) dashboard were run daily to identify residents who needed the bowel protocol to be initiated. Staff F said she did not know why Resident 37 did not alert for no BM from 10/13/2024 to 10/18/2024 and was unable to tell how the information was missed. On 11/07/2024 at 8:43 AM, Staff J, LPN, said after three days of no BM, facility initiates the bowel protocol, and residents are to be administered either Miralax (a laxative) or Senna (a laxative). Staff J was unable to provide documentation of the BM protocol being initiated for Resident 14 and Resident 58. Staff J stated, They would be expected to be given something [bowel intervention]. We document in the MAR. I should have documented. At 9:21 AM, Staff C, UM and LPN, said if there was no BM in three days, the bowel protocol needed to be initiated. Staff C stated, They need to document it appropriately. Staff C was unable to provide documentation of bowel interventions being initiated for Resident 14 and Resident 58. At 10:27 AM, Staff B, Director of Nursing Services and Registered Nurse, said she expected the bowel protocol to be initiated per facility policy. Staff B stated, We are aware. It's documentation. Reference WAC 388-97-1060 (1) (3)(c)

Based on observation, interview, and record review, the facility failed to ensure assistance with shaving was provided for 1 of 4 sampled residents (224) reviewed for activities of daily living (ADLs). This failure placed residents at risk for unmet care needs, decreased self-esteem, and a diminished quality of life. Findings included . Resident 244 was admitted to the facility on [DATE]. The Admission/Medicare 5-day Minimum Data Set assessment, dated 07/26/2024, documented Resident 244 was alert and oriented. Review of Resident 244's ADLs care plan, revised on 07/30/2024, documented .Will be neat, clean and well groomed daily . PERSONAL HYGIENE: Resident requires extensive assistance. Review of Resident 244's Kardex (a nursing worksheet tool that includes a summary of patient information used to guide nursing care), dated 11/06/2024, showed PERSONAL HYGIENE: Resident requires extensive assistance. On 11/04/2024 at 10:38 AM, Resident 244 was observed with dark colored facial hair about one quarter inch long present on chin and sides of chin. Resident 244 said her chin hair bothered her. Resident 244 said the staff did not offer to shave it, even when she got a bath. On 11/05/2024 at 12:37 PM, Resident 244 was observed lying in bed with dark colored chin hairs present on the bottom and sides of the chin about one quarter inch long. Resident 244 said no one offered to shave her in the morning and she would like to have been. Review of Resident 244's person hygiene task record for shaving, dated 10/08/2024 through 10/22/2024, and 10/31/2024 through 11/06/2024, showed no documented task support for shaving. The record showed Resident 244 was out of the facility from 10/22/2024 to 10/31/2024. On 11/06/2024 at 9:36 AM, Resident 244 was observed lying in bed with dark colored hair present on the chin and sides of the chin. On 11/07/2024 at 8:50 AM, Resident 244 was observed with dark colored hair present on bottom and sides of chin longer than one quarter inch. Resident 244 said staff did not offer her a razor to shave or offer any help to shave, and it bothered her to have chin hair. At 8:52 AM, when asked how staff knew the care needs of a resident, Staff D, Certified Nursing Assistant, said they got their information from the Kardex. At 8:55 AM, Staff C, Unit Manager and Licensed Practical Nurse, said residents should be offered assistance daily and as needed for shaving. Staff C said Resident 244 needed assistance with ADLs. After going to Resident 244's room and observing Resident 244's facial hair, Staff C asked Resident 244 if she wanted to be shaved daily. Resident 244 said she would like her chin hair to be shaved. Staff C said they should have been shaving or offering to shave Resident 244 daily. At 10:46 AM, Staff B, Director of Nursing Services and Registered Nurse, said it was her expectation residents be shaved or offered assistance daily with shaving and ADLs care. Reference WAC 388-97-1060 (1)(2)(c)

Based on observation, interview, and record review, the facility failed to ensure respiratory care was addressed on the comprehensive care plan for 1 of 1 sampled resident (244) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 244 was admitted to the facility on [DATE]. The Admission/Medicare 5-day Minimum Data Set assessment, dated 07/26/2024, documented Resident 244 was alert and oriented, had a diagnosis of obstructive sleep apnea (a condition that occurs when the throat muscles relax during sleep, partially or completely blocking the airway interrupting breathing), and had a CPAP (continuous positive airway pressure, a machine that helps treat sleep apnea). Review of Resident 244's Electronic Health Record showed the comprehensive care plan did not document a focus area, goal, or intervention for a CPAP machine. On 11/04/2024 at 10:56 AM, a CPAP machine with tubing and mask was observed on Resident 244's nightstand. Resident 244 said the staff would put water in it. Resident 244 said she did not use it every night, but she should. On 11/05/2024 at 12:37 PM, Resident 244 was observed lying on her back in bed. A CPAP machine with tubing and mask was observed at the bedside on a nightstand. On 11/06/2024 at 9:36 AM, Resident 244 was observed lying in bed. A CPAP machine with tubing and mask was observed at the bedside on a nightstand. At 2:00 PM, Staff C, Unit Manager and Licensed Practical Nurse, said residents with a CPAP machine should have it care planned. Staff C said she could not find a care plan for Resident 244's CPAP machine and there should have been. At 2:55 PM, Staff B, Director of Nursing Services and Registered Nurse, indicated it was her expectation care plans were in place for residents with a CPAP machine. Reference WAC 388-97-1020 (1) (2)(a)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when medication orders were incorrectly transcribed, not reconciled and incorrectly administered for 1 of 3 sampled residents (Resident 1) reviewed for significant medication error. This caused harm to Resident 1 when the resident was administered potent medications not prescribed and had a serious change of condition requiring hospitalization . This failure placed residents at risk of adverse reactions to medications, change in health conditions and a diminished quality of life. Findings included . Review of the facility policy, dated 07/2015 and revised 11/2023, showed: Admission orders will be obtained/approved through the Provider as soon as possible following or prior to the resident admission/re-admission to the center . Staff will review medication orders and assure standards of practice with orders to include the following: - Right route, dosage, frequency. - Stop dates for antibiotics - Each medication has a corresponding diagnosis - PRN (as needed) Psychotropics have 14 day stop date Resident 1 was admitted to the facility on [DATE] with diagnoses including weakness, stroke, and history of elevated blood pressure. The admission Minimum Data Set assessment, used by the facility to complete the plan of care, was pending prior to discharge on 02/11/2024 to the hospital. Record review of the hospital physician encounter note, dated 02/13/2024, showed on 02/11/2024 the resident reportedly received the wrong medications and noted to have decreased level of consciousness, difficulty breathing and coffee ground emesis. Resident 1 was transported to the hospital emergency department and admitted for treatment. Review of Resident 1's medical record showed medication errors were discovered after the resident's change in condition following the morning medication pass on 02/11/2024. The facility investigation showed Resident 1 received medications ordered for a non-facility resident (NFR) and the admission medications for Resident 1 had not been verified per protocol by two nursing staff. After the error was identified, the correct orders were then obtained from the prior discharging hospital and placed in Resident 1's medical record prior to the resident's readmission back to the facility on [DATE]. The after-visit summary, dated for the initial hospital discharge of 02/09/2024, showed 10 medications were ordered for Resident 1, and were not started on admission to the facility, that included: = Acetaminophen 325 milligrams (mg) - 2 tablets as needed every 6 hours.(pain relief) = Amlodipine 5 mg daily (high blood pressure) = Aspirin 81 mg daily (stroke prevention) = Atorvastation 40 mg every night (high cholesterol) = Bisacodyl 10 mg suppository as needed daily (laxative) = Colace 100 mg twice daily (laxative) = Famotidine 20 mg daily (ulcer, esophagus, digestive treatment) = Lidocaine 4% patch apply on skin every night (pain) = Miralax 17 grams (g) daily as needed (laxative) = Senna 8.6 mg one tablet twice daily (laxative) The after-visit summary, dated 01/31/2024 through 02/08/2024, showed a NFR's name clearly listed on the top of the summary and included a recap of the NFR's hospital stay. The summary for the NFR showed the following 20 medications were erroneously documented on Resident 1's February 2024 Medication Administration Record (MAR) and were initiated by nursing on 02/09/2024: = Aspirin 81 mg one daily (pain) = Ciprofloxacin HCI 500 mg tablet. One tablet every 12 hours for 3 doses (antibiotic that had a *black box warning* - often referred to as simply boxed warning - is the strongest warning issued by the FDA in the United States on drugs that carry specific health risks - serious or life-threatening adverse effects). = Fludrocortisone 0.1 mg tablet 1 tablet daily (for adrenal gland diseases) = Tamsulosin 0.4 mg one every morning (for prostate urine flow problems) = Acetaminophen 325 mg take 2 tablets every 6 hours as needed (pain) = bisacodyl suppository 1 daily as needed (laxative) = Bupropion 150 mg tablet every morning (antidepressant with a *black box warning*) = Carbidopa-Levadopa 25-100 mg 2 tablets four times daily (a medication for Parkinson's, central nervous system disorder affecting movement, with a *special precautions noted for potential side effects of coffee emesis, bloody stools*) = Cholecalciferol 1000 unit tablet. Take 2 tablets every morning (vitamin) = Finasteride 5 mg tablet. One nightly (medication for a prostate disorder that is *not approved by the Food and Drug Administration for use in women*) = Guaifenesin 100 mg/milliliters(ml) Take 10 ml every 4 hours as needed (decongestant) = Lactobacillus Rhamnosus 10 billion cell capsule. Take one every morning (supplement for gut health) = Lidocare 4% patch. Place on skin as needed (pain) = Loratadine 10 mg tablet every morning (allergens) = Melatonin 3 mg tablet once nightly as needed for healthy circadian rhythm (rest) = Multivitamin one daily (supplement) = Miralax 17 g daily as needed (for constipation) = Pravastatin 40 mg one each night (cholesterol lowering) = Sertraline 100 mg Take 2 tablets every morning (an antidepressant with a *black box warning*) = Vitamin B-12 1000 micrograms (MCG) one tablet every morning (supplement) Review of Resident 1's February 2024 MAR showed on 02/09/2024 through 02/11/2024 the following medications on Resident 1's original order were omitted when not transcribed and were not given: = Amlodipine 5 mg - Omitted two days. = Famotidine 20 mg daily - Omitted two days. = Lidocare patch - Omitted. = Colace 100 mg twice daily - Omitted. = Senna twice daily - Omitted. Review of the February 2024 MAR showed on 02/09/2024 through 02/11/2024 Resident 1 erroneously was administered the following medications that were prescribed to the NFR, not to Resident 1: = Bupropion HCI ER 150 mg - Received two days. This medication had a *black box* warning. = Cholecalciferol 25 mcg - Received two days. = Cyanocobalamin 1000 mcg - Received two days. = Finasteride 5 mg - Received one PM dose. = Fludrocortisone 0.1 mg - Received two days. = Loratadine 10 mg - Received two days. = Multi Vitamin - Received two days. = Pravastatin 40 mg - Received one PM dose. = Probiotic (gut health) - Received two days. = Sertraline 100 mg/take 200 mg each day - Received two days. This medication had a *black box* warning. = Tamsulosin 0.4 mg - Received one PM dose. = Cipro 500 mg - Received three doses. Resident 1 was allergic to medication class. This medication had a *black box* warning. = Carbidopa-Levadopa - Received two days, six doses. On 02/23/2024 at 1:40 PM, Collateral Contact (CC) 1, Confidential Source, said the facility reported to them, on 02/11/2024, Resident 1 had received the wrong medications causing a change in condition that required hospitalization . At 1:20 PM, Staff A, Resident Care Manager, said when Resident 1 was admitted to the facility the discharging hospital failed to include the medication list. Staff A said after the facility requested the papers, the orders were uploaded, entered offsite, and not verified by two nursing staff per facility protocol. On 04/01/2024 at 12:38 PM, when asked how Resident 1's medication errors were discovered, Staff B, Licensed Nurse, stated, It was just a fluke. Staff B said he was giving medications and another nurse pulled up Resident 1's medications. They looked into documentation and did not see where two people had checked the resident's record. Staff B said Resident 1 had received her morning doses of medications, had a change in condition, was not feeling well and had an episode of coffee ground emesis. Staff B said Resident 1 was transported to the hospital for treatment. The incorrect medication list was discontinued once the medication error was identified and the correct medication list was requested from the discharging hospital. Resident 1 was transported to the hospital for attention and evaluation for a significant change in condition and after learning she was administered the wrong medication. The facility completed a fully facility audit of all hospital transfer order to ensure accuracy. Immediate education to nurses regarding two patient identifiers as well as re-education on admission policy occurred on 02/11/2024 and 02/12/2024. An audit tool was created for IDT to review in daily clinical meetings and to be completed on every admission. The admission Resident Care Manager (RCM) and Director or Nursing (DON) or designee will audit admission orders and the audit tool for 12 weeks and review results in QAPI. The admission RCM and DON will be responsible for ensuring compliance. This was Past Non-Compliance. Reference WAC 388-97-1260 (3)(k)(iii)

Based on observation and interview, the facility failed to ensure staff completed hand hygiene during meal service on 1 of 2 halls (Hall B) reviewed for serving meals in a sanitary manner. This failure placed residents at risk of contracting an infectious disease and a decreased quality of life. Findings included . Record review showed on 10/09/2023 the facility was in outbreak status for COVID-19 (a highly infectious virus that can cause severe illness in the elderly population). On 10/09/2023 at 8:32 AM, Staff D, Resident Care Manager and Licensed Practical Nurse, and Staff E, Physical Therapy Assistant, were observed passing out food trays and drinks. Staff D and Staff E did not wash their hands upon entering the Hall B dining room. At 8:40 AM, Staff F, Nursing Student, said staff should clean their hands when leaving a resident's room. At 8:43 AM, Staff E, Physical Therapy Assistant, was observed touching her facemask while holding an empty mug. Staff E then filled the mug with coffee from a communal coffee dispenser and went to deliver it to a resident. Staff E did not clean her hands after touching her dirty mask. At 8:44 AM, Staff D was observed assisting Resident 48 with their fluids. Staff D moved to the next table to assist Resident 248 with feeding. Staff D did not wash her hands between assisting different residents. At 8:50 AM, Staff D was observed assisting Resident 78 with setting up their straw and drink without washing her hands in between residents. At 8:51 AM, Staff D was observed assisting Resident 248 with feeding without washing her hands in between residents. At 8:32 AM to 8:55 AM, Staff D was observed touching her dirty facemask multiple times without washing hands before resuming care with residents. At 8:57 AM, Staff D was observed picking up dirty plates in the Assist Dining Room. Staff D left to the hallway nurses' station and returned with a thickened shake for Resident 63. Staff D did not clean her hands after touching dirty meal tray items before pouring and serving the shake. At 9:03 AM, Staff E was observed putting a dirty meal tray on the kitchen cart and did not clean her hands when done. Staff E went into Room B10-1, moved the resident's personal items, and removed the dirty meal tray. Staff E did not clean her hands after putting the tray on the kitchen cart. Staff E was observed repeating this process by going into Room B12-2, Room B7, and Room B3 to remove the dirty meal trays all without cleaning her hands. An emergency was called down Hall B where Staff E went to assist with unclean hands. On 10/13/2023 at 10:23 AM, Staff G, Infection Preventionist and Registered Nurse, said staff were educated on handwashing on hire and annually. Staff G said she did hand hygiene spot checks throughout the year. Staff G said she expected staff to clean their hands when exiting a resident room. Reference WAC 388-97-1320 (1)(c)

Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity, and provided a dignified and timely meal service for 2 of 2 meals observed in 1 of 3 dining halls (Hall B) reviewed for resident rights. This failure placed the residents at risk for feelings of institutionalization, unmet care needs and a diminished quality of life. Findings included . The facility Meal Services Schedule specified Hall B Dining Room, undated, showed residents were served breakfast daily at 8:00 AM and lunch at 12:00 PM. 1) On 10/09/2023 at 7:30 AM, three residents were observed in the Assisted Hall B Dining Room. More residents were brought into the dining room by staff shortly after. No drinks or meals were brought out and served at this time. At 7:45 AM, seven residents were observed to be seated in the Hall B Dining Room with no drinks or food served. One resident was observed to have left the dining room without a meal. At 8:35 AM, Resident 56 said he was not sure how much longer he would have to wait, and said he did not know what time meals were scheduled to be served. Residents in the Hall B Dining Room were observed to sit with minimal stimulation while waiting for their meals. At 8:43 AM, the breakfast cart was observed to arrive, and residents were served breakfast at that time. Residents were observed to wait for their breakfast meal for a total of 43 minutes after the scheduled breakfast time. 2) On 10/12/2023 at 11:50 AM, three residents arrived for lunch in the Hall B Dining Room. A few more residents were observed to arrive shortly after. At 12:51 PM, lunch trays were observed to be served by staff. Residents in the Hall B Dining Room waited 51 minutes before being served lunch. On 10/12/2023 at 11:27 AM, Staff M, Dietary Manager, said he was surprised residents waited a long time for their breakfast. Staff M stated, That's not usual. I am not sure what happened. At 11:29 AM, Staff N, Registered Dietitian, said they were not aware of long wait times the previous day. Staff N stated, That's really surprising. At 2:54 PM, Resident 58 stated, I really feel sorry for some of those guys on B Hall. They wait too long. All the time. At 3:08 PM, Staff D, Resident Care Manager and Licensed Practical Nurse, said to be more efficient with meal service, the facility tried different service arrangements. Staff D said the residents on Hall B did often wait longer than appropriate for their meals. Staff D stated, They should not be brought in so early. It bothers me. I come in sometimes and bring drinks. They are alone in there. At 3:41 PM, Staff A, Administrator, stated, Monday [10/09/2023] was rough. Staff A said delayed meal service had been an issue. Reference WAC 388-97-0180 (1-4)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for therapeutic medication levels via regular blood testing for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life. Findings included . Resident 59 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and non-Alzheimer's dementia. The significant change Minimum Data Set, an assessment tool, dated 09/09/2023, documented the resident was severely cognitively impaired. A physician's order, dated 03/16/2023, documented the resident was ordered Depakote, an antipsychotic medication. Resident 59's medical record did not show a documentation of a valproic acid level, a test used to determine a therapeutic level of Depakote. On 10/11/2023 at 1:09 PM, Staff C, Assistant Director of Nursing Services and Registered Nurse (RN), said Depakote levels should be obtained every six months. At 2:55 PM, Staff B, Director of Nursing Services and RN, said Depakote levels should be obtained every six months. Staff B was observed reviewing Resident 59's medical record and could not locate a Depakote lab. Staff B said labs were obtained via physician order. Staff B said Resident 59's Depakote lab was missed, and a stat order was obtained. Reference WAC 388-97-1060 (3)(k)(i)

Based on observations, interview and record review, the facility failed to ensure residents were provided necessary care and services to maintain or improve range of motion and failed to implement diet-related recommendations for 2 of 6 sampled residents (17 & 66) reviewed for quality of care related to rehabilitation services and nutrition. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . <Rehabilitation Services> Resident 17 was admitted to the facility on [DATE]. The significant change Minimum Data Set (MDS), an assessment tool, dated 09/01/2023, indicated Resident 17 was moderately cognitively impaired. The Occupational Therapy (OT) Discharge Summary, dated 06/14/2023, documented, Patient keeps her L [left] hand in a fisted position, but is able to fully extend L fingers with assistance. On 10/10/2023 at 9:25 AM, Resident 17 was observed lying in bed. The resident's left hand was in a fisted position. Resident 17 said she was supposed to wear a splint; and when she was not using the splint, she could use a washcloth the rest of the day. Resident 17 said the brace was in the drawer. The inside of the resident's left hand had some fingernail markings from her fingers pushing into her palm. At 1:18 PM, Resident 17 was observed without a splint on. A rolled-up washcloth was next to the bed on the dresser. On 10/11/2023 at 8:38 AM, Resident 17 was observed without her splint on but had a washcloth in her left hand. At 3:27 PM, Resident 17 was observed without the splint or washcloth in her left hand. On 10/12/2023 at 11:51 AM, Collateral Contact (CC) 1 said when he visited Resident 17 she did not usually have the splint on. CC 1 said he had to give her a washcloth to keep her nails from digging into her hand. 10/13/2023 at 8:36 AM, Resident 17 was observed lying in bed and had her splint on. At 10:06 AM, Staff L, Director of Rehabilitation, said the splint was not for a contracture but for a resting hand. Staff L said Resident 17 could open and close her hand when she was discharged from services. At 10:34 AM, Staff I, Unit Manager and Licensed Practical Nurse (LPN), was observed asking Resident 17 to open her hand. Resident 17 started to complain of pain once she got about an inch above her palm. The inside of the resident's palm had some marks. Staff I offered to get Resident 17 a towel. At 11:30 AM, Staff J, Restorative Services Coordinator, said staff should monitor how residents tolerate the splint. If any issues came up, they should report it to the nurse so they could seek an assessment. At 11:47 AM, Staff K, Restorative Aide, was observed asking Resident 17 to open her hand. Resident 17 was able to extend her thumb and little finger. Staff K assisted Resident 17 attempting to open her hand. Resident 17 began to complain of pain when Staff K attempted to open it. 46244 <Diet-Related Recommendations> Resident 66 was admitted on [DATE] with multiple diagnoses including muscular dystrophy (a group of diseases that cause progressive muscle weakness including trouble swallowing). The annual MDS, dated [DATE], showed Resident 66 was cognitively intact. Resident 66's Speech Therapy (ST) notes, dated 06/06/2023 and 06/19/2023, showed Resident 66 had a diagnosis of dysphagia (difficulty swallowing) and diet recommendations included cut up assistance (providing a food texture that is cut up in small pieces). Resident 66's electronic medical record did not show the cut up assistance for food was implemented. On 10/10/2023 at 11:02 AM, Resident 66 said he was having trouble swallowing. Resident 66 said a dietician told him to take smaller bites and the facility would cut up his food. Resident 66 said the staff did not cut his food unless he asked them. Resident 66 stated, They drop off the tray and run out the door. I can't do it. I need assistance. Resident 66 said he had not choked on food but had choked on medicine. On 10/12/2023 at 9:05 AM, Resident 66 was observed being served a breakfast of pancakes and sausage links that were not cut up. Resident 66 said he had to get the aide to cut it later on, when she returned to deliver coffee. Resident 66 said a couple of months ago, he had a conversation with a former speech therapy staff who was the person who said they would have his food cut up. At 12:38 PM, Resident 66 said he choked on his pills about a month ago, saw stars before it went black and fell back on his bed. Resident 66's lunch was observed to include roast beef, hash browns, cabbage, and a BLT sandwich. The pieces of beef were very large, varying in size from half dollar to half a credit card in size and the meat appeared dry. Resident 66 said the beef was cut up by the aide. Resident 66's meal slip showed a regular diet; no cut up texture was included. Resident 66 was observed holding a fork with some difficulty and had poor coordination of motor movement. At 3:23 PM, Staff D, Resident Care Manager (RCM) and LPN, indicated she was not aware Resident 66 had dysphagia. Staff D said she did not have access to therapy notes, therefore was not aware of speech therapy's recommendation. Staff D said the speech therapy department submitted a diet slip to the kitchen and changed the diet order. Staff D said in the recent past, speech therapists would give us (nursing) a copy so we would know about the changes. Staff D said the dietician would know about the change in texture because they were responsible for the nutrition care plan. Staff D said the care aides would know about diet changes by the diet slip printed on the meal tray. Staff D said nursing was not notified of diet or texture changes. At 3:47 PM, Staff M, Dietary Manager, said he talked to Resident 66 about four to five months ago and changed him to finger foods per his request. Staff M said he was not notified by speech therapy that Resident 66 should be on cut up foods. Staff M said he could not make texture decisions. The dietitian or speech therapist had to determine the texture. Staff M said the kitchen could cut up food prior to leaving the kitchen for any resident. Staff M said he did not ask about texture when interviewing residents about their food preferences. At 4:01 PM, Staff N, Registered Dietician, said speech therapy would take a diet slip to the kitchen and put an order in the electronic healthcare system (PCC) with specific instructions. When asked how she was notified of new orders, Staff N said she just looked for orders in PCC. When asked who was responsible for the nutrition portion of the care plan, Staff N said the former speech therapist would talk with the RCM to make changes/updates. Staff N said ideally RCMs would be notified and the RCMs notify me. Staff N said she was hopeful on developing a relationship with the new speech therapists, so communication issues did not occur. Staff N said there seemed to be a disconnect with Resident 66's texture order after the former speech therapist's evaluation. On 10/13/2023 at 8:55 AM, Staff C, Assistant Director of Nursing Services and Registered Nurse (RN), said diet changes were brought to nursing managers to discuss and then they put in the order/change. Staff C said dietary changes were brought to nursing and nursing made the change then updated the care plan. Staff C said the department head was responsible for communication between departments if it was an issue generated from their area of work. At 9:04 AM, Staff A, Administrator, said the Interdisciplinary Team (IDT), her and Staff B, Director of Nursing Services and RN, were responsible to keep all departments on the same page regarding resident care recommendations. Staff A said if speech made a recommendation it was sent to the doctor or nursing, then if approved, the provider would put the order in. Staff A said the Dietician wanted to see all changes and was a part of the IDT. Staff A said for a new diet order, a diet slip was made by nursing and handed to the kitchen or Staff N. Staff A discussed the miscommunication and how each department described a different system for addressing new or changed diet recommendations. Staff A said diet changes or recommendations needed to go through nursing to ensure all aspects of the change was addressed like consent or approval from doctor/family/resident prior to making the change; then the change could be implemented. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure residents received reasonable accommodations with meals for 1 of 7 sampled residents (41) reviewed for reasonable accommodation and preferences. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included . Resident 41 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 08/01/2023, showed the resident was severely cognitively impaired and required extensive assistance with eating. Resident 41's care plan, revised 01/27/2020, documented, needs one person assist with meals; she is able to feed self but needs cueing direction to slow down during meals; set up dishes. The care plan did not show the resident was to eat food with bare hands. Resident 41's order indicated she was on a cardiac diet: dysphagia advanced texture [foods that were nearly normal textures with the exception of crunchy, sticky, or hard foods], thin consistency [non-restrictive for intake], food in bowls . On 10/09/2023 at 8:30 AM, Resident 41 was observed eating with her left hand and not using a spoon. Two staff were in the dining room, and did not intervene. On 10/11/2023 at 12:25 PM, Staff I, Unit Manager and Licensed Practical Nurse, said Resident 41 was care planned to eat meals with her fingers. On 10/13/2023 at 9:13 AM, Staff I said Resident 41 eating with her hands should be in the care plan because it was her preference. At 9:21 AM, Staff C, Assistant Director of Nursing Services and Registered Nurse, said residents can use their hands if it was their preference but it should be care planned. Reference WAC 388-97-0860 (2)

Based on interview and record review, the facility failed to operationalize its policies and procedures to prevent and protect residents from actual and/or potential abuse for 1 of 3 current residents (#1) reviewed for abuse/neglect prohibition. Failure to implement abuse prevention measures created an environment where a reasonable person would have felt demeaned, embarrassed and helpless, and resulted in harm to intellectually challenged Resident #1 when she could not verbally or physically defend herself from being inappropriately touched by Resident #2. Findings include: Resident #1 was admitted in January 2017 with multiple health conditions. The resident was totally dependent on staff for all care and services. She was severely cognitively/intellectually impaired (not able to measure cognition) and was not able to be interviewed. An evaluating psychologist's note, dated 1/18/17, showed Resident #1 was .severely intellectually impaired .she needs 24 hour one-to-one supervision for her own protection and the protection of others . Resident #2 was admitted to the facility in November 2014 with multiple physical and mental health conditions including moderately impaired cognition. He could make his needs known and was independent in the facility using a wheelchair (w/c). The Resident's Comprehensive Care Plan (CCP), dated January 2017, documented the socially inappropriate behaviors exhibited by this resident were addressed. In March 2017, the CCP was updated due to the ongoing issues with the resident's behaviors. The resident was to be monitored for inappropriate sexual behaviors and was to be redirected to other activities including having the resident in staff line-of-sight when awake. The Social Services (SS) and IDT (interdisciplinary team) note, dated 12/13/16, documented Resident #2 had exhibited behavioral symptoms since admission by being verbally and physically sexually inappropriate and acting out. He exhibited the inability to control behavior and potential for violence, such as aggressive behavior directed at self or others .continues to be monitored for behaviors that are inappropriate . The nurse practitioner's progress note, dated 4/6/17, noted, Patient has been demonstrating inappropriate behavior that has been sexual in nature .see chart notes for details .it is warranted to add following [DIAGNOSES REDACTED]. The SS assistant progress note, in January 2017, showed the resident needed one-on-one monitoring due to behaviors and issues with other residents. The resident had been seen by a psychological service since 2016, and the last documented visit was dated 3/28/17. The documents did not show the treatment issue was for his behaviors or inappropriate sexual physical or verbalizations but for dysphoric mood, a major disorder of mood characterized by a persistent anxiety, irritability, fear, brooding, appetite and sleep disturbances, difficulty in concentrating or thinking, possible delusions . The facility documentation showed, on 4/14/17, Resident #3, who had high cognition and was alert and oriented, reported to the nurse on duty that she witnessed Resident #2 touching Resident #1's breasts while both Resident #1 and Resident #2 were sitting side by side in the hallway in their wheelchairs. The on-duty nurse reported the incident on 4/17/17. On 4/25/17 at 3:00 p.m., the SS assistant stated the resident was moved to another room due to the resident's inappropriate verbalizations and behaviors towards others and said, He now is a one-to-one to protect other residents. At 4:15 p.m., the Director of Nursing Services (DNS) said the previously one-on-one staff observations and line-of-sight monitoring had been discontinued a while ago since the resident had not exhibited any behaviors. Failure of the facility to implement abuse prevention measures when Resident #2's behaviors and risks of inappropriate behaviors were known to the facility, created an environment that delayed protection to Resident #1 for abuse, and placed all residents at risk of inappropriate behaviors demonstrated by Resident #2. Reference WAC 388 97 -0640 (2)(a)(b) .

Based on observation, interview and record review, the facility failed to promote care in a manner and environment that maintained dignity for 1 of 8 sampled residents (#19) reviewed for respect and dignity. Failure to protect and promote residents' dignity created an environment in which a reasonable person would have felt demeaned and embarrassed. Findings Include: Resident #19 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Resident's Minimum Data Set (MDS), an assessment tool, dated 2/18/17, showed the resident needed assistance with personal care and sometimes understood verbal content. She responded adequately to simple, direct communication. On 3/1/17 at 8:26 a.m., the resident's room was observed with a urine odor. The resident was asked if staff had checked her brief before giving her breakfast. The resident shook her head from left to right and said, No. When asked if her brief was wet she nodded and said, Yes. The resident then lifted her covers and revealed her draw sheet and bed sheet were both soiled with urine. At 10:29 a.m., the Resident's brief was observed to be saturated, urine odor was present in the room and the resident's draw sheet and bed sheet were soiled with urine. At this time, Nursing Assistant (NA) D and Licensed Nurse (LN) H entered the resident's room without knocking, announcing themselves and waiting for the resident's permission to enter the room. When NA D provided perineal care for the resident, she did not pull the privacy curtain and left the resident uncovered/exposed when leaving to obtain needed supplies. Since the privacy curtain was not pulled, the resident's buttocks were exposed to the closed doorway during the entire personal hygiene process. On 3/2/17 at 11:39 a.m., NA B and NA C were observed to provide personal care to the resident without the privacy curtain being pulled between her bed and the closed door. NA B and NA C left the resident's chest, abdomen and buttocks exposed to the doorway where any person entering would have seen the resident undressed. At 11:49 a.m., NA C said to ensure a resident's privacy during care, the room door should be closed or the curtain should be closed if the door is left open. When asked if one barrier between a resident and possible exposure to the hallway was sufficient to ensure their privacy NA C said, No, and indicated both the door and the curtain between the bed and door should have been closed. NA B said all curtains, in addition to the resident's door should have been closed. During the care process, NA B said, O.K. Honey, I'm going to turn you toward me. When handing the resident her dentures, NA B said, Here you go, Sweetie. When asked if it was alright for staff to call her Honey and Sweetie, Resident #19 shook her head and said, No. The resident nodded Yes when asked if she would like to try and say how it made her feel when staff addressed her with terms like Sweetie and Honey, did she feel disrespected? The Resident raised her left hand, nodded her head and said, Yes. Resident #19 indicated having the curtain left open when she was undressed made her uncomfortable. At 11:53 a.m., NA B stated it was not appropriate to address a resident as honey or sweetheart without getting permission from the resident first. On 3/7/17 at 12:04 p.m., when asked about the expectation for ensuring privacy during care, the Administrator stated, The curtain should always be closed. Failure to ensure privacy was maintained, the resident was clean and dry and that staff addressed the resident in a respectful manner created a situation during which a reasonable person would feel demeaned and disrespected. .

Based on interview and record review, the facility failed to ensure planned interventions were implemented to keep residents safe, failed to monitor and report changes in residents' condition, and failed to provide sufficient training of staff in positioning residents in a manner to ensure their safety for 3 of 4 residents reviewed (#1, 2 and 3) for falls with injury. These failures caused harm to Resident #1 when she received a head injury which required suturing on two occasions and had a marked decline in condition. These failures placed all residents at risk for falls and possible injuries. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #1 was receiving hospice services. The Minimum Data Set (MDS), an assessment tool, dated 4/12/16, documented the resident had significantly impaired cognition and required extensive assistance with activities of daily living (ADLs). Resident #1 was assessed to be at high risk for falls. The facility's Incident Log documented the resident had an unwitnessed fall on 6/9/16 which did not result in injury while attempting to toilet herself. According to the MDS, Resident #1 was not on a toileting program. The facility's Incident Log documented Resident #1 had a second, witnessed fall out of her wheelchair onto her forehead on 6/9/16 at 4:30 p.m. The resident received numerous skin tears and bruises, and required transport to a hospital to have the head wound sutured (stitched) closed for healing. On 6/30/16 at 10:02 a.m., the Director of Nursing Services (DNS) stated the resident was noted to lean significantly forward while sitting in her wheelchair. On 6/13/16, Resident #1's Care Plan was updated to include the use of a Velcro seatbelt to be used whenever the resident was in her wheelchair as a reminder to request help when she wished to stand up. Between 6/13 and 6/19/16, Resident #1 was frequently active, propelling herself around the unit or walking several times a day with staff. On 6/19/16, a nurse's note in Resident #1's chart documented, Makes needs known. Good appetite. Active on unit. Ambulated by (Licensed Nurse (LN)) and caregivers per restorative program. The sutures on Resident #1's head wound were removed. A facility investigation documented on 6/20/16 at approximately 7:00 p.m., Nursing Assistant (NA) B was wheeling Resident #1 in her room when the resident fell out of her wheelchair, re-opening the head wound as well as acquiring other injuries to her arms and legs. The facility investigation documented the resident did not have the Velcro belt on at the time of the fall. The facility investigation documented NA B told the LN I thought I could make it from the resident's bathroom to the bed. The resident was transported to the hospital for evaluation and treatment and returned to the facility later in the evening at approximately 1:00 a.m. On 6/30/16 at 9:46 a.m., the DNS stated that staff are expected to monitor residents closely after any incident in which they are injured for a minimum of 72 hours. The DNS stated in addition to frequent neurological assessments, staff would be expected to write a nurse's note of the resident's condition a minimum of once a shift after a significant fall. Changes in a resident's level of consciousness, mental state or other changes would be expected to be reported to a physician after a fall. Resident #1's Neurological Assessment flowsheet documented assessments for 22 hours rather than the minimum of 72 hours stated by the facility's Episodic Documentation Procedure, dated July 2015, and stated by the DNS to be the expectation of care. At 9:34 a.m., the DNS stated that neurological assessments should have been done since there was no order to discontinue them and noted, Absolutely there was a change in condition. After falling and hitting her head a second time in the same month, the resident returned to the facility at 1:00 a.m. on 6/21/16. The time of her arrival was charted, as well as the presence of stitches in her forehead and dressings on her knees. Neither a neurological assessment or description of Resident #1's mental or physical state was documented at that time. Neurological assessments charted on 6/21/16 at 5:00 a.m., 9:00 a.m., and 1:00 p.m., chart the resident's level of consciousness as drowsy and appropriate. One hour later, on 6/21/16 at 2:00 p.m., a nurse's note documented, (Resident) only stays awake for a moment while being repositioned. Has nonsensical speech, talking about people who are not in the room, restless. Falls asleep and is not arouseable to voice to gentle touch, with eyes rolled back. Spoke with (POA) who gives verbal OK for pain medication. Order requested for morphine liquid and lorazepam liquid. A nurse's note for dayshift on 6/21/16 documented the resident was in bed all day shift, her head felt sore and she slept. The facility failed to ensure fall precaution interventions were followed consistently for Resident #1 who was noted to have a marked decline following a fall on 6/20/16 in which she sustained a second head injury. 2) Resident #2 was admitted to the facility with multiple medical [DIAGNOSES REDACTED]. The resident's MDS documented the resident required extensive assistance with bed mobility, turning and toileting. On 5/8/16, a facility investigation documented the resident was assisted on the bed pan by NA B during the evening shift. The investigation documented the resident fell out of her bed onto her face. The resident incurred multiple injuries which required transportation to the emergency room for assessment. On 6/29/16 at 3:35p.m., when interviewed about the accident on 5/8/16, NA B stated, I thought it would be easier if I positioned her on her side with the bedpan under her. I pulled on the draw sheet. I left her on (her) left side, covered her with a blanket and left (to find the nurse). A few minutes after, I heard the resident cry out for help. I heard the bang. On 6/30/16 at 8:55 a.m., when asked about the incident on 5/8/16, the resident stated, I took a bad fall. On 6/29/16 at 4:36 p.m., when asked about Resident #2's fall, the DNS stated, The resident was trying to shift her bottom on the bed pan. Due to her weight, she shifted. She was too close to the edge and fell off. The aide needed a nurse, left the resident on her side. (NA B) thought she was in a safe position. When asked if she would ever question the aide's judgment, the DNS replied, yeah. If the shifting would not have happened, the fall probably would not have occurred. I don't think NA B's judgment was to put (Resident #2) in an unsafe position. Could she have rolled her over? possibly, probably, but not necessarily. The facility failed to ensure Resident #2's safety when she was left on her side on the bed pan and subsequently fell out of bed and sustained injuries to her scalp, face, and hand. 3) Resident #3 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #3's most recent MDS, dated [DATE], documented the resident required extensive assistance with bed mobility and positioning and was totally dependent on staff with transfers. Per the facility's investigation documentation, the resident had a witnessed fall out of his Broda chair (specialized tilt wheel chair) on 4/22/16 in the main dining room (DR) during mealtime. Documentation indicated he had another fall in his room on 5/31/16, when he fell out of the Broda chair again. The facility determined that the falls were most likely related to the sleek nature of the sling (used to lift the resident in and out of bed) and wrong position in the Broda chair. The facility documented a new intervention of removing the resident's sling while he was sitting in the Broda chair. The care plan and care delivery guide document the resident needed to be transferred with a Hoyer lift (a mechanical lift) by using a split leg sling and that the Hoyer sling should be removed from under the resident when he is up in his wheelchair. On 6/29/2016 at 9:00 a.m., Resident #3 was observed in his wheelchair in the dining room sitting on a full sling. The resident was alone in the DR. On 6/29/16 at 10:10 a.m., when asked about the assessment of root cause for the falls, the Director of Rehab (DOR) stated, We think he was in the reclined positon at the times of fall which allowed him to slide out due to the sleek surface of the chair and the sling. On 6/29/16 at 10:25 a.m., Licensed Nurse (LN) A indicated he was familiar with Resident #3. LN A stated he was not aware the resident should not sit on the sling as a fall precaution measure. At 10:35 a.m., LN C stated, He should not sit on his sling. When asked what her expectation of the nursing staff caring for the residents was, LN C stated the floor nurses should be familiar with the individual care plan for the residents entrusted into their care. At 11:10 a.m., NA A was asked about Resident #3's care. While looking at the resident's care delivery guide, which documented the resident should not sit on the sling, NA A stated, I did not even see that. The facility placed Resident #3 at risk for further falls and possible injuries by failing to ensure his fall prevention care plan was being consistently followed.

Based on observation, interview and record review, it was determined the facility failed to obtain emergent medical evaluation and services for 2 of 2 sampled residents reviewed (#45 & 56) who experienced significant changes of condition. This failure caused harm to Resident #45 when he did not receive immediate treatment for [REDACTED]. Failure to obtain emergent medical evaluation also contributed to Resident #56's decline and subsequent death. This was determined to be an immediate jeopardy and the facility was informed on [DATE]. The facility also failed to have systems in place to ensure adequate care and services were provided to manage bowel issues, fluid restrictions, pain, non-pressure wounds, and follow-up appointments for 6 of 6 residents reviewed for care and services (#16, 59, 68, 22, 20, & 2). These failures placed residents at risk for unmanaged pain and unmet care needs. Findings Include: 1) According to the American Stroke Association it's critical that you get medical attention right away. Immediate treatment may minimize the long-term effects of a stroke and prevent death. The only Food & Drug Administration (FDA) approved treatment for [REDACTED]. tPA works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow. If administered within 3 hours (and up to 4.5 hours in certain eligible patients), tPA may improve the chances of recovering from a stroke. A significant number of stroke victims do not get to the hospital in time for tPA treatment; this is why it's so important to identify a stroke immediately. Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED]. On [DATE] at 3:54 p.m., the resident's power of attorney (POA) stated she had a telephone conversation with the resident on [DATE] at 1:30 p.m. The POA stated, He was slurring his speech and I had to insist they send him to the hospital. They did not even know what a stroke was when he had one there. It wasn't until about 3:00 or 4:00 p.m. that they finally sent him to the hospital. I had to demand they do something. The POA stated the nurse thought it was a side effect from his medication. The POA was tearful as she stated, Since the stroke, I don't see the Grandpa I know anymore. A communication form titled SBAR (Situation, Background, Appearance, Review and Notify), documented the resident had been showing symptoms consistent with a stroke including slurred speech, decreased level of consciousness, dizziness, pinpoint and non-reactive pupils, weakness, and decreased hand-eye coordination. The SBAR form documented the physician was notified, but there was no date or time indicating when the physician was first notified of Resident #45's stroke-like symptoms. The form documented that the resident was Sent to ER for eval (uation), report sent and called to ER 1610 (4:10 p.m.) This SBAR communication form was the only documentation available in the resident's medical record describing the stroke-like symptoms and what the resident had experienced that day. The SBAR form had the date of [DATE], but did not include any times or sufficient details to describe the situation. It was not clear when the resident first began to experience stroke like symptoms, which nurse assessed the resident, if any, and when the physician was notified. On [DATE] at 8:52 a.m., Licensed Nurse (LN) B stated the resident started having a change of condition between lunchtime and 2:00 p.m. On [DATE] at 12:45 p.m., when asked what the timeline for transportation to the hospital should be for someone experiencing stroke symptoms, the Director of Nursing Services (DNS) stated, Within a short period of time, it should be less than an hour. The communication form previously identified was shown to the DNS and she agreed that the symptoms listed on that (communication form) were consistent with a stroke and needed prompt medical attention. When asked about the resident's change in function after returning from the hospital, the DNS stated that, His balance has definitely changed. He used to be able to get up to the bathroom before and now cannot. He is more impulsive. He is not as stable. I would say his function has decreased; he is very different due to the confusion and the stroke itself. A hospital discharge summary, dated [DATE], documented a discharge [DIAGNOSES REDACTED]. The lack of prompt identification of stroke-like symptoms and subsequent delay of emergency medical response led to the ineligibility for the resident to receive potentially brain saving medication. This delay caused harm to Resident #45 when he experienced a significant change in functioning after the stroke. 2) Resident #56 was admitted to the facility on [DATE] with multiple medical diagnoses, including [MEDICAL CONDITION], heart failure, kidney disease, and diabetes. The resident's Minimum Data Set (MDS), an assessment tool, dated [DATE] documented the resident had moderate cognitive impairment, inattention and disorganized thinking. Prior to admission to the facility, on [DATE], Resident #56 signed a POLST (physician's orders [REDACTED]. The POLST documented the resident wanted Limited Additional Interventions, which specified the use of medical treatment including hospitalization , intravenous fluids and cardiac monitoring. An Advance Care Planning Care Plan, dated [DATE], documented the resident's goal was to return home after receiving physical and occupational therapy. A care conference note, dated [DATE], documented the resident's goals were to transfer better, get stronger and have better endurance in order to be discharged home. On [DATE] at 10:47 a.m., the Social Services Assisstant (SSA) stated that resident's goal was not palliative care or end of life care, that was not even a concern. Review of the Social Services notes do not document any refusals of medications or discussions regarding change of the resident's goals of care to a palliative focus. On [DATE], the physician ordered Resident #56 to be weighed daily and set parameters for notification to the physician regarding weight gain. Monitoring day-to-day weight fluctuations is an important component of fluid management for residents with heart failure. In reviewing the chart, the resident's weights were not available. On [DATE], an SBAR communication form documented the resident began to experience [DIAGNOSES REDACTED] (low blood sugar level). The SBAR documented the resident was unresponsive, breathing fast and exhibiting [MEDICAL CONDITION] activity. The blood sugar level was documented at 27 (normal range ,[DATE]). The SBAR documented the resident was administered two [MEDICATION NAME] injections (a medication to raise blood sugar level) between 3:05 a.m and 3:20 a.m., but the resident remained unresponsive. A self adhesive note on the first page of the SBAR documented Spoke with (physician) at 0620. Orders to notify POA (if there is POA) and send out for eval. The documentation does not identify what time the resident was transported to the hospital. The facility failed to act promptly and seek emergency medical services when the resident's blood sugar remained low for an extended period of time despite treatment. A period of over three hours elapsed between the resident's initial critically low blood glucose level and when her physician relayed orders to transport the resident to a higher level of care. The resident returned to the facility the next afternoon. On [DATE], a laboratory report documented a critically high BUN (a lab reflecting kidney function) and a critically low calcium level (essential for muscle and nerve function). A physician's orders [REDACTED]. The November Medical Administration Record (MAR) documented the resident received one extra dose of [MEDICATION NAME] and refused the [MEDICATION NAME] on [DATE]. The MAR documented the resident refused her routine [MEDICATION NAME] (a more potent medication for swelling) on the morning of [DATE]. Documentation does not show the physician was made aware of the resident's refusals of the diuretic medications that were central to her care. Documentation does not show that the risks and benefits of refusing this medication were reviewed with the resident. On [DATE] at 8:15 p.m., a nursing progress note documented that the resident was unresponsive. The note documented the resident's lungs sounded moist and her oxygen level was low. An SBAR communication form dated [DATE] at 10:00 p.m. documented the LN identified the resident was in possible fluid overload, exacerbation of her heart failure and [MEDICAL CONDITION]. The physician was notified and ordered the resident to be sent to the hospital for evaluation. The nurse's progress note dated [DATE] at 8:15 p.m. documented the resident aroused and was responsive enough to refuse transfer to the hospital. The progress note documented a phone message was left for the resident's spouse. The documentation does not show the physician was notified of the resident's refusal to be seen at the hospital. The documentation does not support the resident was able to make sound decisions regarding her future well-being since her vital signs, such as oxygen saturation and blood pressure, were decreased. On [DATE] at 11:33 a.m., the DNS stated, Yes, the doctor should be notified per policy if the resident refused to be transferred to the hospital. The DNS agreed the doctor should have been notified regarding Resident #56's refusals, especially the state she was in. The nurses progress note dated [DATE] at 8:15 p.m. documented the resident was found not breathing and with no pulse at 3:40 a.m. on [DATE]. On [DATE] at 11:46 a.m., in reviewing the documentation and timeline of events for the resident prior to her death, the DNS acknowledged, It doesn't show the reactions to what you're seeing. The nurse should have made the executive decision to transfer the patient to the hospital. The facility failed to ensure prompt medical evaluation as the resident's condition deteriorated. The resident was documented as being unresponsive and able to refuse hospitalization in the same note. The resident's spouse was not aware of the resident's refusal to be hospitalized . The resident's physician was not aware of the resident's refusal to be hospitalized . The facility failed to monitor, assess and reapproach the resident for over five hours, after which time she was found expired. These failures harmed the resident by contributing to her ongoing deterioration, which ultimately resulted in her death. 3) Resident # 16 was admitted to the facility [DATE] after a fall that resulted in a broken bone requiring surgery. The resident's admission MDS dated [DATE], indicated Resident #16 was cognitively intact, required two-person assistance with toileting and had occasional bowel incontinence. On [DATE] at 11:06 a.m., Resident #16 reported a history of colon surgery that made it difficult to have a bowel movement (BM). The resident stated, prior to admission, his/her daily routine was to use an enema and then sit on the toilet. Resident #16 stated staff had not asked about prior bowel patterns during his/her admission assessment. The resident continued that since admission to the facility, s/he reported having difficulty getting the assistance needed to have a BM and had required digital stimulation (insertion of gloved finger into the rectum to assist in passing of stool) and removal of stool. During a follow up interview on [DATE] at 1:48 p.m., when asked if s/he had shared his/her previous routine and current difficulties with the facility staff, Resident #16 replied, Heck yes. I'm not bashful. I've helped it out myself many times but it is pretty hard to reach. Resident #16 said, They don't listen. You know your own body, but they think they know better. Resident #16's care plan for alteration in bowel elimination dated [DATE] was reviewed. Interventions did not include Resident #16's normal routine of an enema and sitting on the toilet or digital stimulation and removal. On [DATE] at 1:49 p.m., NA I reported that Resident #16 had stated s/he does not have muscles there so it just kind of comes out (referring to having a BM). At 2:08 p.m., NA J said Resident #16 sometimes required the nurse's assistance with digital stimulation due to inability to get a BM out. NA J stated that was normal for Resident #16 and it had been going on since the resident first got to the facility. On [DATE] at 2:33 p.m., LN K, a Unit Manager, reported Resident #16 to be alert and oriented. LN K stated she had no knowledge of Resident #16's difficulty with BMs. On [DATE] at 2:02 p.m. LN G reported several days ago Resident #16 was asking for assistance in having a BM and indicated S/he wanted me to get a glove on and get it out of there. LN G told Resident #16 she could not perform digital stimulation or removal but administered a suppository per the resident's request. LN G believed it was an ongoing issue and not something new. LN G stated, I did not report this to the doctor or the unit manager. Maybe I should have. A Fax Communication Form to the resident's physician dated [DATE] was reviewed. The form documented Resident #16 was severely impacted, requiring digital removal of hard feces. Was given suppository and enema. History of [MEDICAL CONDITION]. Would like scheduled doss or polyetholyn [MEDICATION NAME] daily. The returned form in Resident #16's chart was signed by the physician. The physician reply area included the following instructions for the care manager: is [MEDICAL CONDITION] current? I am concerned with this history that there might be a recurrence. Please assess and give me more information. No documentation of follow up was found in the resident's chart. On [DATE] at 2:33 p.m., LN K reviewed the faxed memo to the physician with the surveyor. LN K stated the physician's reply and instructions to further assess the resident's bowel issues had not come across her desk and she was not aware of it. LN K reported hearing of the resident's history of [MEDICAL CONDITION] but had not confirmed the [DIAGNOSES REDACTED]. The resident's Bowel Data Collection and Assessment form was reviewed. Section 2 which assessed factors affecting bowel function had not been completed. Section 3 which assessed medications that could affect bowel function had not been completed. Section 6 which assessed whether a treatment/management program should be initiated had not been completed. The facility failed to adequately assess the resident's bowel history and failed to further assess the resident's bowel condition as directed by the physician placing the resident at risk of having unidentified needs met and additional health complications. 4) Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS, an assessment tool dated [DATE], indicated Resident #59 was cognitively intact and required only set up assistance with meals. A review of a Post Treatment Report from the outside treatment facility, dated [DATE], stated the reason for an additional day of treatment was due to fluid overload due to dietary non-compliance. A progress note written by the Registered Dietician on [DATE] noted Resident #59 was notably non-compliant with the 1000 cc fluid restriction. No documentation was found to indicate a discussion was had with the resident regarding potential outcomes of non-compliance. On [DATE] at 11:03 a.m., LN E stated the resident's fluid intake was monitored on the MAR and said the facility did not have an Intake and Output process. On [DATE] at 11:26 a.m., a 16 ounce bottle of water and a 24 ounce bottle of Diet Coke was observed on the tray table at the bedside of Resident #59. A gray water pitcher was present half full of a light brown liquid. On [DATE] at 11:30 a.m., Resident #59 stated he was aware of his fluid restriction and had received extra treatments for [MEDICAL CONDITION] when he had been bad referring to how many fluids had been consumed. Resident #59 stated staff provided reminders of the restrictions but had not offered any other interventions to stay within the limits. During an interview on [DATE] at 10:50 a.m., NA F reported Resident #59 had fluid intake documented for meals in Care Tracker but it was very hard to monitor what s/he drank between meals because Resident #59 went to the vending machines independently. On [DATE] at 1:25 p.m., LN E reported Resident #59 was not 100% compliant with fluid restriction but tried to be. On [DATE] at 2:28 p.m., Resident #59 was observed at the A-wing nurse's station with a grey water pitcher asking for ice. The Maintenance Director filled the pitcher with ice and returned it to the resident. The facility's [MEDICAL TREATMENT] Management ([MEDICAL TREATMENT]) Policy, dated [DATE], was reviewed and designated the facility responsible for monitoring the fluid status of the resident and managing the fluid restrictions as ordered by the provider/[MEDICAL TREATMENT] center. Chart review revealed no documentation that the facility had worked with Resident #59 to develop a plan that would assist the resident in being compliant with the fluid restriction. The facility's inconsistent monitoring of fluids and lack of interventions that were individualized to help the resident to stay within the physician ordered fluid restriction put the resident at risk of decrease in physical well-being requiring additional medical treatments. 5) Resident #68 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. A Pain Assessment, dated [DATE], documented the resident had pain in her left arm and buttocks during turning and repositioning. Resident #68's care plan, dated [DATE], documented the resident had persistent pain and alteration in comfort related to repositioning. The care plan directed staff to administer pain medications as ordered, assess for verbal and non-verbal indicators of unrelieved pain, and observe during rest and movement for signs of pain. Resident #68's Care Delivery Guide, updated [DATE], directed staff to use two people when transferring and repositioning the resident. The resident's physician's orders [REDACTED]. The order directed the LNs to replace the pain patch every 72 hours. The physician's orders [REDACTED]. On [DATE] at 2:36 p.m., NA H began to change Resident #68's brief. As NA H was providing the care, Resident #68 cried and moaned throughout the process. The resident yelled, Ouch! Ouch! and it hurts! many times. NA H attempted to roll Resident #68 and had difficulty turning the resident by herself. NA H stated, I'm going to turn you again alright? Resident #68 responded, No! It is not alright. NA H stated, I'm so sorry, but it is going to hurt a little more, and continued to attempt to roll the resident to provide care. At 3:04 p.m., after care was completed, the resident was observed moaning and had a pained facial expression on her face. The resident nodded yes, when asked if she was in pain. At 3:06 p.m., NA H stated she had worked with Resident #68 the past few days. NA H indicated the resident often moaned, cried, and exhibited signs of pain during transfers and care. NA H stated, yes two people would have helped, but yesterday when we had two people helping, she was still hurting and crying. NA H did not stop the care process to obtain assistance from another staff. NA H did not stop the care in order to have the nurse come and assess the resident for pain and offer pain medication before care was continued. The March MAR did not show the resident received any 'as needed' pain medication on [DATE]. On [DATE] at 5:30 p.m., Resident #68 was observed sitting in her wheelchair in the dining room. The resident was sliding down in her wheelchair and her feet were dangling past the footrests. The resident was moaning loudly, Ouch, ouch! My butt hurts so bad! and it hurts, it hurts! At 5:32 p.m., the Medical Records Director (MRD) stated, Are you hurting? You are sliding out of the chair aren't you? The MRD went to get a staff member to assist the resident. At 5:34 p.m., Resident #68 stated to LN P, I am in a lot of pain. My butt hurts! At 5:36 p.m., two staff took Resident #68 to her room and used the mechanical lift to reposition her in her wheelchair. From 6:01 p.m. to 6:56 p.m., intermittent observations showed the resident moaning and grimacing in pain during the dinner meal. At 6:56 p.m., the resident nodded yes when asked if she was in pain. At 7:06 p.m., NA H and NA M used the mechanical lift to assist Resident #68 into bed. Resident #68 screamed, You are hurting my butt, Ouch, Ouch!! as she was being transferred into the bed. The resident was observed to cry and moan throughout the process of care. At 7:07 p.m., NA M stated, we'll let the nurse know you need something for the pain. At 7:11 p.m., the resident's upper thighs and perineal region were observed with a bright red and raised rash. The resident cried out in pain as the NAs cleaned the area. NA M asked, are you sensitive down there? It does look red. Resident #68 responded loudly, yes! At 7:17 p.m., NA H stated, she doesn't get any sort of cream on her bottom that I'm aware of. At 7:20 p.m., LN J entered the room to replace a bandage on Resident #68's bottom and observed the resident's buttocks and thighs. LN J stated, That does look red. Despite the resident crying out in pain, the NAs did not stop the care in order to have the nurse come and assess the resident for pain and offer pain medication before care was continued. The NAs did not mention the resident's pain when the nurse came in to replace the bandage. The March MAR did not show the resident received any 'as needed' pain medication on [DATE]. Review of Resident #68's medical chart on [DATE] at 11:54 a.m., revealed no identification of a painful, red rash to the resident's perineal area. There was no documentation showing the physician had been notified in order to prescribe a treatment for [REDACTED]. On [DATE] at 12:01 p.m., LN G stated she was not aware of any skin problems for Resident #68. At 2:32 p.m., the surveyor requested LN K, a nurse manager, to observe Resident #68's perineal rash. LN K stated the area looked red and indicated it appeared to be a yeast related rash. Resident #68 stated the area was very painful. LN K stated she would get an order for [REDACTED]. LN K agreed the LN observing the rash on [DATE] should have contacted the physician to obtain a treatment. On [DATE] at 4:56 p.m., the DNS stated Resident #68 had a yeast rash that waxes and wanes. The DNS stated, If we see it spike, we get cream ordered. The DNS indicated, if the LN assessing the rash thought it needed cream, the physician should have been faxed to obtain a new order. Regarding the resident's ongoing pain, the DNS stated, the nurses should have been involved and if repositioning didn't work, a pain pill should have been given. The DNS indicated that if a resident was experiencing pain during care, the NAs should stop care (if safe to do so) and immediately get the nurse. The NAs should re-approach the resident after the nurse assessed the resident for pain and came up with a treatment plan. Review of the resident's MARs show the resident was not consistently getting her narcotic pain patch replaced every 72 hours as the physician had prescribed. The December MAR documented a pain patch replacement on [DATE]. The next patch was due to be replaced on [DATE]. The nurse's initials documenting the pain patch on [DATE] were circled, which indicated the pain patch was not replaced. The note on the back of the MAR mentioned the patch was unavailable from the pharmacy. The resident's pain patch was not replaced until [DATE], at least 24 hours after it was due to be replaced. The January MAR documented the resident received a new pain patch on [DATE]. The next pain patch was due on [DATE], but the documentation box had a large 'X' placed through it which indicated the resident did not receive a new pain patch as ordered. There was no documentation on the back of the MAR to indicate why the patch was not placed per the physician's orders [REDACTED]. The February MAR documented a pain patch being placed on [DATE]. The next pain patch was due on [DATE], but the documentation box had a large 'X' placed through it which indicated the resident did not receive a new pain patch as ordered. There was no documentation on the back of the MAR to indicate why the patch was not placed per the physician's orders [REDACTED]. On [DATE] at 5:08 p.m., the DNS stated, I don't see any orders or any reasons why (Resident #68) did not receive her [MEDICATION NAME]es in a timely manner. The facility failed to promptly identify and intervene when the resident was observed to be in pain during care over multiple observations. The facility failed to promptly identify and intervene when the resident developed a painful rash. The facility failed to consistently apply the resident's narcotic pain patch per the physician's orders [REDACTED].#68 harm when she experienced a painful rash, pain during care and inadequate pain management. 6) Resident #22 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's MDS, an assessment tool, dated [DATE], documented the resident was cognitively intact and did not have memory problem. The MDS documented that pain limited the resident's daily activities. The Physician orders, dated [DATE] documented the resident took several pain medications including [MEDICATION NAME], and a [MEDICATION NAME] to control her pain. [MEDICATION NAME]es are time released pain medication that are re-applied every 72 hours to keep a constant level of pain medication. The resident's MAR documented the resident wanted her a.m. medications no later than 7:30 a.m. On [DATE] 10:22 a.m., Resident #22 stated she had not yet received her morning medications. The resident stated she had also asked for additional pain medication and not received that yet. The resident stated a delay in her morning medication happens once or twice a month and she had talked to the charge nurse about it. Resident #22 stated this has been an ongoing problem for a year. The resident described she also had some unresolved dental issues which were causing her pain. At 11:15 a.m., Resident #22 stated she was still waiting for pain medication and her morning medication. At 11:30 a.m., Resident #22 stated she had received her requested pain medication and her morning pills. On [DATE] at 2:20 p.m., Resident #22 stated she is having dental pain. The March MAR documented the resident had an order for [REDACTED]. The space for the LN to sign was left blank, indicating the resident did not receive her ordered [MEDICATION NAME]. On [DATE] at 1:19 p.m., Resident #22 stated she is still having some dental pain. She stated she has not received any information from staff as to if she will be getting a dental appointment or what the plan is to address her dental pain. The resident stated she last told staff, LN E, a few days ago about the pain. On [DATE] at 10:26 a.m. review of the resident's medical record reveals no notes or referrals regarding the resident's dental issues and pain. At 10:46 a.m., LN G stated she was unaware of the resident having any dental issues or dental pain. At 03:58 p.m., LN L stated she was unaware of resident having any dental issues. On [DATE] at10:34:40 a.m., LN G stated whenever a nurse had charted not given they should have recorded on the back of that page why it wasn't given. LN G was unable to find any documentation which indicated why the [MEDICATION NAME] was not given to Resident #22 on [DATE]. At 11:46 a.m., LN B stated the narcotic book could be checked to see when the last [MEDICATION NAME] was signed out. At 3:01 p.m., LN L stated Resident #22 indicated to her that on some days the resident has difficulty getting her morning medications on time. The resident stated to her it is generally when agency staff is on the run. LN L stated she noted the blank on the [MEDICATION NAME] due [DATE] but found a patch with tape over it on the resident's body and so she thought it had been placed per the order. LN L stated it wasn't until the next time the patch was to be changed, on [DATE],that she realized the patch being removed was dated [DATE]. It was at that time LN L realized the resident missed getting her patch replaced on [DATE]. At 3:55 p.m., LN A stated his expectation was if a nurse were to find a blank spot on a MAR he would expect they would turn it over to see if the reason was documented. If not the LNs should contact the previous nurse. LN A stated they should check for documentation on back of MAR and check the narcotic count to see if the medication or patch had been signed out. LN A stated he would expect the LNs would put the date and initials on the paper tape so it would be clearly visible and not directly on the patch under the tape. 7) Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, an assessment tool, dated [DATE] documented the resident's cognitive skills for decision making were severely impaired and the resident rarely/never made decisions. <Follow-up Appointment> A hospital Discharge Summary for Resident #20, dated [DATE], documented that Psychiatry was consulted during her hospital stay and ECT (Electroconvulsive Therapy, a procedure that changes brain chemistry to reverse symptoms of certain mental illnesses), was recommended but did not occur due to the resident not having a legal guardian to sign the consent. The Discharge Summary documented a follow up appointment was to be scheduled with a designated specialist in Psychiatry when Resident #20 obtained a court appointed legal guardian. Thorough reviews of Resident #20's chart on [DATE] and [DATE] failed to reveal any documen

Based on interviews with residents, family, and staff and record review it was determined the facility failed to provide sufficient nursing staff to ensure care and services were provided to residents according to their care needs. Staff did not adequately assess, evaluate, report, or document information needed to formulate effective and timely interventions. This placed residents at harm due to not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being on 2 of 2 wings in the facility. Findings include: <Resident and Family Interviews> On 03/3/16 10:28 a.m., Resident #22 stated, I have had to wait on pain meds. I get [MEDICATION NAME] four times a day, but have to wait a lot for it. If I have doctor's appointment and need help to get ready, I don't always have that. About six weeks ago, I fell between my bed and my roommate's and couldn't reach a call light. Both of us yelled for help for about 30 min before someone came. On 3/3/16 at 10:29 a.m., Resident # 53 stated, Not enough staff on evenings to get me to bed when I want On 3/3/16 at 11:37 a.m., Resident #44 stated, They're very low on nurses and staff. They need more people. My call light - I've had to wait up to 45 minutes for pain medication. On 3/3/16 at 11:26 a.m., Resident #66 stated, Two weeks ago it took them two hours to answer the call light. On 3/3/16 at 12:56 p.m., Resident #146 said she puts call light on to get repositioning because she wants to sit up so she can eat. It's so hard to get help here. You never know, you could be dying and they wouldn't know for three hours. I feel like they are just warehousing me. On 3/3/16 at 3:45 p.m., Resident #60 stated, We should have more people help. It can take 30 to 60 minutes depending on the time of day. I've had trouble getting toileted and I have a rash that hurts now. It feels abusive On 3/4/16 at 9:04 a.m., Resident #114 stated, (There are) very long wait times. Period. Just long wait times. Lately we have had hospitality aides which has been nice because they have been here in between aides. I think they are in training. I have waited as long as two to two and a half hours for anything from brief changes, drink, handing my phone, or asking social services for something. Resident #114 continued, The aides in the morning have two meals. They are gone off the hall for almost two hours because they are dealing with dining. It's just known that they are going to be gone for that long. Other aides will walk by because 'it's not their room'. So every meal we are without an aide for two hours. They are definitely under-staffed. I could be here having a [MEDICAL CONDITION]. I think if they weren't so understaffed they wouldn't be so rushed, so short tempered. I've heard the caregivers say they're just going to go work someplace else because they're overworked and overstressed. On 3/4/16 at 9:22 a.m., Resident #64 stated, We don't have enough staff. I have to wait a long time. For example- getting my briefs this morning, the aides get distracted. It is frustrating. On 3/4/16 at 9:59 a.m., Resident #170 stated, Have to wait when I put my call light for what seems like a 'helluva' long time. On 3/4/16 at 10:45 a.m., Family member for Resident #45 said, I see (residents) being neglected in the hallways when they don't get help right away. Every time I come in, which is once a week, I notice it. I hear people screaming, 'help, I need to go to the bathroom' and when I tell staff, I'm told that it's not your responsibility On 3/4/16 at 12:07 p.m., Resident #171 stated, Some days I waited seven hours in my wheelchair. Everybody was busy. Sometimes I have to wait too long to go to the bathroom On 3/7/16 at 12:00 p.m., Resident #171's son said, The people here are working hard but they can't keep up. Unless you are screaming or falling out of bed, you wait. I have witnessed the staff get frustrated. For a solid week and a half there was always a new face. Always agency. I don't like that I have to be here to make sure she gets the nursing care she needs. Weekends are horrible staffing wise. On 03/8/16 at 11:32 a.m., daughter of Resident #68 said, they seemed short-staffed and stressed more often than not, but not every day. On 3/9/16 at 3:40 p.m., Resident #6 said that the facility has been short staffed and it often takes an hour or two to get help. She stated, There are CNA's that won't answer other CNA's call lights. It hasn't happened since you guys have been here. There are always going to be call light issues. I have MS and I take muscle spasm pills. The other day they were really late. Usually they're given to be at 7 a.m. but I didn't get them until 11:00 a.m. On 3/11/16 at 1:48 p.m., Resident #16 reported having a tough morning explaining s/he had to wait three hours to lie down after therapy and that her/his bottom hurt and felt need to have a bowel movement during that time. This happens all the time. I don't know what the problem is but it is ridiculous. On 3/14/16 at 3:51 p.m., Anonymous Visitor (AV) 1 and Resident #72 stated the facility needed more staff. AV 1 said there had been times when it took up to an hour and a half from the time Resident #72's call light was turned on for the resident to be in his wheelchair and ready to go. There have been times when it had taken staff so long to be able to assist the resident he was told if they got him up they would have to put him back in bed in an hour so he didn't get up those days. Resident #72 said he did not think staff would have the time to get him back in bed on this day until after dinner, which he felt, was too long for him to sit in his wheelchair. Both AV 1 and Resident #72 requested it be noted by this surveyor that the staff treat the resident very well and the problem is not the staff but the fact they need more help. <Staff Interviews> On 3/3/16 at 12:54 p.m., AS 4 said, Care could be better with better education and pride in their work. The staff is getting burnt out and there is lack of pay. If you pay me more and give me the tools to do my job appropriately, I might be more willing to stay. Management just doesn't get it. It's an overall lack of leadership. The hardest thing with lack of the tools is the Hoyer's -they're from the '80s. On the weekends when management isn't here it sucks. On the weekends, there are no eyes to watch what's going on. It's the same people that call in every weekend and nothing is done about it. You wonder why people don't want to work here or agency doesn't want to come back and it's because there is no team work. They pay me twice what they pay a regular aide. Why can't they pay their regular staff? They are good and hardworking people that are just burning out. On 3/3/16 at 3:05 p.m., When asked about Resident #68 having been up in her chair since 7:30 a.m. and not having been put to bed yet, NA Q said, I think next shift will have to do it. I have to stay here in the dining room. I'm running out of time! On 3/9/16 at 2:35 p.m., HA 2 stated, I honestly don't know what is going on here. There is a lot wrong with this facility. Many of the aids have forgotten to take their time to speak to the residents slowly and react. I think they promote many behaviors that way. Many of the aids are pushy with resident #45. They don't want to give him time to respond. They are rough with him. He had a stroke but he's still there inside; it's just not coming out right. He gets frustrated. I can go in there and we talk back and forth. There is a lot of roughness. The gate belts are not in use. You will not see them using them anywhere. Since you, guys have been here, we've been better staffed then before. Suddenly we have business staff floating the halls, but it's actually made things more chaotic. NA P just disappears. She was out smoking by the rehab building. When I talk to the DNS about it I just get a blank stare. Nothing ever happens. I don't know if it's just because they're burnt out or have just lost sight. They end up putting the hospitality aids as a 1:1 for Resident #45, but I'm like, I can't even do this because that's guided assist right? What if he falls? Am I in trouble if I catch him? They told me I am covered under the Good Samaritan law, but I don't know if that is right, is it? So they said, 'Just hit the light for another staff to come in if he gets out of bed.' Well, I tried that and waited thirty minutes. While they can't even get the lights down the halls. I've seen aides rolling residents too fast, like they're in a hurry. They have a lot to do. I was watching Resident #142 and she said she didn't want to get up, and they were forcing her to get up. I told her that she doesn't have to get out of bed. She is of the feeling that she has no control and she verbalized that to me. On 3/9/16 at 4:05 p.m., AS 1 stated staffing had been an issue for about one year because a lot of staff, (8 nurses and 18 caregivers), had quit and since then many staff had to pick up extra shifts. AS 1 said it did not seem like the facility had been able to replenish staff since then and that was why there were so many temporary on-call people working. AS 1 said there had been times when new staff quit while still being trained because they had found jobs elsewhere that paid more. On 3/10/16 at 10:08 a.m., when asked about the numerous complaints regarding call light wait times from residents the DNS said, It has been a constant concern that comes up in waves. We try and address immediate reports and some turn into accident reports. We've beefed up how many people are on the floor and have the hospitality aides to help eliminate some of the things that (residents) have to wait for. When asked if there has been a shortage in staff or a lot of turnover, the DNS stated, No shortages, but we have a lot of staff turnover and administrator turn over. Some staff are just not the right fit and so we are going through some turn over and using agency. On 3/10/16 at 1:32 p.m., AS 4 said, There's not really enough of us to go around. So many residents need feeding assistance during mealtime that there really is no one to answer call lights or provide care. We are trying to juggle three different things at once. Residents come up to dining room and ask for help but we can't leave because of residents with choking concerns. If we take longer, feeding residents we can't always get the other residents changed and laid down in a timely manner. We are supposed to have twelve residents on average but usually have fifteen. We are responsible for the showers for those residents. AS 4 also stated, A lot of the nurses have to work doubles because there are not a lot of nurses right now. Some aides work thirteen or more days in a row. A while back, a bunch of people were fired, another bunch quit, and five or six people were on light duty. This left us very short handed. On 3/10/16 at 1:41 p.m., HA 1 was interviewed regarding his being a 1:1 sitter for Resident #45. HA 1 said he's a fall risk so I can't really physically do anything. If he's looking like he's going to fall or anything I'd have to call for an aide. I just hit the call light and then they know we need something in here. It usually takes about five minutes. Not exactly fast enough for (if resident fell or is falling), but as a hospitality aide there are only certain things we are allowed to do. They need the CNAs on the floor, so they use the hospitality aids for 1:1s. Unfortunately, there aren't enough CNA's. They work hard here, but are generally understaffed. Preferably, what they would want is six CNA's on each hall, but four is what it generally is. I have seen the restorative aids helping out, but I am not sure, when they are being restorative aids or CNA's. The Maintenance Director helps out with breakfast and lunch trays when he can, but I know sometimes he is actually assigned to the cart. On 3/10/16 at 1:59 p.m., NA S reported that some days she may have as many as six showers/baths to do and that it is very challenging to complete along with her other duties. On 3/11/16 at 9:20 a.m., NA F stated, Prior to you guys coming here the staffing was just awful. We've lost a lot of staff. They were overworked. We didn't have the proper staff for the amount of people in the building and people got burned out. We have agency now, we didn't before, just since you been here. We have our own float pool but not agency. When asked what kind of care is missed due to staffing issues, NA F said, Showers is a big one and getting people up. You need two people to use the Hoyer lifts (equipment that assists in getting residents out of bed). There are some that we wouldn't get up, due to not having the staffing. Some of our staff aren't the best. I see that it tends to roll over to the residents. The residents worry about getting their care and will say things like, ' is someone going to be here when I need them.' We need staff that are committed to the job so that residents get proper care. On 3/14/16 at 10:52 a.m., AS 2 stated they felt there was not always enough staff on duty to provide the level of care some of the residents needed. On 3/15/16 at 10:25 a.m., AS 3 stated agency staff often times had to be used because of insufficient facility staff. When asked what typical staffing levels were in the facility AS 3 stated, The staffing levels we are seeing now (during this survey) are not the normal staffing levels, they are higher right now. <Record Review> On 3/8/16 Resident Council minutes were reviewed. There was a repeated concern regarding call light response times and/or concerns related to shortage of staff in 7 of 8 months reviewed. Refer to F309, F311 and F314.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for 4 of 4 residents (#45, 56, 68, & 2) when they failed to monitor or recognize changes in the Resident's condition and failed to implement physician orders [REDACTED].#45, #56, #68 and #2. Findings include: According to the American Nurses Association, Scope and Standards of Practice, 2011, A licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. According to WAC [DATE] Standards of nursing conduct or practice. (3) The following standards apply to registered nurses and licensed practical nurses: (b) The registered nurse and licensed practical nurse shall document, on essential client records, the nursing care given and the client's response to that care; Findings Include: <Resident #45> The lack of prompt identification of stroke-like symptoms and subsequent delay of emergency medical response led to the ineligibility for the resident to receive potentially brain saving medication. This delay caused harm to Resident #45 when he experienced a significant change in functioning after the stroke. Refer to F-309 for additional information <Resident #56> The facility failed to ensure prompt medical evaluation as the resident's condition deteriorated. The resident was documented as being unresponsive and able to refuse hospitalization in the same note. The resident's spouse was not aware of the resident's refusal to be hospitalized . The resident's physician was not aware of the resident's refusal to be hospitalized . The facility failed to monitor, assess and re-approach the resident for over five hours, after which time she was found expired. These failures harmed the resident by contributing to her ongoing deterioration, which ultimately resulted in her death. Refer to F-309 for additional information <Resident #2> The facility has failed to sufficiently assess and care for the resident's wounds in a timely manner, thereby exposing the resident to risk of infection, increased wound severity and deterioration of condition and potential decline in functional ability. The facility failed to provide education to the resident regarding his wound care needs, and failed to provide the resident the opportunity to heal and improve. Refer to F-309 for additional information <Resident #68> The facility failed to promptly identify and intervene when the resident was observed to be in pain during care over multiple observations. The facility failed to promptly identify and intervene when the resident developed a painful rash. The facility failed to consistently apply the resident's narcotic pain patch per the physician's orders [REDACTED].#68 harm when she experienced a painful rash, pain during care and inadequate pain management. Refer to F-309 for additional information

Based on observation, interview and record review it was determined the facility failed to provide medically-related social services to 4 of 7 residents (#2, 80, 20, and 146) who exhibited refusal behaviors and/or depression. Failure to identify depression and reasons for frequent refusals of care without determining the reason caused harm and impacted residents' medical conditions, including wound healing and psychosocial behaviors and created a diminished quality of life. Findings include: 1) Resident #2 was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Assessment (MDS), an assessment tool, dated 2/16/16, noted the resident required moderate assistance with his activities of daily living. The discharge summary from the hospital, dated 2/11/16, discussed the resident's desire for mobility durable medical equipment (DME) but also stated the resident's physical status at that time precluded his ability to use the DME. The physician wrote, Explained to pt that even with a (mobility DME) .he did not have a .leg capable of ambulating. The resident was very vocal about his self-identified goal of acquiring the desired mobility DME. At the Care Conference on 2/18/16, the Social Service Manager (SSM) describes Resident #2 as being very disgruntled. As documented by the SSM, He states that the only thing that he is concerned with is getting his (mobility DME). During the care conference, the SSM described the resident resisted efforts to redirect discussion toward the benefits of therapy, again stating that he just wants his (mobility DME). After that, the SSM wrote, Due to increased agitation care conference was ended. In an interview with the SSM on 3/11/16 at 2:18 p.m., the SSM stated, they tried to do a care conference with him and it went south real quick. He pretty much just ran us out of the room. On admission, the physician ordered daily wound care to resident's multiple wounds and a follow-up with the resident's orthopedic physician. Physical and occupational therapy was also ordered during the first week of the resident's admission. Review of the resident's Progress Notes documented the resident began to refuse medications, physical therapy and occupational therapy, as well as wound care and at times assistance with activities of daily living (ADL). 2/21/16 1500: Refused all meds except pain (medications) & (a medication to treat arthritis). Patient refused therapy. 2/22/16 eve: Continues to refuse meds. Did request and receive pain meds. 2/24/16 PM: refused all meds this pm. The record reflected that on 2/25/16 Resident #2 requested to meet with the SSM. Per documentation by the SSM, the resident requested to see his orthopedic physician, a follow-up appointment which was ordered to be scheduled within a couple of weeks after the resident's admission to the facility. At that time, the SSM documented the resident was very angry because he states that the only reason he came here was to get his (mobility DME). In a progress note dated 2/27/16, the SSM wrote that the resident spoke about losing everything. He stated that he does not mean to be mean and yell at people he states that he is just bitter about being in this situation. The progress notes record the resident's escalating refusals: 2/26/16 Day: Resident in distress about (mobility DME) he is suppose (sic) to be getting. Has been refusing all care until he gets his (mobility DME). Refused dsg changes. Resident's attitude is very negative and disgruntal (sic). Resident frequently has outburst of anger and yelling at staff. RCMs and Director of Nursing Services (DNS) made aware. 2/27/16 0630: Resident is on strike until he gets (mobility DME). Refusing to let CNAs care for him. Won't let us empty cath bag which is full. Refused soiled dressing change. 2/29/16 0300: Resident very uncooperative with cares and refusing to take most meds. Complains it takes too long to get someone to help (with toileting). 3/2/16 0300: Resident grumpy. Complains about everything, states nobody can do anything right around here. Refusing all meds except pain pills and antidiarrheal medicine. 3/3/16 0600: continues to refuse all meds except gout medicine and pain pills. Complaining about wanting to get his (mobility DME). 3/4/16 1530: refused TB test. 3/5/16 0200: pain meds requested, all other meds refused On 3/7/16 at 3:10 p.m., Resident #2 was awaiting transport to an appointment with his orthopedic physician, when he learned that the appointment was cancelled. The resident became upset while interacting with a staff member. (See F223 for additional information.) On 3/7/16 at 5:26 p.m., the resident was observed to yell at Licensed Nurse (LN) I, and then begin to apologize saying, I know it's not your fault. After leaving the room, LN I stated, You bite your tongue and walk away. What is there I can say or do? He is angry at life. I don't think he wants to do anything - PT, OT, take meds. He isn't accepting the services we are offering. On 3/9/16, the Social Services Assistant (SSA) documented numerous losses the resident has undergone in the year prior to his admission to the facility, including the death of a spouse, loss of his home, progressive weakness, and permanent, life-altering surgery. In an interview on 3/11/16 at 2:18 p.m., the SSM stated she was aware Resident #2 had been refusing care, including dressing changes. Initially characterizing lots of times coordinating with LM N to talk to the resident to encourage him to permit wound care, the SSM stated she had gone to the resident's room one time to talk and let him vent so that his dressing could be changed. When asked about a plan the staff should follow when the resident refuses care, the SSM stated they really need to encourage him, they need to go over - do risks and benefits with him to let him know. When asked if there had been any education or direction provided to the direct care staff on how to approach the resident, the SSM stated she had not given any in-service. The SSM stated, I just tell them, you can't be scared of the yell. She stated that if the aides are not going to her with their frustrations (about interactions with the resident), they go to their nurse managers. In an interview on 3/11/16 at 3:00 p.m., when asked about the facility's plan when the resident refuses care, the DNS stated. It depends on what he is refusing. With the wounds, you just give him a little time to cool off. If we can do a little bit of distraction that seems to work. When asked if the facility had ever gotten Social Work involved, the DNS indicated the SSM had been in several times to speak with the resident, and that helped sometimes. The facility had multiple opportunities to address Resident #2's increasing frustrations prior to the point where the resident went on strike with cares. The DNS characterized Resident #2 as a chronic refuser of cares (interview with DNS on 3/7/16 at 4:49 p.m.) and facility staff elected to utilize redirection or distraction techniques in their interactions with him rather than investigate why the resident refused care. The facility failed to acknowledge the resident's increasing frustration regarding progress on his self-identified goal of obtaining desired mobility DME. The facility failed to recognize the numerous losses Resident #2 had experienced, or to correlate how those losses and frustrations exhibited in refusals of care, to the resident's detriment. Both Administration and Social Services were notified of the resident's frequent and increasing refusals of care, yet failed to formulate a plan which enlisted the resident's goals, or to educate or assist staff in modifying their interactions with the resident. The facility failed to provide medically necessary social services to Resident #2. Social Service knew of difficulties the staff and resident were experiencing in interpersonal exchanges, as well as difficulties coping with functional losses, but did not work to develop interventions for staff to utilize when approaching and caring for the resident. Failure to develop an interdisciplinary comprehensive behavior management plan caused Resident #2 harm by placing him at risk for escalating behaviors, impaired wound healing and interfered with his psychosocial well being. 2) Resident #80 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 3/4/16 at 10:09 a.m., Resident #80 was observed lying in his bed in a dark room. When the surveyor attempted to speak with him, he responded with few words and appeared to show signs of depression such as a flat affect, slow speech and a troubled look on his face. When asked where he ate his meals in the dining room or his room, the resident stated, In the dining room, but it's not worth going up there anymore. When asked if he was unhappy with the food, he stated, The food tastes fine. It is just a waste of time. When asked if he participated in activities he said, Used to, but don't anymore. I don't like much of anything anymore. It is no use to ask me any more questions. On 3/7/16 at 10:30 a.m., Resident #80 was observed sitting on his bed in the dark. At 12:30 p.m., Resident #80 was observed sitting in his wheelchair at the medication cart. When asked how he was doing, he shook his head and had a troubled look upon his face. When asked if he was okay, the resident said, No and stared with a flat affect upon his face. On 3/8/16 at 10:05 a.m., Resident #80 was observed sitting by the nurse's cart and was unshaven and had messy hair. When asked if he was waiting for someone, the resident stated, No, I am just biding my time. They kind of skip over me because of the way I talk. At 10:40 a.m. to 11:23 a.m., the resident was observed lying on his bed in the dark. On 3/9/16 at 10:09 a.m., the resident was in bed in a dark room. On 3/14/16 at 3:26 p.m., the resident was observed lying in bed and stated, I don't like it here. This place is a morgue. On 2/9/16, a Life Enrichment Assessment was completed. Documentation indicated when the resident was asked about his goals for his stay at the facility, the resident stated he did not have goals and said, Why should I? Nursing progress notes during February indicated the resident had attempted to leave the facility, had refused care and had made suicidal comments. The pharmacist's review of the resident's drug regimen on 2/25/16 included a recommendation to initiate an antidepressant based on a chart review of the resident's depressive symptoms. <Mental Health Evaluation> Chart review showed the resident had been referred to a Mental Health (MH) assessment on 2/9/16 due to sadness, worry, history of suicidal ideations, sad/angry over lost role/status. The MH consultant documented the resident had symptoms of feeling depressed/hopeless, insomnia, anger, feeling bad about himself, and psychomotor retardation (slow speech). The MH consultant documented, States he will cut his throat. The clinical summary of the 2/9/16 visit included, SSD (Social Services Director) and Administrator notified. Recommend med review for anti-depressant. He is able to benefit from psychotherapy. On 2/11/16 the MH consultant saw the resident again and documented, Client lying in bed with an angry expression in a dark room. The note also stated, Med eval requested 2/9. On 3/4/16, the MH consultant again noted Resident #80 was in need of a medication evaluation. On 3/8/16 at 12:42 p.m., the MH consultant stated, I went to Social Services. I remember telling the SSM and I told the nurse on the cart when he made a suicidal statement. I remember the SSM went to interview the resident following the statement to determine if he had a plan to commit suicide. <Facility Staff Interviews> On 3/8/16 at 12:24 p.m., when asked if there had been any follow through on the pharmacist's 2/25/16 recommendation to consider initiating an antidepressant, the SSM stated that recommendation had not been given to the resident's physician yet. The SSM stated, We plan to meet today and discuss it before asking the doctor about it. When asked if Resident #80 had exhibited symptoms of depression, the SSM stated, He is depressed. I know when he got here he was very depressed. He was tearful at times. If you ask how he is doing, he will put his head down. When asked when the facility normally held Mind Over Meds meetings, the SSM stated, If we see signs of depression, we would do it on the spot. There is no specific timeframe to do it in. The SSM stated a medication evaluation had not yet been done for Resident #80. At 12:33 p.m., when asked if she read the mental health notes written by the mental health provider, which were found in the resident's chart, the SSM said, I do sometimes. At 1:05 p.m., the DNS was asked how recommendations from the MH consultant were acted upon, the DNS stated, If they tell us about it about it, we would get on it right away. If they don't, we wouldn't find out about it until the quarterly review when we do a full chart review. At 6:10 p.m., the resident's family member stated, He is having a hard time adjusting. He doesn't know anyone here. The facility failed to act upon the apparent and severe symptoms of Major Depression being experienced by Resident #80 and placed him at risk for potential self-harm and diminished quality of life. 3) Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE] documented the resident's cognitive skills for decision making were severely impaired and the resident rarely/never made decisions. A hospital Discharge Summary (DS), dated 10/2/16, indicated Psychiatry had been consulted during Resident #20's hospital stay and ECT (Electroconvulsive Therapy- a procedure that changes brain chemistry to reverse symptoms of certain mental illnesses), was recommended but did not occur due to the resident not having a legal guardian to sign the consent. The DS showed a follow up appointment was to be scheduled with a designated specialist in Psychiatry when Resident #20 obtained a legal guardian. On 3/14/16 at 11:16 a.m., the SSM said Social Services (SS) reviewed the Staff Assessment, History and Physical, and Hospital DS for all residents admitted to the facility. On 3/21/16 at 11:12 a.m., Resident #20's Legal Guardian, who was appointed on 1-8-16, stated she did not recall being contacted by the facility regarding consent for an appointment with a specialist in Psychiatry. A review of Resident #20's SS Short Stay Care Plan, last updated on 12/24/15, showed an intervention of Schedule appointments as needed with an initial due date of 1/15/16. Thorough reviews of Resident # 20's chart on 3/9/16 and 3/15/16 failed to reveal any documentation showing the SSM made the above appointment, communicated the resident's need for the above appointment to other staff, or followed-up to see if the resident went to the above appointment. On 3/8/16 at 11:54 a.m., this surveyor observed NA B and NA C appear frustrated while providing care to Resident #20. When asked, on 3/11/16 at 1:45 p.m., how the SSM communicated interventions that were listed on SS related care plans for Resident #20 to the NAs she said, The CNA's come to us, sometimes frustrated and if staff are having any concerns they will come to Social Services and find out what to do. SSM states staff are educated on that process during their initial orientation. SSM said NA's should be going into Resident #20's room in pairs. She stated SS coordinated care with other departments and updated the Care Delivery Guide (CDG) as needed. SSM said that during the Daily Meeting the department heads make sure the CDG matched the resident's current needs. During a review of Resident #20's chart on 3/14/16 no SS documentation was found that demonstrated consistent coordination of care with other facility departments for the resident. The SS department did not communicate essential behavioral interventions to staff working directly with the resident on a daily basis. No documentation was found that demonstrated SS communicated to or educated the NA's regarding the preventive interventions, individualized needs, or recommended behavioral related interventions for the resident. <Resident secluded> On 3/3/16, 3/4/16, 3/7/16, and 3/8/16, this surveyor observed Resident #20's door closed multiple times each day, even when direct care was not being provided by staff. On 3/8/16 at 10:07 a.m., the Rehabilitation Coordinator stated she thought it was Resident #20's choice to always have her door closed. On 3/9/16 at 2:50 a.m., LN B stated he thought Resident #20's door was always closed because the noise in the hallway exacerbated her agitation. A Social Services Progress Note, dated 1/12/16, showed Resident #20 Does not like to have her door closed and She likes to look out the door. The Care Delivery Guide for Resident #20, last updated on 1/26/16, directed staff to leave the residents room door open and to decrease the bed curtain use. The lack of follow through on the SS's care planned intervention for Resident #20 isolated the resident and placed her at risk for seclusion and emotional harm. 4) Resident #146 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] documented the resident had symptoms consistent with mild depression including low energy, feeling bad about herself, and feeling down, depressed, or hopeless. A Care Conference (CC) Note, dated 1/22/16, documented, (Resident #146) was very tearful during the meeting . A physician visit note, dated 2/4/16, documented her affect is moderately flat. Her care managers, by the way, do note that she has seemed a bit 'depressed. The recommendations documented, I have ordered (an interdisciplinary team meeting to review medications) with mental health evaluation to further address the possible depressive symptoms. A SS Progress note, dated 2/16/16, documented the (SSM) spoke to the resident regarding reports of increased tearfulness. According to the note, the resident was offered MH Services, but refused because she did not feel she could afford to pay for the services. No alternative treatment plans to address the resident's tearfulness were discussed. A CC Note, dated 2/17/16, documented Resident #146 was concerned regarding the out of pocket cost of her care and being left in poverty. The Care Conference Note documented, She began to talk about money and all negatives that have occurred. The CC note had a section labeled Issues for follow up that was left blank. The resident identified multiple concerns and stressors during the care conference. The only intervention identified to support the resident was to encourage (Resident #146) to focus on the positive so that she will be motivated to go home. The resident's SS Care Plan, dated 1/27/16, did not identify the resident's increased tearfulness or multiple life stressors. The care plan did not have any resident specific interventions identified to promote the resident's coping and ensure the resident's mental and psychosocial well-being were maintained. On 3/3/16 at 12:56 p.m., Resident #146 was in bed. The resident's lunch tray was in front of her, but she was not eating. The resident became tearful when the surveyor asked how things were going for her at the facility. The resident stated she had many worries. The resident described multiple stressors which included financial concerns, health related concerns, as well as concerns regarding a family member. On 3/9/16 at 10:31 a.m., Resident #146 was in bed. The resident stated, I have so many, many worries and became very tearful. The resident stated she had financial concerns over being able to pay for her stay at the facility because her insurance was not covering her stay. The resident indicated she had talked with the social worker and the social worker said she would come back and never did. The resident stated, I don't know what to do or where to go. The resident stated she worries often and agreed she felt depressed. The resident indicated her goal was to discharge home, but currently she could not walk without assistance and was not sure how she could take care of herself. At 10:42 a.m., the Business Office Manager dropped off a bill to the resident which totaled $8,998. The BOM stated, This is the room and board and does not include the physical therapy. We will help you figure out a payment plan for that. On 3/9/16 at 11:38 a.m., the SSM stated the resident's goal of care was to gain strength to return home. The SSM stated the resident was very self-limiting and negative. The SSM stated the resident's insurance program dropped her coverage of therapy services within the first week. The SSM described the resident was now participating in physical therapy services, but was paying out of pocket for that. The SSM stated the resident was fixated on the money aspect. At 11:47 a.m., the SSM stated she offered the resident mental health services on 2/16/16, but the resident had declined because of financial reasons. When asked if staff had conducted an interdisciplinary team meeting to discuss medications, as the physician had ordered on [DATE], the SSM stated, that information didn't get to me. I will have to talk to nursing about that. The SSM stated, She should have a mood and behavior care plan in place. The facility was aware the resident was experiencing symptoms of depression, tearfulness, and multiple life stressors. The facility failed to provide intensive and proactive support to Resident #146 to ensure she maintained the highest practicable level of psychosocial well-being. .

Based on observation, interview and record review, it was determined the facility failed to provide restorative services to maintain or improve function for 5 out of 7 residents (#65, #72, #78, #115, #160) reviewed for restorative services. Failure to implement appropriate restorative services caused decline in residents overall mobility and strength, reducing independence and quality of life. Failure to provide restorative services caused harm to Resident #78 when her function and strength declined. Findings include: 1) Record review of Resident #78 revealed that she was discharged from physical therapy 1/8/16. At that time Resident #78 was able to ambulate 57 feet. Physical therapy made recommendations for a restorative program 1/8/16 directing the staff to provide contact guard assistance (stand by assistance while having one hand on the resident) for passive and or active range of motion (ROM), transfer training, and walking with a front wheeled walker (FWW) up to 60 feet with care giver assistance. Approximately six weeks after the referral, on 2/23/15, the restorative program was put into place. Restorative records showed Resident #78 received fifteen minutes of ROM services and fifteen minute transfers services on 3/2/16 and 3/9/16. From 1/8/16 to 3/2/16, Resident #78 received no restorative program services. On 3/4/16 Resident #78's physical therapy evaluation stated, Patient demonstrates needs for skilled therapy based on new onset of impaired functional mobility, impaired transfers and impaired strength ( ) patient with a recent decline in overall mobility and gait. Reported maximum assistance for transfers. Failure to provide restorative services caused harm to Resident #78 when they experienced decline in overall mobility which took place between 1/8/16 and 3/2/16 when no restorative services were being provided. 2) Record review of Resident #160 revealed that physical therapy made a recommendation on 1/22/16 to the restorative program for passive or active ROM, transfer training, stand by assist, and walking parallel bars. From 1/22/16 to 3/14/15 the resident received active ROM only on 3/08, 3/10 and 3/11. Restorative records showed no services for transfers or walking throughout that period. On 03/14/2016 1:58 p.m., Resident #160's son stated He's done everything on his own. No one does anything. It's ask and wait, ask and wait. Restorative ,Aid (RA) B said she'd walk him to exercise class as far as he can get. That's maybe happened once, but I don't think so. The resident stated, I fell a couple of times transferring myself, which they don't want me to do, but they don't come. I have to keep moving or everything stiffens. Two weeks ago I couldn't even get out of bed. On 03/14/2016 at 11:01 a.m., RA B stated, I try my hardest. A couple recent admits have been difficult to fit into the schedule. (Resident #72) doesn't get out of bed much. With active range of motion it's better to do it in the chair. I didn't get to (Resident #60) for walking, transfers and active range of motion. I've done the math. To do it every day, with this list, I can't do it. 3) Record review of Resident #115 revealed on 8/18/15 that physical therapy recommended restorative services for standing frame with the assistance of two staff. At the time, Resident #115 was up to 20 minutes in the standing frame. No restorative services were provided for 2 weeks from the time of referral until restorative services began on 9/2/15. Resident #115 went to restorative active range of motion (ROM) services for the standing frame from 9/2/15 until 10/16/15. RA A stated, For a while he was coming down consistently and standing in the standing frame for about fifteen minutes. Then he just stopped wanting to go. I don't know why. The resident restorative chart states Resident #115's last active ROM services were on 10/16/15. LN K indicated that no additional efforts were made to offer restorative services to Resident #115 and no alternative interventions were offered. No documentation was provided explaining why Resident #115 was unable or unwilling to continue restorative therapy in the standing frame. 4) Record review of Resident #72 revealed physical therapy recommended restorative services for ROM on 12/8/15 and again on 2/9/16. Restorative records showed no services had been provided to Resident #72 from 12/8/15 through 3/14/16. 5) Record review of Resident #65 revealed physical therapy recommended a restorative program 11/19/15 for ROM and walking with FWW with care giver assist as tolerated. From 11/19/15 through 2/14/16, only one, five minute service was recorded on 2/5/16. From 2/15/16 through 3/11/16 services were provided for six, fifteen minute intervals and one, thirty minute interval. On 3/9/16 at 3:45 p.m., RA A stated, I get to about ten to fifteen of my residents a day out of the 40 I have. There will be people that are in the computer that doesn't make it to my list so I won't know to do them so I'll get these notes from other RCMs saying that I didn't do my charting. With the previous Restorative Director we had more input when we had weekly meetings. As of now we don't really have any input. When She (LN K, who is responsible for the Restorative Program) first took over the position we had a couple meetings. We've had kind of poor communication. Every now and again we'll have meeting. We've had no meetings in the past three months. We're supposed to have one this Friday, which I'm really excited about. LN K is pretty busy. This is kind of a secondary job. The facility Restorative Nursing Program policy states, The Restorative Nursing Program consists of two options, Restorative Improvement and Restorative Maintenance. Residents requiring contracture prevention and management and bowel and bladder continence program. Skill practice or training in mobility, activities of daily living, dining and communication. On 03/11/2016 at 2:11 p.m. the Director of Nursing Survices (DNS) indicated residents in the restorative program are receiving about half of the services that they should be getting. When ask why so many residents were not receiving restorative services while in the program, she stated, I can't answer that. We need a change in the restorative nurse.

Based on observation, interview, and record review, it was determined the facility failed to prevent and treat pressure ulcers for 3 of 5 (#142, 2, & 68) current sampled residents reviewed for pressure ulcers. Failure to ensure residents at risk for pressure ulcers were repositioned frequently, remained clean and dry, and received ordered wound dressing changes in a timely manner caused harm to Resident #142, #2 and #68 when they developed pressure ulcers and/or their wounds increased in size and severity. Findings include: 1) Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Skin Assessment sheet dated 10/1/15 indicates Resident #142 was admitted with a Stage 4 pressure ulcer to the hip. A physician order [REDACTED].#142's pressure ulcer was to be treated with a [DEVICE] (closed drainage system which promotes healing) applied to the resident's hip. The order stated to change the dressing 3 times a week and prn (as needed). As noted in record review, Resident #142 was to be seen weekly at a wound care clinic. The resident's Treatment Administration Record (TAR) contained a handwritten note which specified the facility was to change the resident's wound vac two times a week, as the wound care clinic changed it on Mondays. On 3/7/16 at 11:55 a.m., while cares were provided, the resident's left wound vac dressing was observed with the date of 3/2/16 written on it in black marker. The nurses initials for the 3/5/16 dressing change were circled, indicating that it was not done. There was no documentation on the back of the TAR or in the nurse's notes to indicate why the wound vac dressing was not changed. On 3/8/16 at 11:28 a.m., Licensed Nurse (LN) K was interviewed about what time the treatment nurse's shift starts. LN K stated, The treatment nurse is only here Monday, Wednesday and Friday. And she was not here yesterday (Monday). When she is not here, the medication nurses are to do the treatments. When asked how that is communicated to the staff, how they know they have to do the treatments as well as the medications, LN K stated, They know. The nurses are well versed in that. At 4:39 p.m., LN G looked in the treatment book and stated, (The Wound Vac) needs to be changed today. I have not looked at that (the treatment book) today. It will probably have to be evening shift. When asked why it wasn't done on 3/5/16 (circled date on the TAR), LN G stated, I'm not exactly sure why that was circled. Maybe she (Resident #142) was at the wound clinic that day. In reviewing Resident #142's medical record, progress notes dated 2/29/16 document, Resident back from wound consult with recommendations as follows; return in 2 weeks to wound care clinic, continue POC (plan of care), and WCTM (will continue to monitor). The date 2/29/16 fell on a Monday. According to the recommendations from the clinic, the resident was to return in two weeks, which would have been 3/14/16. The clinic's recommendation did not appear to have been communicated to the individuals interviewed on 3/8/16 regarding Resident #142's wound vac dressing change schedule. Notations in the TAR or other form of communication did not appear to reference a change in the resident's wound care clinic schedule. Both front-line staff and supervisory staff did not have clear communication regarding assignments for residents in general, as well as specific schedules for individual residents. Even though 3/8/16 was not a day the treatment nurse was scheduled to work, the staff medication nurse was not aware that she was also responsible to complete resident treatments that day. During an interview with LN G, at 4:39 p.m., with less than two hours left in her shift, she had not even looked at the treatment book for the residents in her care that day. On 3/8/16 at 5:09 p.m., LN A, in preparing to change Resident #142's wound vac dressing, looked at the dressing and confirmed, It is dated 3/2/16. On 3/8/16 at 5:18 p.m., LN A and LN P were observed to change Resident #142's wound vac dressing. Upon removing the old dressing, the LN reported a little odor. The surveyor noted a strong, foul odor. After removal of the dressing, LN A was observed to clean the wound using gauze and a bottle of pink liquid spray. Upon examination of the spray it was entitled [MEDICATION NAME] Personal Cleanser and contained benzethonium chloride 0.13%. Directions on the bottle stated the product was not intended to be applied over deep or puncture wounds, infections, or lacerations. LN A measured the wound's length as 1.8 cm, width of 2.5 cm and tunneling depth of 3.0 cm. Review of the Skin Grid for Resident #142, on 3/2/16, the date the wound vac was last changed, the wound measured 1.3 cm long, 4.5 cm wide, and 2.3 cm tunneling depth, indicating an increase in the depth of the tunneling. On 03/08/2016 at 5:41 p.m., LN A stated, I didn't know I was applying peri-cleaner to her wound. The resident's February TAR showed two blanks for the record of wound vac dressing changes, one on 2/10/16 and another on 2/26/16. On 3/9/16 at 3:32 p.m., LN A stated, I can't tell you why that is blank. You will have to ask LN M about that. At 3:39 p.m., LN M was asked if that was what happened on 2/10/16. LN M answered, Yes, there were no supplies to do her dressing change. The facility failed to ensure Resident #142's wound care was done per physician's orders [REDACTED].#142 at risk for infection, poor wound healing, wound deterioration and increased pain. Failing to change Resident #142's wound vac when ordered caused harm to Resident #142 when her wound tunneling increased in size. 2) Resident #2 was admitted [DATE] with multiple medical diagnoses, including failure to thrive, a pressure ulcer on the resident's sacrum, blackened areas on his foot, depression and anxiety. On admission, the resident had a number of areas of skin breakdown requiring daily treatment and monitoring. On admission the physician ordered weekly skin assessments to assess for areas of impairment. On 2/11/16, a skin assessment sheet was completed by LN M, which described the pressure ulcer to the resident's coccyx as red and non-blanchable (indicating reduced blood flow to the area). On 2/17/16, LN M noted a new open area to red coccyx measured as 4 cm long x 2 cm wide, with a depth of 0.1 cm and minimal drainage. An order to cleanse and dress the wound every three days was written. Review of the resident's February 2015 TAR documented gaps of up to five days between dressing changes. Review of the resident's TAR documented the facility failed to consistently monitor and provide care for the resident's numerous skin issues as evidenced by a pattern of blank entries in the TAR, as well as circled entries, indicating that the resident refused cares. (See F250 for additional discussion regarding refusals of care), which resulted in the resident's wound increasing in size and severity. In reviewing the resident's TAR for March 2015, the entry for the resident's coccyx describes application of the protective cream ordered on [DATE] rather than cleansing and dressing the wound as ordered on [DATE]. On 3/11/16 at 3:00 p.m., the DNS acknowledged the resident accepted care after his arrival and agreed the refusals of care had increased and that the resident's wounds had progressed. When asked what the facility is doing about the resident's refusals, the DNS indicated when the resident refused wound care, they give him time to cool off. When asked how direct care staff know how to assist the resident, she indicated the care delivery guide was being updated and she had not yet communicated changes to the staff. The facility has failed to sufficiently assess and care for the resident's wound in a timely manner, thereby exposing the resident to risk of infection and increased wound severity. The facility failed to provide education to the resident regarding his wound care needs, and to provide the resident the opportunity to heal and improve. 3) Resident #68 was admitted to the facility on [DATE] with multiple medical diagnoses. Resident #68's Skin integrity Care Plan, dated 1/16/16, documented the resident was at high risk for skin breakdown. The care plan directed staff to increase the frequency of turning and repositioning and manage moisture, friction and shear. The Skin Grid, used by staff for ongoing monitoring of skin impairments, documented the resident developed a Stage II pressure area to her coccyx on 1/16/16. The area was documented as healed on 2/17/16. On 3/2/16, The Skin Grid documented the same area to the coccyx had opened up again and was a cluster of open areas. On 3/7/16 at 5:30 p.m., Resident #68 was observed sitting in her wheelchair in the dining room. The resident was sliding down in her wheelchair and her feet were dangling past the footrests. The resident was moaning loudly, Ouch, ouch! My butt hurts so bad! and it hurts, it hurts! At 5:32 p.m., the Medical Records Director (MRD) stated, Are you hurting? You are sliding out of the chair aren't you? The MRD went to get a staff member to assist the resident. On 3/8/16 observations from 9:47 a.m. to 1:38 p.m. documented the resident was sitting up in her wheelchair, tilted back at approximately 60 degrees. Staff were not observed to reposition Resident #68. At 11:52 a.m., Resident #68's family member requested staff help boost Resident #68 up in the chair. The resident remained sitting in her wheelchair tilted back at approximately 60 degrees after staff boosted her. At 11:53 a.m, Nursing Assistant (NA) P stated, I need to lay her down and change her. I will probably do that after lunch. She has been up since about 7:30 a.m., before breakfast. On 3/8/16 at 12:01 p.m., LN G, the nurse caring for Resident #68 that day, stated she was unaware of any skin problems or refusals of care for Resident #68. At 1:34 p.m., when asked if the resident would be assisted to bed soon, NA P stated, Nope. I think next shift will have to do it. I have to stay here in the dining room. I am running out of time! At 1:38 p.m., Resident #68's brief was saturated with urine and bowel movement. Resident #68's pants were wet with urine. The resident cried and moaned throughout getting her brief changed. At 2:13 p.m., NA P agreed the resident had been up in her wheelchair for about 6 hours without having her brief changed. At 2:14 p.m., Resident #68's family member stated they had been visiting since about 10 a.m. and no one had offered to assist Resident #68 back to bed or reposition the resident. Resident #68's family member indicated she had sought out a staff member to boost her mom up in the chair before lunch because she seemed to be sliding down in the chair. On 3/10/16 at 5:02 p.m., the DNS stated they encourage resident #68 to allow repositioning every 2 hours. The DNS indicated Resident #68 often refused to lie back down after getting up. No documentation could be located in the resident's medical record to indicate any refusals of care and what interventions staff should take if the resident refused recommended care. Resident #68 was at high risk for skin breakdown. Staff failed to ensure Resident #68 was repositioned frequently, did not slide down in her chair, and remained clean and dry. This caused harm to resident #68 when the pressure ulcer on her coccyx which was healed, reopened and caused the resident increased pain.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to at least 14 residents (#2, 68, 80, 20, 146, 45, 56, 16, 59, 22, 65, 142, 168, #13) referenced in F223, F226, F250, F281, F309, F311, F314 & F353 and impacted their care and quality of life. Findings include: The information below is more detailed in the individual citations: 1) Refer to 42CFR 483.13(b)&(c), F 223, Free From Abuse for facility failure to ensure residents #2 and #68 were free from seclusion and abusive actions. 2) Refer to 42CFR 483.13(c)(1)(ii)(A)&(B) , F226, Develop and Implement Abuse/Neglect Policies for facility failure to thoroughly screen newly hired employees which caused harm to Resident #68. 3) Refer to 42CFR 483.15(g)(1), F 250, Provision of Medically Related Social Services for facility failure to provide proactive and intensive medically related social services regarding refusals of care and depression. The failures caused harm to Residents #2, 80, 20 & 146. 4) Refer to 42CFR 483.20(k)(3)(i), F 281, Services Provided Meet Professional Standards for facility failure to ensure care and services met professional standards which led to harm of Residents #45, 56, 68. 5) Refer to 42CFR 483.25, F 309, Provide Care and Services for Highest Well Being for facility failure to ensure adequate care and services were provided related to resident changes in condition, pain management, bowel issues, non-pressure skin conditions, and follow-up appointments. The failures were identified as an immediate jeopardy on 3/15/16 and caused harm to Resident's #45, 56, 16, 59, 68, 22, 20 & 2. 6) Refer to 42CFR 483.25(a)(2), F 311, Treatment and Services to Maintain/Improve Activities of Daily Living for facility failure to ensure residents received adequate restorative services which caused a decline in function for Resident #65. 7) Refer to 42CFR 483.25(c), F 314, Treatment and Services to Prevent/Heal Pressure Sores for facility failure to ensure residents did not obtain a pressure sore, and residents with pressure sores received adequate care and services. This failure caused harm to Residents #142, 2, and 168. 8) Refer to 42CFR 483.30(a) Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were protected from abuse by staff including involuntary seclusion and fear-producing situations for 2 of 6 current sampled residents (#2 and 68) reviewed for abuse. This failure placed residents at risk for exposure to potentially involuntary seclusion, fear producing situations, and frustrated staff which could lead to diminished physical, mental and psychosocial well-being. Resident #68 experienced intimidation when a staff member threw a supply box at the bed the resident was in while providing care and in the presence of a family member. The family member asked the facility not to have the nurse care for the resident again. Findings include: 1) Resident #2 was admitted on [DATE] with multiple medical diagnoses, including failure to thrive, pressure ulcers, depression and anxiety. The Minimum Data Assessment (MDS), an assessment tool, dated 2/16/16, noted the resident required moderate assistance with his activities of daily living. A physical therapy initial evaluation dated 2/12/16 documents Resident #2's profound weakness in his bilateral shoulders, and a clinical impression of the same date also notes the resident's impaired wheelchair mobility. On 3/7/16, at 3:10 p.m., Resident #2 was observed taken via wheelchair to an outside courtyard and left alone by the Staff A. Immediately prior, the resident was observed to be speaking loudly and was verbally upset when speaking to Staff A. Staff A asked the resident, Where do you want to go then? Resident #2 responded, I don't care. Just take me outside, anywhere away from this place. You can push me into the street for all I care! In the courtyard, the resident expressed he was upset about missing an appointment. While he was outside, the resident stated, I can't believe (Staff A) just left me out here. When the resident was attempting to re-enter the building, he was unable to cross the threshold. The automatic door was observed to close while he was attempting to pass through the doorway. The resident required assistance in order to propel his wheelchair through the doorway. During an interview on 3/7/16 at 4:17 p.m., Staff A stated the resident and the employee were butting heads. Staff A also stated, He (the resident) was upset, so I asked him where he wanted to go. He was upset, he needed to cool down. The employee stated the resident didn't want the employee to stay outside with him but that the employee was keeping an eye on him, even though the employee was involved in other activities at the nursing station and in residents' rooms distant from the courtyard while the resident remained outside, out of the line of sight of the employee. On 3/7/16 at 4:49 p.m., the Director of Nursing (DNS) stated, That's his cooling off spot. Usually whoever takes him out there will leave him for 5 to 10 minutes to cool off. The DNS acknowledged awareness the resident may have difficulty re-entering the building on his own when she stated, there's enough staff traffic through the courtyard if he needs assistance getting back in. And I can also see him through my window. On 3/7/16 at 5:16 p.m., in an interview with a different surveyor, the resident stated his reaction to being left in the courtyard, I told (the UC) to put me outside. I never thought (he/she'd) actually do it! In an interview with the Social Services Manager (SSM) on 3/7/16 at 5:41 p.m., the SSM was asked whether it is part of the facility's planned interventions for the resident to be put outside for a cool down. The SSM stated, I'm not sure it would help. I think having someone there to vent to, that is what helps him. Yeah, I don't know why they would put him outside. That is a concern. The facility failed to protect the resident from involuntary seclusion. A facility employee placed the resident outside, in a confined courtyard, after the resident verbalized frustration to the staff member. 2) Resident #68 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's MDS dated [DATE], documented the resident had moderate cognitive impairment and required extensive assistance with her Activities of Daily Living (ADLs). On 3/8/16 at 11:14 a.m., a family member of Resident #68 described that Licensed Nurse (LN) O had asked the family to leave while she was changing Resident #68's urinary catheter back in December. The family member, who is the resident's legal decision maker, stated she visited often and indicated Resident #68 preferred the family member stay during care to provide support. Despite this request, the family member indicated the nurse stated multiple times in a rude tone that it was odd the family member wanted to be present during the care. The family member described feeling bullied by the nurse. The family member stated during the urinary catheter procedure, LN O became frustrated when she grabbed the wrong supplies and threw the plastic supply box (catheter kit) against the end of the bed, causing it to bounce off the wall and then onto the floor. The family member stated Resident #68's eyes got wide and she jumped. The family member stated Resident #68 was clearly scared and startled, she had fear in her eyes! The family member stated, it left us both feeling scared. We don't want that woman around (Resident #68). Documentation in the facility's investigation report showed the facility became aware of the allegation on 1/11/15 when the family member reported it during the resident's care conference. The investigation report documented the incident occurred on 12/13/15 during the evening shift. The incident was reported to the department on 1/13/16. In a follow up call, on 1/14/15 at 10:33 a.m., the DNS stated, LN O admitted she did have frustration because she accidentally contaminated the Foley. On 3/14/15 at 5:01 p.m., the Director of Nursing Services (DNS) stated she began an immediate investigation when she became aware of the incident. The DNS stated she suspended LN O during the investigation. The DNS stated, LN O was no longer assigned to care for Resident #68. The DNS stated, the nurse herself could have handled things differently. She is an older nurse and culture change is hard. I think the nurse (LN O) panicked when the family members wanted to stay for the procedure. I don't think she meant any harm, ill-will, or frustration. When the surveyor informed the DNS that LN O indicated she interacted with the resident on a daily basis, the DNS agreed that was concerning. The DNS stated, She is not supposed to care for the resident per the family's request. I will talk to her about that, it is good to know. The facility failed to protect Resident #68 from an abusive, intimidating action when the nurse threw the supply box which scared the resident and family member. The facility failed to ensure Resident #68 was protected from LN O after the incident occurred. See F-226 for further information regarding LN O. .

Based on interview and record review the facility failed to thoroughly screen 1 of 5 newly hired employees (LN O) reviewed for pre-employment screening. This failure placed all residents at risk for abuse and/or neglect. This failure caused harm to Resident #68 when she was exposed to a fear producing situation by an unscreened staff member. Findings include: The Prevention and Reporting: Resident Mistreatment, Neglect, Abuse, Including Injuries of Unknown Source, and Misappropriation of Resident Property Procedure, effective July 2015, documented all potential employees will be screened for history of abuse, neglect or mistreatment of [REDACTED]. The procedure indicated the screening should include reference checks from previous and/or current employers and criminal background checks. Licensed Nurse (LN) O's employee file was reviewed on 3/14/16 at 10:32 a.m. LN O was hired in July, 2015. No background check could be located in LN O's file. A Telephone Reference Check form, dated 7/20/15, documented LN O had worked at the facility from 2010-2012 and was terminated for disorderly conduct. Under additional information, the form documented rehireable and good nurse from other employees. The form did not elaborate regarding why LN O was terminated in 2012 or the details of what disorderly conduct meant. The Telephone Reference Check form did not document which, or how many, other employees provided a reference for LN O. The other Telephone Reference Check form, dated 7/20/15, provided no information or insight into LN O's work history. Under the section would you rehire? the letters N/A were listed, indicating 'not applicable.' Under the section overall job performance the letters N/A were listed. No other reference checks could be located in LN O's employee file. On 3/14/16 at 2:53 p.m., the Payroll and Support Assistant (PSA) indicated she conducted the reference checks when LN O was hired. The PSA indicated she did not know why LN O was terminated in 2012. The PSA indicated the references were from at least two current facility employees who had worked with LN O in the past, but the PSA was unable to recall which employees she obtained the references from. On 3/15/16 at 1:34 p.m., the PSA stated, when I pulled (LN O's) file I noticed there wasn't a background check completed. We hadn't got one back on her. The PSA indicated she was aware LN O had worked at the facility previously and had been terminated. The PSA again confirmed she did not know why LN O was terminated. Upon review of LN O's previous employee file (from 2010-2012), an Employee Performance and Development Review documented, your communication has been perceived as rude or domineering. A goal for the next rating period was documented as, communication will improve (as evidenced by) no complaints received regarding rude communication from staff/residents. A Disciplinary Action Report, dated 4/4/12, documented a situation between LN O and a nursing assistant (NA) that left the NA injured across the throat. The Employee Separation Report, dated 4/17/12, documented LN O was terminated. At 1:39 p.m., the Administrator (ADM) indicated the previous administrator was responsible for rehiring LN O. The ADM stated he was unaware of LN O's history and was unable to provide any details regarding why LN O was terminated in 2012. The ADM stated one step in the hiring process is investigating if the potential employee had worked for the facility before. At 1:47 p.m., the Corporate Nurse Consultant indicated she did not have direct hand knowledge of regarding the screening of LN O before she was hired, but indicated, I would agree after looking at the file (of LN O), I don't think that nurse should have been rehired. Refer to F 223 for details of LN O's behavior while caring for Resident #68.

Based on observation, interview, and record review it was determined the facility failed to ensure 1 of 3 current sampled residents (#13) reviewed for nutrition received necessary nutritional care and/or interventions when Resident #13 had an unplanned weight loss of 30 pounds. This failure placed residents at risk for unplanned weight loss and associated health complications. Findings include: Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool dated 2/9/16, the resident was moderately cognitively impaired and required extensive assistance with activities of daily living and was totally dependent upon staff when transferring from a bed to a wheelchair. On 9/28/15, the Registered Dietician (RD) assessed Resident #13's nutritional status and documented the resident was at an increased risk for weight loss. The plan was to offer the resident enhanced foods at all meals due to a history of recent weight loss and increased metabolism due to a recent stroke. Keeping the resident's weight stable was the goal. Review of the resident's weight record showed an unplanned weight loss of 30 pounds over a four month period. On 10/6/15, the resident weighed 206 pounds and on 2/25/16 the resident weighed 176 pounds. On 10/26/15, according to resident's Weight Detail Report, the resident weighed 198.6 and had lost 7.4 pounds since admission to the facility a month prior. On 11/17/15, the RD reassessed Resident #13 and recommended the resident receive Med Pass, a high protein, high calorie nutritional supplement. On 11/19/15, the facility documented the resident weighed 189.2, which was a loss of an additional 9.4 pounds in three weeks. On 12/23/15, the facility documented Resident #13 weighed 182.4, which was a loss of an additional 6.8 pounds. On 12/23/15, the RD reassessed Resident #13 utilizing a weight of 198.4 from 12/8/15 which was inconsistent with the 12/2/16 weight of 191.6 and the 12/23/15 weight of 182.4. No evidence was found to show facility staff reweighed the resident when discrepancies were documented. No new interventions were recommended at the 12/23/15 Nutritional Assessment. The resident's weight continued on a downward trend and on 12/29/15, the resident weighed 178.8 which indicated an additional loss of 3.6 pounds in six days. Record review revealed the Dietary Manager (DM) had written a progress note, dated 1/4/16 and had documented the resident would be offered enhanced meals and Med Pass 2.0 60 cc three times a day. Both interventions had previously been recommended on 9/28/15 and/or 11/17/15. The DM also noted the resident would be referred to the Registered Dietician for follow up. On 2/1/16, nearly one month later, the RD recommended the resident's Med Pass 2.0 be increased from 60 cc three times a day to 120 cc three times a day. A physician order [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. On 3/15/16 at 3:16 p.m., the surveyor and Director of Nursing Services reviewed the resident's MAR indicated [REDACTED]. The DNS stated, Yes, that's what it looks like. On 2/25/16, the resident weighed 176.1 pounds. Further chart review revealed the resident had indicated he would like snacks between meals during his 1/16/16 activity quarterly review. On 3/11/16 at 2:13 p.m., when asked if he was receiving snacks between meals, the resident stated he was not. Review of the resident's food preference card on 3/15/16 showed the resident's food likes had not been identified. The facility failed to implement adequate and timely interventions to promote and improve the resident's nutritional status and resulted in an unplanned 30 pound weight loss over a four month period. .

Based on interview and record review it was determined the facility failed to provide necessary care and services for 1 of 3 sampled residents related to pain management. This failure caused the resident to have unnecessary and prolonged pain and discomfort when the facility failed to ensure the resident received pain medication in a timely manner. Findings include: Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. On 9/25/15, a concern was reported regarding a several hour delay in administering pain medication to Resident #8. On 11/19/15 at 3:30 p.m., Resident #8's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The resident's nursing progress notes were reviewed and also did not contain information about the resident's pain or when medication was provided. On 11/20/15 at 2:33 p.m., when asked to describe the normal procedure for a resident experiencing pain upon arrival to the facility, the Director of Nursing Services (DNS) stated, Any nurse could fax a prescription to the pharmacy and pull medication from the emergency kit. When discussing it had been difficult to determine the time the facility provided pain medication to Resident #8 on the day of admission, the DNS stated, If there is no time on the MAR indicated [REDACTED]. On 11/23/15, the facility provided the surveyor a statement written by Licensed Nurse D, who had completed Resident #8's admission. LN D documented she recalled the resident's family had asked for pain medication for the resident and she explained she could give medication as soon as she received a MAR for the resident. On 12/1/15 at 10:20 a.m., during a telephone interview, the resident's family member stated the resident was admitted to the facility on [DATE] at approximately 4:00 p.m. and had come from [MEDICAL CONDITION] treatment. The family member said facility staff were informed the transport had been rough on him and the resident was in pain and needed medication right away. The family member continued, They had the orders from the hospital. I don't know why it took so long. The nurse told us they had pain medication but they kept putting us off. We were real frustrated. He was hurting bad and getting anxious. The family member said, After waiting for hours, I went home and got his medication. On 12/2/15 at 12:15 p.m., the DNS was unable to say when the facility administered pain medication to Resident #8 and whether it was provided by the family or the facility's emergency kit. The DNS stated she would locate the nurse who completed the resident's admission to see if she could provide more information about the resident's pain and pain medication. When asked what the normal time frame was for having a resident's MAR prepared and available, the DNS stated, We try to have them ready before the resident arrives at the building. At 12:51 p.m., LN D said she remembered the family had asked for pain medication for the resident and said when there was a delay in providing that medication, the family left the facility and drove home to obtain pain medication the resident had at home. The LN stated, I think the family gave the resident pain medication at about 8:30 p.m., which was approximately 4 hours after the resident arrived at the facility and requested medication for pain. The facility failed to ensure Resident #8 was provided pain medication in a timely manner and caused the resident unnecessary and prolonged pain and discomfort. .

Based on interview and record review, it was determined the facility failed to accurately assess and provide treatment to a resident with a known skin impairment for 1 of 3 sampled residents (#8) reviewed for care and services. This failure resulted in the resident developing an infected Stage 3 (full thickness tissue loss) pressure ulcer, causing him discomfort and requiring specialized wound care treatment. Findings include: Resident #8 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. (tail bone). Resident #8's plan of care was reviewed and no interventions were found to treat the wound and/or prevent the wound from worsening. There were no physician orders regarding the wound and no treatments were found on the resident's treatment record. On 11/20/15 at 2:10 p.m., the Director of Nursing Services (DNS) was asked to describe her expectations for completing skin assessments on newly admitted residents. The DNS stated, Skin assessments should be done within 24 hours of admission per policy. We are notoriously poor at it. The DNS stated a skin sheet with the outline/form of a person is included in the admission packet for the admission nurse to document skin concerns on. The DNS said, If something of concern was identified, the location of the problem area should be documented on the form and the information should be placed on the facility's 24 hour report. The DNS stated, If the nurse completing the initial skin assessment found something on the skin check, that nurse should call the physician to get a treatment order and interventions should be put on the resident's care plan. If the wound was stageable, we would use our pink sheet to show measurements and in an ideal world, I would want a chart note as well. At 2:20 p.m., the surveyor reported to the DNS and LN A that Resident #8's medical chart contained hospital documentation noting the resident had impaired skin upon admission. The surveyor informed the DNS that no evidence was found in the resident's chart to show the facility had identified impaired skin to the coccyx or provided care to heal the wound or prevent worsening of the condition. At 2:25 p.m., the DNS stated she kept documentation on the progress of or worsening of pressure ulcers on a spreadsheet in her computer and upon reviewing it, she stated there was no information about Resident #8 and said she had not been aware Resident #8 had a pressure ulcer. At 2:28 p.m., LN A looked through Resident #8's entire chart and at 2:45 p.m., the LN stated she was unable to find orders for treatment of [REDACTED]. The LN stated, I wasn't aware he had a pressure ulcer. At 2:46 LN C stated, I don't remember anything about it. At 2:50 p.m., the DNS stated, Obviously nothing was done appropriately. He fell through all of our fail-safes. At 2:51 p.m., the facility's pressure ulcer policy was provided which documented, Assess all residents upon admission .Identify individualized interventions. On 11/23/15 at 11:00 a.m., the Regional Nurse Consultant (RNC) was asked what she thought about Resident #8 and the lack of treatment related to his pressure ulcer. The RNC stated, I can't argue with you about it. I am not disagreeing with you. On 12/1/15 at 10:20 a.m., the resident's family member stated the family had informed the facility's staff that Resident #8 had impaired skin during the admission process. The resident's family stated, They didn't care for it. By the time he went back to the hospital, it stunk. On 12/2/15 at 12:51 p.m., LN D stated the resident's coccyx was reddened when he admitted to the facility. Hospital records documented Resident #8 went to the hospital due to a change in mental status on 9/9/15 and was found to have a urinary tract infection,[MEDICAL CONDITION] (acute infection) and an infected Stage 3 sacral decubitus ulcer (wound with full thickness tissue loss). Hospital records documented [MEDICATION NAME], an intravenous antibiotic, was started and a wound care evaluation was ordered. The facility failed to ensure an accurate and timely skin assessment was completed and failed to identify and treat the resident's skin impairment, resulting in the development of a Stage 3 pressure ulcer during his stay at the facility between 9/3/15 to 9/9/15. .

br>Based on Interview and record review it was determined that Resident #1, 1 of 3 sampled residents, was placed in an unsafe position when receiving care and as a result rolled off the bed sustaining a L hip fracture. Findings include: Resident #1 was admitted to facility on 7/6/2015 with multiple diagnoses. Resident #1 had a care plan in place for mobility bars on bed, transfer with one person assist and two person assist as needed. Resident needs assistance with toileting and is a two person assist for repositioning. Transfers are to be performed with a Hoyer Lift. According to a witness statement written by Staff A dated 7/27/15 while performing routine care with Staff B for Resident #1 on 7/22/15, evening shift, Staff A stepped out of the room leaving Staff B with the resident. Staff A returned to room to find Resident #1 on the floor. Resident #1 was returned to bed and checked by the Licensed staff. Witness statement written by Staff B dated 7/24/15 1930, stated at 1930 she was providing routine care for Resident #1 with Staff A. After Staff A left the room Resident #1 rolled off the bed . Staff B stated While holding on to the small side rail she fell asleep and relaxed her grip . Staff B states In the past Resident #1 has fallen asleep for moments at a time and I think this is what happened . Review of Resident #1's Medication record (MAR) showed Resident #1 had received Hydrocodone (pain medication) at 0445 and 1900 on the day of the fall. The resident also received Ativan (for anxiety) twice on the day of the fall. Nursing note dated 7/22/15 states Resident was in bed being cleaned and she fell out of the bed. Resident complaints of left hip pain after fall. Resident and husband requested to go to emergency room for evaluation. Social Services note dated 7/23/15 states that Resident #1 has a left hip fracture and will not be returning to facility after discharge from hospital. Interview with Licensed Nurse A clarified that Resident #1 was being cared for by Staff A and Staff B when Staff A left the room to gather supplies and clean bedpan. Staff B stayed in the room with Resident #1 and was positioned facing Resident #1 ' s back. Resident #1 remained turned on to her side in her bed. Staff B could not run around the bed fast enough to stop her from falling .

Based on observation, interview and record review, it was determined the facility failed to ensure adequate nutritional services were provided to 1 of 4 current sampled residents (#138) reviewed for nutrition by failing to regularly assess planned interventions and consistently implement substantial interventions to improve the resident's nutritional status. This failure resulted in a 23% loss of the resident's total body weight and placed the resident at risk for a decline in health status. Findings include: Resident #138 was admitted to the facility on [DATE] with a weight of 112.4 pounds. One year later, the resident weighed 86.3 pounds. The facility's Nutrition Policy dated October 2014 indicated the Interdisciplinary Team would manage/improve a resident's nutritional status by identifying, monitoring, evaluating and/or treating risk factors affecting the resident's nutritional status. Facility procedure directed staff to identify risk factors, monitor food intake, identify and assess residents with risk factors for nutritional disorder including [MEDICAL CONDITION], pressure ulcers and unintended weight loss, and evaluate other risk factors such as arthritis, depression, and medication use. The procedure directed staff to develop and implement individualized interventions including offering food substitutions, providing snacks and reviewing food preferences, reporting a weight loss of (5) five percent to the Physician to obtain orders as appropriate, and communicate interventions with staff. Review of the resident's first quarterly nutritional review, dated 8/21/14, showed the resident's weight had decreased to 92 pounds on 8/7/14, which was a 20 pound weight loss and had acquired an unstageble pressure ulcer in June 2014. A nutritional supplement drink was added 7/31/14. The 8/21/14 nutritional note documented the resident continued to be agreeable with oral supplement consumption. Planned interventions were to maintain plan of care, continue to encourage patient to consume more food and more calorically dense food. The next quarterly review, dated 11/25/15, noted the resident lost an additional three pounds and weighed 88.9 pounds. An anti-depressant was added on 10/28/14 and staff were asked to encourage snacks between meals. The 2/24/15 quarterly nutrition assessment documented a five pound increase which was suspected to have occurred from temporarily taking [MEDICATION NAME] which can increase appetite and cause weight gain. The resident's nutritional status was reviewed on 4/9/15 when the resident had a 9 pound weight loss between 3/17/15 and 4/16/15, dropping from 94.8 pounds to 86.1 pounds, resulting in a severe weight loss of 9.17 % in 30 days. No documentation was found to show the resident's physician had been notified of the weight loss or given the opportunity to direct new orders. A nutritional note written by the Registered Dietician (RD) on 4/9/15 documented Resident #138 had experienced a 10 pound weight loss during the previous month and had a pressure ulcer/wound on her coccyx (tail bone). The recommended intervention was to add super spuds with extra butter for extra calories and continue to monitor. The resident's nutritional care plan documented the resident preferred foods such as cream soups, ice cream and sweets. The care plan directed staff to offer the resident options when meals were declined. The resident's meal and fluid detail report provided by the facility showed consistent meal and snack refusals between April 12, 2015 to May 11, 2015. Resident #138 refused all or most of her lunch nine out of the 26 times her lunch intake was monitored, 14 out of 24 times her dinner was monitored and 25 out of 26 times her evening snack was monitored. Documentation was not found to show the resident had been offered alternatives following repeated refusals of meals and snacks. On 5/11/15 at 4:18 p.m., the Director of Nursing Services was asked what nutritional interventions had been provided to Resident #138 following her severe weight loss the previous month. A food preference record dated 4/10/15 was provided and indicated the resident liked tomato soup and to serve it with lunch and dinner meals. A nutrition services request/change order dated 4/9/15 was provided which stated No cream soup except tomato soup. The request to change the order was signed by the Registered Dietician. Received by was blank. On 5/12/15 at 9:50 a.m., Resident #138 said she liked tomato soup. When asked if she received it every day shook her head and said she did not. The resident indicated she liked ice cream but did not get it often. At 10:15 a.m. the Dietary Manager stated the resident's food preferences had been updated and was sure the resident had been receiving tomato soup with every lunch and dinner meal. At 10:25 a.m., Kitchen Staff A stated Resident #138's dietary order had indicated the resident received the soup of the day and was just changed to reflect her preference of tomato soup only. When asked when the change took place, she stated, Today, I didn't see it yesterday. On 5/12/15 at 10:10 a.m., the RD stated, I reviewed her at the beginning of April. We were giving her mashed potatoes with butter. The big thing has been encouragement by staff. I visit her every month to encourage her. When asked if the resident had ever been prescribed an appetite stimulant, the RD stated he could not recall but did know the resident was currently on the anti-depressant [MEDICATION NAME]. The 2015 Drug Reference Guide documented anorexia and taste perversion as potential side effects of [MEDICATION NAME]. Following a severe weight loss, the facility failed to update the resident's food preferences in a timely manner, failed to ensure the resident received her known food preferences or offered alternates when she refused her meals and failed to notify the resident's physician and/or consider an appetite stimulant and/or review potential side effects of medications being given to the resident. .

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well-being for 4 of 6 current residents (#1, 2, 5, & 6) reviewed for care and services. Failure to request, attain and/or administer prescribed medications in a timely fashion caused harm to resident #1 when she did not receive pain medication promptly and Resident #2 when she was given the wrong dose of [MEDICAL CONDITION] medication. <Resident #1> Resident #1 was admitted from a hospital to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool dated 4/14/15, indicated the resident was cognitively intact and had frequent pain. The MDS indicated the resident's pain was being treated with routine and as needed pain medication. The resident was admitted with physician orders [REDACTED]. On 4/22/15 at 9:20 a.m., Resident #1 explained the facility had run out of her narcotic pain medication on 4/15/15 during the day time and again the evening of 4/16/15 into the night of 4/17/15. The resident stated that her pain is often a level of 5-6 out of 10 and with pain medication it decreases to a level of 2 out of 10. The resident stated, Without pain medication, it can get really bad, a 9 or a 10! I also worry about my blood pressure going up because I am hypertensive and pain makes it worse. The resident described lying in bed crying in pain during the early morning hours of 4/17/15. The resident said that a nurse finally called the Director of Nursing Services (DNS) at 3 a.m. and they were able to get her narcotic pain medication at that time. On 4/22/15 at 9:45 a.m., Licensed Nurse (LN) A stated that she was informed, when coming on for day shift the morning of 4/15/15, that Resident #1 did not have any narcotic pain medication available. LN A indicated she faxed a request to the pharmacy for authorization codes to pull the medication out of the facility's emergency medication kit. LN A indicated when she did not hear back from the pharmacy, she called them at 2:00 p.m. on 4/15/15 and was able to get authorization codes and give the resident the narcotic pain medication she was asking for. LN A indicated she gave the resident the scheduled [MEDICATION NAME] and a dose of muscle relaxant medication to help her pain when she was unable to access the narcotic pain medication. Review of the resident's April Medication Administration Record [REDACTED]. On 4/22/15 at 10:15 a.m., the DNS explained that facility policy directs nursing staff to get medication out of the emergency kit if a medication has run out or is unavailable. For narcotics the nurse must get authorization codes from the pharmacy in order to access the emergency kit. The DNS stated, residents should never have to wait that long or go without ordered pain medication, and indicated she had provided education to LN A. <Resident #2> Resident #2 was admitted on [DATE] from the hospital for healing of numerous rib fractures received from a fall in her assisted living facility. Resident #2 had [DIAGNOSES REDACTED]. According to nurses notes, Resident #2's family member contacted the nurse on 3/21/15 about the hospital discharge medications being incorrect, including the [MEDICAL CONDITION] medication, [MEDICATION NAME]. The facility contacted the resident's physician to clarify medication needs on 3/21/15. It was not until 4/1/15 that one of the resident's physicians requested the resident's neurologist be consulted regarding the resident's [MEDICAL CONDITION] medication, [MEDICATION NAME]. The hospital discharge medication orders, dated 3/12/15, ordered the [MEDICAL CONDITION] medication, [MEDICATION NAME], to be given at the dose of 25 milligrams (mg) every day. On 4/2/15, after contact with the neurologist, the [MEDICATION NAME] was increased to 250 mg daily. This was a significantly larger dose. On 4/2/15, in the social service notes, it was noted that the [MEDICATION NAME] ([MEDICATION NAME]), a medication for restless leg syndrome, was discontinued by the neurologist due to the resident's co-morbidities, the increased risk for falls, and interference with her [MEDICAL CONDITION] movement. There were no nurse's notes in regard to this change. In an interview on 4/28/15, a family member stated that she told the facility the medication doses for [MEDICATION NAME] were incorrect and faxed the medication list that Resident #2 had been receiving from her neurologist. There were no faxed medication lists from the family in the medical record. The family member indicated visits with Resident #2 showed she was functioning noticeably different. The family member stated Resident #2 could talk, but she was not there, like she was lost. The family member indicated Resident #2 did not move at all and was functioning at a lower level than before the hospitalization . From 3/12/15 to 4/2/15, Resident #2 was being under-dosed for her [MEDICAL CONDITION] making her susceptible to falls, causing increased difficulty overcoming muscle stiffness and thus affecting performance of activities of daily living. From 3/21/15 to 3/28/15, Resident #2 was receiving [MEDICATION NAME] which was affecting her [MEDICAL CONDITION] movements and also increased her risk of falls. <Resident #5> Resident #5 was admitted to the facility in 2004 with [DIAGNOSES REDACTED]. On 4/24/15 at 11:00 a.m., LN B indicated that the facility has had intermittent problems obtaining medications for residents. LN B mentioned recently there had been a problem obtaining Resident #5's ADD medication. A nurse's note dated 4/10/15 at 8:45 a.m., stated per pharmacy (ADD medication prescription) needs physician signature. Resident is out of medication and will expedite process. Review of Resident #5's April MAR indicated [REDACTED]. On 4/27/15 at 4:30 p.m., LN C indicated that the ADD medication was not in the facility's emergency medication kit and the pharmacy had trouble obtaining the physician's signature needed to send the medication to the facility. <Resident #6> Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's physician's orders [REDACTED]. Review of Resident #6's April MAR indicated [REDACTED]. On 4/27/15 at 4:30 p.m., LN C indicated that the resident ran out of the stroke prevention medication because of insurance reasons. LN C stated, the insurance will only authorize 14 days supply at a time. LN C indicated she called the pharmacy and got them to send the medication over as soon as she was aware of the issue. LN C indicated she did not know the resident was out of the medication for over 3 days.

Based on record review and interview, a staff (Staff #A) verbally threatened one of one resident, (Resident #1), with taking the resident's call bell if the resident didn't stop using it. This failure, resulted in the resident's expressions of intimidation, with verbalizing fear, and feeling upset. In addition, although the facility identified the incident occurred, the facility failed to recognize resident abuse. Findings include: Review of the facility documentation of the investigation revealed, Resident #1 stated that on January 25, 2015, a day shift aide came into her room and said to her If you don't stop ringing that call light I'm going to take it away from you. Resident #1 stated she used the call light to call for her roommate who needed frequent attention from the aides during the day. The facility interviewed the resident's roommate who witnessed the event, and confirmed it occurred. According to the facility documentation, Resident #1 was extremely fearful throughout the rest of the day, that her call light was going to be removed from the room. The facility documented that Resident #1 was hiding the call light in her bed afraid someone would take it away and, she was extremely upset. Review of nursing progress notes dated 1/25/15, found Resident #1 .needed continuous consoling after the event. The documentation indicated the facility confirmed the event occurred. Interview of Resident #1 on 1/28/15 by the facility investigator, Staff B, noted that Resident #1 was still fearful that someone was going to take her call light and interviewer observed her call light tucked under shirt. Even though Resident#1 was not clear on 1/28/15 during this interview as to who was the staff member and that she had to refer to her roommate about the details, she was anxious about her call light being taken away. In interview on 2/10/15 at 2:45pm, Resident #1 stated .they may not like me anymore for telling on the aide. She expressed ambivalence about whether she had done right or wrong with using the call bell for her roommate, .who was so ill. Obervations revealed Resident #1 started to cry and quickly covered her eyes and lowered her head.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well-being for 6 of 10 current residents (#1, 2, 3, 4, 5 &10) and 5 former residents (#s 6, 8, 9. 10. 14) reviewed for care and services. Failure to document or communicate resident refusal and failed to request, attain and/or administer prescribed medications/treatments in a timely fashion caused potential for harm to Resident #1 when evaluation and treatment was delayed after the resident's exhibited increased complaints of urinary issues, behaviors and signs and symptoms of infection. Resident #2 experienced emotional pain and physical discomfort when she requested an antidepressant be prescribed, Resident #3 who experienced physical discomfort and disturbed sleep when the facility did not obtain a medication for weeks. Resident #10 was not monitored for 72 hours after a bruise was observed. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS, an assessment tool, dated 07/05/14, indicated that the resident was severely impaired in cognition. The resident required a two person physical assist for dressing, toileting, personal hygiene and bed mobility. <Right Lower Abdomen> The facility's policy entitled "Weekly Skin Assessment" reads "Obtain a physician's orders [REDACTED]." On 8/5/14 at 2:40 p.m., the resident's right lower abdomen a 10 cm X 5.7 cm reddened area was noted with an elevated area of 4 cm X 2 cm that was surrounded by dried skin and in the center an open area of approximately 0.5 cm in diameter. A scant amount of clear discharge was noted from the center open area. License Nurse (LN) B first noticed reddened area on Resident #1's lower abdomen and obtained a physician's orders [REDACTED]. Fax to physician indicated this issue would be brought to the next rounds, scheduled 8/5/14. The Treatment Administration Record indicated the area had been monitored for signs and symptoms of infection on 8/2/14 through 8/5/14. Licensed Nurse (LN) A explained that s/he faxed physician on 8/3/14 that 2.5 cm "egg" shaped abscess was raised, red and painful to touch. Fax indicated that this would be brought to next rounds on 8/5/14. On 8/5/14 at 5:20 p.m., when asked about physician rounds, RCM B stated , "The physician didn't physically see the area {Resident #1's right lower abdomen.} Last time I saw the area {8/3/14}, I didn't think it was infected." On 8/6/14 at 8:15 a.m., LN B indicated s/he was concerned that the facility was continuing to monitoring for signs and symptoms for infection, considering the resident had a similar wound before and had Keflex ordered. LN B indicated that the reddened area had worsened since s/he first discovered it four days ago. When asked if she had been informed of the affected area on her mother's right lower abdomen, the resident's family member said the facility had not informed her. The facility did call the family member on 8/5/14 after 7:00 p.m. This was after the surveyor discussed the area with the RCM. The family member stated the facility staff described the area as "a spot on my mother's arm." <Skin> Resident #1 was observed on 8/5/14 at 2:40 p.m. to scratch and asked surveyor, "Could you scratch my back, it is so itchy?" The resident's skin was whitish pink, dry flaky and slightly puffy with occasional reddened scratch marks and some areas had dried scabs. Resident #1 continued to scratch her back, abdomen and chest on repeated observations on 5/8/14 at 2:40 p.m., 4:10 p.m., 17:20 p.m., 18:00 p.m., and 7:15 p.m. and on 5/6/14 at 8:10 a.m., 11:30 a.m., and 12:00 p.m. The physician's progress notes, dated 6/3/14, indicated Resident #1 had problems with picking and scratching at her skin and as a result had "an irritated area on the left side of her upper chest which became more festered and sore." This affected area required treatment with antibiotics. The nursing progress notes, dated 5/29/14 to 8/5/14, show no documentation of an evaluation of resident's itchy skin or any communication with physician regarding evaluation or effectiveness of skin treatments ordered back in April 2014. On 8/2/14, a reddened area on the resident's right lower abdomen was noted by LN B. RCM B indicated that resident's scratching lead to this new reddened area for which antibiotics were ordered on [DATE]. <Urine> According to the physician progress notes [REDACTED].#1 has had a history of [REDACTED]. The resident was admitted with a urinary catheter that was placed to assist with a pressure ulcer healing on her buttocks. Since admission, Resident #1 has had three urinary tract infections on 1/29/14, 4/7/14 and 7/7/14. The physician progress notes [REDACTED].{Resident #1} has acutally done significantly better. She is back to her baseline dementia." The nursing progress notes, from 5/29/14 to 6/18/14, did not reflect any aggressive or delusional behavior. According to nursing progress notes, on 6/19/14, Resident #1 was "extremely confused and became verbally abusive." These behaviors continued on 6/22/14 with refusal of care, yelling and using harsh language with the staff. On 7/4/14 resident placed on alert for increased delusions. On 7/5/14, the resident was combative with staff. On 7/7/14, a urine test was obtained and bacteria was found, which was sensitive to the antibiotics [MEDICATION NAME] and [MEDICATION NAME]. On 7/10/14, physician orders [REDACTED]. The family member was consulted, notified of risk, and she agreed to the treatment. Resident refused to have the central line placed, and the physician and family were notified of refusal. According to nursing progress notes, dated 7/11/14, the resident's behaviors continue with yelling and inappropriate language. On 7/13/14, the resident was yelling out, "Need to go pee", despite having a urinary catheter. On 7/15/14, the resident continues to be confused and "states she has to pee." On 7/18/14, Resident #1 was heard calling for help and the resident was found on the floor having incontinence of bowel. The resident stated she was trying to get up to go to the bathroom and her legs wouldn't work so she sat on the ground and had a bowel movement. On 7/19/14, the resident had an increase in behaviors with "continues to cry out for help majority of shift and begged to go to the bathroom every 2 minutes." On 7/26/14, Resident #1 was sitting in her wheelchair at the nursing station yelling and a resident poured a glass of water on her head. On 8/6/14 at 1:20 p.m., surveyor spoke with the resident's family member and she stated she was concerned about her mother's urine infection. "I understand my mother didn't want the IV {intravenous}, but no other options were discussed with me. They can't just let it {the urinary tract infection} go. There must be something they can do. Can she be put on another antibiotic or something? They can't just not treat her. Because of all of this, I actually wanted to move my mother {from this facility.} I had a private nurse go in to assess my mother because she just isn't getting the care there {at this nursing home.} Now the nurse says it will be difficult to place her because of her behaviors, so I feel stuck." Resident #1 had two different reddened areas that facility staff indicated is related to the resident scratching. Both areas required antibiotic treatment. No monitoring of the resident's scratching in response to the effectiveness of skin care treatment was evaluated or documented. The resident had an abnormal urine test and the treatment for [REDACTED]. There was no documentation of communication with family member for follow up care or an alternative plan of care in regards to the resident's refusal of treatment. The family member was concerned for her relative not receiving the care she required. 2) Resident #2 was admitted to the facility on [DATE], with multiple complex medical [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool, dated 7/3/14, the resident was cognitively intact with no memory impairment and required limited to extensive assistance with activities of daily living (ADLs). On 8/5/14, a sign was observed posted on a resident room door that requested all persons who entered the room either wash their hands or use hand sanitizer in front of the occupant. Resident #2 stated she requested staff to place it there because of her illnesses that had not improved. Resident #2 was observed with a clear dressing with white tape over several areas of it to her left upper chest that was dated 7/29/14. Resident #2 was very congested as she spoke and had stated it was a dressing that covered a catheter that went directly led to her heart that was used for delivering medications. She stated it had not been changed since the date that was on the dressing. "I don't know if it's a sterile dressing or when it's supposed to be changed, but the nurses just keep taping it because the edges aren't holding and they don't have time to change it." Resident #2 took her finger and slid it under a large opening. "See? I'm worried about this too, but the nurses all say there's not enough of them or they don't have time to do the dressing." Resident #2 did not know if there was schedule for the dressings to be changed. Resident #2 continued stating she had not been receiving her medications on time or sometimes not at all. Resident #2 showed a log she had been keeping of when she requested medications and when she received them. Resident #2 stated she recently had taken a copy of her Medication Administration Record [REDACTED]. Resident #2 said she noticed that some medications were documented as given, but stated they were not, specifically acidophilus (a supplement to replace intestinal flora) and her allergy medicine. Resident #2 said she believed she acquired thrush (an infection usually affecting the oral cavity where there is an imbalance of flora) because she had not regularly received the acidophilus. Resident #2 stated the nurses would apologize for not having the medications, but did not believe staff should have documented the medications were given when they had not been, and the physician agreed with her. Resident #2 cried stating she had requested the week prior to receive an antidepressant medication she had been taking long term prior to her admit to the facility. She stated the Social Service Director (SSD) spoke with her and notified the Resident Care Manager (RCM) to contact the physician to request it. Resident #2 stated approximately 2 days prior the SSD followed up to check on her. Resident #2 asked the SSD if she knew whether the medication order had been obtained. The SSD went to check, returned to her and apologized that the physician was not contacted by the nursing staff. Resident #2 continued crying stating she was very overwhelmed and afraid with her health status situation, being apart from her family and felt like she had to manage her own care because of the lack she received from nursing staff. Resident #2 felt if the RCM or nursing staff would request the antidepressant from the physician she might feel less overwhelmed and less anxious about her future. The SSD stated Resident #2 had requested her anti-depressant she was taking prior to admit which was reported to RCM A and D, documented on the facility24 hour report, and was told the physician would be notified during the next visit to the facility 8/5/14. The SSD followed up with the RCM who stated the physician had not been consulted for Resident #2's psychological needs. 3) Resident #3 had previous admits to the facility and was most recently admitted to the facility on [DATE], with multiple complex medical [DIAGNOSES REDACTED]. According to her MDS, dated [DATE], she was cognitively intact with no memory impairment. On 7/22/14, according to the facility documentation Resident #3 gave a staff person a list of concerns several residents compiled regarding nursing care, sufficient staff, dining, environmental and customer service issues at the facility. On 8/5/14, Resident #3 was observed approaching Licensed Nurse (LN) C at the medication cart. LN C was overheard stating to Resident #3, "I'm just too busy, you'll have to wait and I'll try to find it later." Resident #3 began crying as she stated she had been waiting in the bathroom for the cream, after 15 minutes she got off the toilet without assistance to ask the LN for hemorrhoid cream. Resident #3 said the LN said there was no cream, she thought it was ordered a while ago, and RCM A had told her he thought it should have been delivered to the facility a long time ago. Resident #3 stated she was embarrassed to be crying over the issue but she was so frustrated and very uncomfortable from the pain and burning. Resident #3 stated because of several residents voicing concerns over insufficient staff to meet their care needs timely, she wrote a letter to the facility department heads and corporation documenting resident concerns along with a petition to ask for more staff to provide adequate and timely care. Resident #3 stated she went to every resident in the facility asking how they felt. She stated residents who chose to sign the petition did so, and if a resident could not sign their name, although they were in agreement, they did not sign the petition. Resident #3 stated some residents refused to sign the petition although they agreed with the concerns because of fear of being retaliated; of the 21 residents who did sign the petition, Resident #3 stated to them she would act as the person solely responsible if anyone got in trouble. Resident #3 stated she documented the concerns to be an advocate for other residents who would live longer than her as she recently was told she had a poor prognosis to live. Staff verified there was an order obtained for the cream on 7/24/14, but none ordered for the resident. On 8/6/14, Resident #3 stated after speaking with the investigator she received the cream the evening prior to alleviate the pain and burning. She said, "I was finally able to get a good night's rest which hasn't happened in weeks." 4) Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to her MDS, dated [DATE], she had mild cognitive impairments. On 8/5/14, Resident #4 stated she frequently waited long periods of time to receive medications and assistance in a timely manner for toileting. Resident #4 said feelings of urgency with her bowel and bladder made it difficult to manage not soiling herself due to long wait times. Resident #4 stated she would be left on the bed pan for long periods of time which was painful, or she could not wait for assistance and would just wet or defecate in her brief. Resident #4 stated soiling herself happened so frequently she"had just become used to it." 5) Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his MDS dated [DATE], he was cognitively intact. On 8/6/14, Resident #5 and a LN were observed at a medication cart speaking. Resident #5 was holding supplies for a wound vac dressing change he was taking to the wound clinic for his appointment. Resident #5 stated the facility continued to not have supplies for the physician ordered Monday-Wednesday-Friday weekly dressing change (done by the facility Monday-Friday weekly, the Wednesday change by the wound clinic physician) had not been done since the Saturday prior(but due Friday). The LN offered Tuesday to do the Monday dressing change, but because the physician was going to exam it less than 24 hours later so he declined. "Why have it done when it's going to be done that short of time later, it is never done on schedule or there is no supplies. No different from the last time you talked to me" (a previous complaint survey with identified failures related to wounds, supplies and underqualified staff for the wound vac change.) Resident #5 stated he was discharging in a week and no longer cared because his previous complaints regarding inadequate qualifications of staff for the dressing had not been resolved. 6) Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to her MDS, dated [DATE], she was cognitively intact. The medical record was reviewed with a documented physician order [REDACTED]. According to the facility documentation Resident #6 reported to a staff person she requested her stitches be removed as her physician instructed on 7/19/14. The stitches were not removed until 7/21/14, which per Resident #6's report was scabbed over the stitches and caused "unnecessary excruciating pain." Documentation from the LN involved documented that due to the LN's "caseload and priority of other illnesses" the orders were not reviewed to remove the stitches as requested by Resident #6. .

Based on observation, interview, and record review, the facility failed to ensure care and services were provided in a manner which enhanced and maintained resident dignity and feelings of self-worth by ensuring five residents (#s 1, 3, 4 and 5 had their care concerns/needs addressed in a timely manner. This caused harm to Residents # 1 & 3 who experienced diminished quality of life related to the failures. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with multiple medical diagnoses. According to her Minimum Data Set (MDS)an assessment tool, dated 07/05/14, the resident was severely impaired in cognition. The resident required a two person physical assist for dressing, toileting, personal hygiene and bed mobility. The resident was observed on 8/5/14 at 2:40 p.m. to have messy hair on the back of her head, multiple chin hairs approximately 1.5 cm long and her finger nails were different lengths, broken in areas with chipped nail polish. The resident was dressed in a lightweight shirt and black pants which had dried flakes of skin. Resident # 1 was scratching her lower back. Resident #1 continued to scratch and asked surveyor, "Could you scratch my back, it is so itchy?" The resident's skin was whitish pink, dry flaky and slightly puffy with occasional reddened scratch marks and some areas had dried scabs. Resident #1 continued to scratch her back, abdomen and chest on repeated observations on 5/8/14 at 2:40 p.m., 4:10 p.m., 17:20 p.m., 18:00 p.m., and 7:15 p.m. and on 5/6/14 at 8:10 a.m., 11:30 a.m., and 12:00 p.m. Facility staff indicated that Resident #1 scratched and now had an open area which was raised, red and painful on right lower abdomen. Licensed Nurse (LN) A faxed physician on 8/3/14 indicating a 2.5 cm "egg" shaped abscess. On 8/5/14 at 5:20 p.m., Resident Care Manager (RCM) A indicated that Resident #1 developed the open area on right lower abdomen from scratching. 2)Resident #3 had previous admits to the facility and was most recently admitted to the facility on [DATE], with multiple complex medical diagnoses. According to her MDS, dated [DATE], she was cognitively intact with no memory impairment. On 7/22/14, according to the facility documentation Resident #3 gave a staff person a list of concerns several residents compiled regarding nursing care, sufficient staff, dining, environmental and customer service issues at the facility. On 8/5/14, Resident #3 was observed approaching LN C at the medication cart. LN C and was overheard stating to Resident #3 "I'm just too busy, you'll have to wait and I'll try to find it later." Resident #3 began crying as she stated she had been waiting in the bathroom for the cream, after 15 minutes she got off the toilet without assistance to ask the LN for hemorrhoid cream. Resident #3 said that the LN said there was no cream, she thought it was ordered a while ago, and RCM A had told her he thought it should have been delivered to the facility a long time ago. Resident #3 stated she was embarrassed to be crying over the issue but she was so frustrated and very uncomfortable from the pain and burning. Staff verified there was an order obtained for the cream on 7/24/14, but none ordered for the resident. On 8/6/14 (the day after the issue was discussed with the facility), Resident #3 stated "I was finally able to get a good night's rest which hasn't happened in weeks." 3)Resident #4 was admitted to the facility on [DATE], with multiple medical conditions. According to her MDS, dated [DATE], she had mild cognitive impairments. On 8/5/14, Resident #4 stated she frequently waited long periods of time to receive medications and assistance in a timely manner for toileting. Resident #4 said feelings of urgency with her bowel and bladder made it difficult to manage not soiling herself due to long wait times. Resident #4 stated she would be left on the bed pan for long periods of time which was painful, or she could not wait for assistance and would just wet or defecate in her brief. Resident #4 stated soiling herself happened so frequently she " had just become used to it." 4)Resident #5 was admitted to the facility on [DATE] with multiple medical diagnoses. According to his MDS dated [DATE], he was cognitively intact. On 8/6/14,Resident #5 stated the physician ordered Monday-Wednesday-Friday weekly dressing change (done by the facility Monday-Friday weekly, the Wednesday change by the wound clinic physician) had not been done since the Saturday prior to Friday. A LN had offered Tuesday to do the Monday dressing change, but because the physician was going to examine it less than 24 hours later so he declined. "Why have it done when it's going to be done that short of time later, it is never done on schedule or there is no supplies." Resident #5 stated he was discharging in a week and no longer cared because his previous complaints regarding inadequate, underqualified staff for the dressing had not been resolved. On 8/5/14 the facility administrative staff stated they would interview all staff for concerns related to dignity and treatment in the facility. The administrative staff stated they acknowledged residents' current concerns and will notify the Regional Director for additional oversight and guidance. .

Based on observation, interview, and record review, it was determined the facility failed to ensure interventions consistent with the resident's needs and stated facility policies and procedures regarding pressure ulcer prevention and treatment were identified and implemented for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure caused harm to Resident #1 when the resident developed a facility-acquired pressure ulcer and an existing pressure ulcer increased in size causing the resident physical pain and delayed treatment. Findings include: According to the facility's definitions contained in the "Skin Care Management System", dated 2001, a Stage 1 pressure area is an observable pressure-related alteration of intact with persistent redness; a Stage 2 is partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a pink wound bed or an intact or open serum-filled blister; a Stage 3 is full thickness tissue loss with subcutaneous (below the skin) fat visible; and a Stage 4 is full thickness tissue loss with exposed bone, tendon, or muscle. An Unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (blackened dead tissue) in the wound bed. The facility's policy indicated pressure ulcers would be measured and staged weekly with length, width and depth in centimeters. The nurse was responsible for documenting stage, measurements, appearance, and treatment provided in the Nurse's Notes at least weekly. The facility's "Pressure Ulcer Prevention/Treatment" procedure indicated the Braden Risk Assessment and Skin Integrity Assessment were to be used to assess a resident on admission and weekly for four weeks, quarterly, and with a significant change of condition. The Braden Risk Assessment indicated a resident was "at risk" with a score of 15-18; at "moderate risk" with a score of 13-14; at "high risk" with a score of 10-12; and at "very high risk" with a score of 9 or below. Resident #1 was admitted to the facility 5/6/13 with [DIAGNOSES REDACTED]. The resident was hospitalized prior to admission to the facility from 5/2/13 to 5/6/13. On admission, the physician noted the resident had vascular ulcerations to both feet. There was no documentation or assessment of pressure ulcers. The resident's Admission Skin Assessment, dated 5/6/13, described the resident as having an unstageable pressure ulcer on the coccyx measuring 2.5 centimeters (cm) by 3.0 cm. The assessment also indicated the resident had an unstageable pressure ulcer of the left great toe measuring 2.5 cm by 1.2 cm; and an unstageable pressure ulcer of the right ankle measuring 1 cm by 1 cm. There was no documentation to support the phsycian was aware of these areas. The resident's Minimum Data Set (MDS), an assessment tool, dated 5/13/13, indicated the resident was admitted with 3 unstageable pressure ulcers and no venous or arterial ulcers. The resident's Braden Scale, used to assess a resident's risk of skin breakdown, indicated the resident was "at risk" with a score of "19." The resident's care plan, dated 5/7/13, directed the nursing staff to, "monitor wound weekly and as needed" and to "See Skin Grid." Other interventions included keeping skin clean and dry, encourage ambulation and mobility, instruct and encourage repositioning at 15-20 minute intervals and address cause if possible. The resident goals were to "remain free of open areas" and "cooperate with position changes." No documentation was found to support the interventions were implemented or consistently followed. On 5/21/13, a Stage 2 ulcer of the right inner buttocks was noted on the care plan. No new interventions were listed. A nursing note, dated 5/21/13, was the first to address the resident's skin. The note stated, "Skin assessment completed, new open area 0.2 cm by 0.2 cm." This note did not identify the location of the open area. A doctor's note (indicating a physician visit), dated 6/7/13, did not address the resident's pressure ulcers or new open areas noted by nursing staff. A nursing note, dated 6/9/13, stated, "open areas on coccyx remains covered."No further measurements or description was charted. A doctor's note, dated 6/14/13, stated, "[MEDICAL CONDITION] with lower extremity ulcers." A consult to the Wound Clinic was ordered to assess the resident's wounds on her lower extremities. There was no communication about other open areas. On 6/23/13 (38 days after initial findings were documented) a fax to the doctor stated, "Skin audit complete. Treatments updated. Allevyn to open areas on buttocks to be changed every 2-3 days." The nurse did not document a description or measurements of the open area. The Wound Clinic note, dated 6/25/13, indicated the resident's lower extremity arterial ulcers were assessed. There was no documentation the resident's pressure ulcer of the coccyx or new open areas of the buttocks were addressed. On 7/14/13 the evening nurse documented, "Changed dressing to right ischium (the bony area of the hip on which the body rests when in a sitting position), and noted several new open areas to right upper thigh and along outer right labia. The largest measuring 3.0 cm by 3.1 cm to the smallest at 1.1 cm." At 8:30 p.m., the nurse noted the resident's arterial ulcers of the lower extremities had significantly changed and orders were received to transport the resident to the hospital. The resident was admitted to the hospital from the facility on 7/14/13 at 9:31 p.m. The facility on 7/15/13, (the day after the resident was discharged ) an Interdisciplinary Team (IDT) review was completed by the facility. The review noted the facility's documentation of the resident's lower extremities was accurate and complete. The IDT documentation indicated, "right ischium wound noted to have rapidly progressed and new areas were noted at that time to right outer labia, right upper thigh, and next to ischium wounds as well" and "resident also with skin issues to buttocks with one that has rapidly progressed." The initial hospital nursing assessment on 7/15/13 at 4:00 a.m. indicated the resident had an unstageable right gluteal ulcer, an unstageable pressure ulcer of the right ischial tuberosity, and multiple small, full-thickness ulcerations of the perineum. On 7/15/13, at 8:10 a.m., the physician documented, "ulcer about 5 cm by 4 cm present on the right gluteal region." A wound consult was ordered. At 11:43 a.m., Wound Care Nurse (WCN) 1 documented the resident had an unstageable pressure ulcer measuring 4 cm by 6 cm on the right ischial tuberosity. A Stage 3 pressure ulcer was present of the resident's coccyx. Multiple full-thickness ulcerations were observed on the perineum. On 7/17/13, at 1:30 p.m., the resident's pressure ulcers were observed during a dressing change with WCN 2. A pressure ulcer measuring 4 cm by 6 cm was observed on the right ischial tuberosity. The wound bed was covered entirely with slough (a scab). A Stage 3 pressure ulcer measuring 1 cm by 1 cm was observed to be adjacent to the right ischial ulcer. The resident's entire perineal area was bright red with numerous full-thickness ulcerations. Necrotic tissue (dead tissue) was observed to be present on the labia and near the rectum. During the dressing change the resident stated, "Oh that hurts. Please stop." At 2:00 p.m., the resident's family member reported, "she (the resident) had a very small pressure ulcer on her rear end when she was admitted to the nursing home but it is much larger now. She certainly didn't have all the other open areas, especially on her private area." At the facility, on 7/18/13, the facility Director of Nursing Services (DNS) reported the Wound Clinic was not aware of the resident's pressure ulcers of the coccyx. On 7/18/13, at 11:15 a.m., the facility DNS stated "pink sheets" for pressure ulcer assessments were expected to be completed weekly. The DNS stated, "No doubt they were pressure ulcers. Normally there would be "pink sheets" to document progress but there are no "pink sheets" for this resident. The documentation was not consistent from nurse to nurse. They weren't documenting the sites consistently. I think it (the pressure ulcer) just kept getting worse and worse. We have the responsibility of providing care and documenting the resident's condition." The facility failed to accurately and consistently assess the resident's skin integrity; identify and address the resident's risk factors for worsening existing pressure ulcers or developing new ulcers; and identify and revise interventions to prevent worsening or developing pressure ulcers. This failure caused the resident harm when an existing pressure ulcer increased in size and new facility-acquired pressure ulcers developed. .

Based on observation, interview and record review, the facility failed to ensure 2 of 4 (#4 & 9) residents who displayed mental and/or psychosocial adjustment difficulty received care and services in a timely mannner to maintain the highest level of mental and psychosocial functioning. This failure caused harm when the facility failed to recognize and report severe depressive symptoms and behaviors for Resident #4 and delayed treament for Resident #9 who stated he had a plan to commit suicide and exhibited inappropriate behaviors . FINDINGS INCLUDE: <Resident #4> Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He required extensive assistance by two staff for dressing and transfers, and one staff for bed mobility, toileting, and eating. The resident was documented as having mild cognitive deficits and a known history of verbal outbursts. On 3/14/13, an outside mental health care agency Advanced Registered Nurse Practitioner (ARNP) documented an intake evaluation and initial treatment plan for Resident #4. The Mental Health (MH) ARNP documented the referral was from the facility staff requesting to do a mental health evaluation of Resident #4. Resident #4 told the MH ARNP he had; "depressed mood daily, increased irritability, increased appetite, poor concentration, short term memory impairment, [MEDICAL CONDITION] and thoughts of suicide without a plan or means." Resident #4 relayed to the ARNP he was isolated, and conversed with staff only when spoken to. Resident #4 discussed medications with the MH ARNP, and stated he was agreeable to start antidepressant therapy. The MH ARNP documented the resident had significant depression with [MEDICAL CONDITION]. The ARNP ordered Resident #4 to start [MEDICATION NAME] 10 mg (an antidepressant) each day, Trazadone 50 mg every night (antidepressant) for insominia, and [MEDICATION NAME] 100mg (an anticonvulsant) three times daily for his mood and nerve pain. There was no evidence the facility implemented the MH ARNP medication orders prescribed with the resident's input and agreement for his mental or notified the primary care physician (PCP) of the orders. According to the facility documentation the resident demonstrated abnormal emotional behavriors on 4/7, 4/8, and 4/10/13. The facility accident/injury log, documented an incident occurring on 4/11/13, where Resident #4 was witnessed in a dining room yelling and cursing at another resident. The Primary Care Provider was contacted regarding the resident to resident altercation and ordered scheduled dosing of a p.r.n (as needed) anti-anxiety medication, [MEDICATION NAME], and started an additional anti-anxiety medication, [MEDICATION NAME]. A nursing progress noted dated 4/13/13, documented the pharmacy did not have [MEDICATION NAME], and it would not be delivered until the night shift on 4/14/13 .The first dose of [MEDICATION NAME] was given in the afternoon of 4/14/13 . On 4/15/13, in the nursing progress note Resident #4 was documented as being "teary." According to a Social Service Progress Note dated 4/16/13, Social Service (SS) B had a decline in his mood score of dropping from a "12" to a "10" which indicated moderate depression. On 4/17/13, SS B documented the resident had 3 room changes while in the facility, continued to have periods of calling out and cursing and could "generally be redirected or if feelings are validated, he could be calmed down." On 4/18/13, the MH ARNP saw Resident #4, and documented he "endorses being severely depressed at this time. He also complains of frequent mood fluctuations that affect his anger level and quick reactions to other if they interfere with his isolation." The MH ARNP documented Resident #4 was "agreeable to antidepressant therapy and a non-narcotic sleep aide at this time." The MH ARNP prescribed the same orders for Resident #4 to address his significant depression as 5 weeks prior, on 3/14/13. On 4/23/13, an Interdisciplinary team (IDT) [MEDICAL CONDITION] medication review progress note, documented Resident #4 mental health notes and [MEDICAL CONDITION] medication were reviewed, and "IDT team recommends no changes at this time related to resident recently starting [MEDICATION NAME]. Will have MD review recommendations." On 4/24/13, SS B had a care conference with Resident #4, his guardian, and RCM A present. The staff present documented that Resident #4 " has now become incontinent of bowels just recently," and the guardian wanted the physicians to talk about the plan for treating the resident's health conditions. SS B documented, "WCTM (Will Continue To Monitor)." Further documentation in the medical record revealed the resident continued experiencing crying episodes, isolative behaviors, and verbal outbursts. On 5/16/13, SS B stated the facility IDT team was aware of the recommendations from the outside mental health agency ARNP, but chose not to implement the changes because of the recent start of the anti-anxiety medication from the PCP. SS B did not respond when asked if the PCP was notified of the MH ARNP's medication recommendations one month prior (March 2013) to the PCP orders April 2013. On 5/17/13 Resident #4 recalled the verbal altercation incident with Resident #5. He stated he yelled at Resident #5 because she had made him mad. When asked if someone from the facility had talked to him regarding his feelings around the incident, or to find out why he became angry, he dropped his head and stated "No." Resident #4 buried his face in his hand and began to cry when asked how that made him feel, and said " It makes me feel like no one here cares about me." LN B stated when Resident #4 was first admitted to the facility he did not have episodes of crying or frequent outbursts. LN B stated since the resident has been admitted to hospice services, he has become more labile. LN B stated the resident was displaying more depressive symptoms of crying and difficulty falling asleep at night. There was no evidence to support any of the MH ARNP 's medication orders were implemented or the facility notified the PCP of the orders to address Resident #4 severe depression. Resident #4 remained on anti-anxiety medications although he continued to demonstrate depressive symptomology that was not recognized by the facility staff to notify the PCP. <Resident #9> Resident #9 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The resident was identified as cognitively intact with no memory problems. Resident #9 required two person extensive assist with dressing and bed mobility and was totally dependent on staff for toileting and transfers. The resident had an identified history of substance abuse and [MEDICAL CONDITION]. The medical record was reviewed, on 3/14/13, a MH Advanced Register Nurse Practitioner (ARNP) from an outside agency documented an intake evaluation and initial treatment plan for Resident #9. The reason for the evaluation was documented as a referral from staff. Resident #9 documented as demonstrating a tearful affect, depressed mood and was angry. Resident #9 acknowledged ongoing depression, and that his current medication was not working. Resident #9 discussed he had a tendency to worry alot, and had difficulty falling asleep, and a history of suicide ideation, but none at the time of the intake. The MH professional documented Resident #9 had a moderate depression, and he wanted to try a different anti-depressant that would also help his anxiety, and pain. The MH professional who had the ability to prescribe medication, wrote an order for [REDACTED]. According to the facility documentation, 36 days later, 4/19/13, a IDT "psych med review" progress note documented "Resident chart reviewed by Lantern Group (outside mental health agency). IDT concurs with recommendation and will refer" to the primary care physician. On 4/23/13, a total of 40 days after the ARNP MH professional prescribed the change in Resident #9's medications, an order was received from the primary care physician to administer the medications as written by the MH ARNP. A Social Services progress note dated 4/23/13, documented the changes and that "SS Will Continue to Monitor (WCTM)." Six days later, 4/29/13, a SS note documented as "Wellness check" documented a follow up with the resident, and he did not report adverse side effects to the medication at that time. Resident #9 was documented as expressing frustration about his placement in the nursing home, that SS "spent approximately 30 minutes listening to resident vent feelings, which appeared effective. SS WCTM." On 5/1/13, SS A documented a progress note stating "Resident continues to yell at staff, demanding assistance immediately and causing scenes in hallway when he has to wait to be hoyered (mechanically lifted) to bed. SW continues to encourage resident to use more appropriate means of venting frusrations (via journal, mental health services, to SW) but resident continues to exhibit these behaviors. Resident often will calm down when request is addressed. SS WCTM." The resident's mood and behavior plan of care dated 3/7/13, documented interventions for staff to provide if Resident #9 had [MEDICAL CONDITION]. It directed staff to monitor the resident for emotional lability to notify the Social services, Resident care manager (RCM) and physician of changes. To ensure the resident has no plan to harm self, initiate every 15 minute check, and to send to the emergency room (ER) immediately for assessment, contact MD/Mental Health (MH). On 5/16/13 Resident #9 was observed in his bed with food stains on his hospital gown and PICC line dressing. Resident #9 stated he felt depressed about his current living situation. He wanted to return to a lesser care setting and be reunited with his animal. Resident #9 said he felt being apart from his cat was like "a death, you know, pets really are like family." Resident #9 relayed being bored, and discussed his perceived losses regarding his prior living situations and outlets of sexual expression that were not addressed in the facility. The DNS and SS A were notified of Resident #9's stated grief, and lack of facility documentation, including care plans with interventions to help Resident #9 with his perceived losses. The DNS stated Resident #9 had a history of [REDACTED]. The lack of facility documentation was readdressed. SS A stated she could document the issues. SS A later reported that Resident #9 had told a NA he was going to leave the facility, purchase a gun and kill himself. SS A stated the resident would be placed on checks every 15 minutes. On 5/16/13, at 1:58 p.m., a communication fax to the PCP documented Resident #9 had made suicidal statements about purchasing a gun, and had recent changes in anti-depressants. On 5/17/13, the medical record was reviewed. Not present the day prior, SS A had documented a behavioral socially inappropriate care plan problem, "Discussion of sexually inappropriate nature to staff," that included staff interventions of having two staff present during discussion of inappropriate topics. A 5/17/13, a physician progress notes [REDACTED]. There was no evidence the MD was made aware of Resident #9 ' s suicidal statement, or fax stating the resident threatened to kill himself on 5/16/13. LN C, who authored the fax, stated she probably should have telephoned the physician in regards to the resident's [MEDICAL CONDITION], as he was capable of leaving the facility. There was no evidence to support SS "WCTM" with identified provisions/implementation of interventions (journaling, Mental health services, SW visits), suicide interventions, or adequate nursing/SS monitoring was done for Resident #9's complex psychological issues. The DNS stated the facility did not seek any coordination of care or interventions for Resident #9 with the PCP, and MH although Resident #9 had made depressive/suicidal statements, and voiced inappropriate behaviors of a sexual nature toward staff. Refer to F225, F 157 .

Based on observation, interview and record review it was determined that the facility failed to provide appropriate tube feeding treatment and services to minimize complications for 1 of 3 Sampled Residents (#61) reviewed for tube feeding of the 31 sampled residents who were included in the Stage 2 review. For this resident there was harm due to development and/or worsening of multiple medical complications [REDACTED]. Findings include: Record review revealed Resident #61 was discharged from the facility to the hospital on [DATE] and was unconscious for ten days with [DIAGNOSES REDACTED]. While in the hospital, the gastrostomy tube (G tube) feeding regime was changed to a product the manufacturer described as formulated for managing blood sugar levels for people with diabetes (labeled Glucerna); in addition, the amount of water added was increased to flush the tube and meet her fluid needs. The facility failed to provide Resident #61 with appropriate tube feeding treatment and services to minimize complications of dehydration, insulin-dependent diabetes with abnormally high blood sugar levels and risk for aspiration pneumonia. During interview on 2/27/13, Collateral Contact (CC) #1 expressed great concern about care did not meet the needs of Resident #61 who had diabetes and was on tube feeding at the facility. She stated the resident was unconscious in the hospital for ten days in January. Unsafe Position with Tube Feeding Running, and Staff Not Checking Position of Feeding Tube Before Changing Tube and Formula Did Not Minimize Risk of Aspiration Pneumonia: CC #1 stated during interview on 2/27/13 she was upset she visited the resident in the nursing home she would find the resident lying flat on her back with the tube feeding formula running, which she felt was unsafe. The following observed procedure by Staff LN B did not follow the facility policy for safe administration of tube feeding formula or the current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Instill 20 - 30 ml of air into tube while auscultating", and "HOB (head of bed) to be elevated 30 - 45 degrees. This placed the resident at risk for aspiration pneumonia in the event formula went up into her throat and down into her lungs related to impaired swallowing (dysphagia). Observation on 3/4/13 at 10:15 a.m. revealed Resident #61's torso was positioned flat and below the elevated upper section of the bed with her abdomen lower than her hips on the bed while the pump was running the tube feeding formula at a rate of 60 ml per hour. Staff LN B entered the room, stated the tube feeding needed to be changed as the bags of formula and water were almost empty and she would come back to hang new bags of formula and water. Staff LN B returned and switched empty bags with full bags of formula and water. Staff LN B removed and replaced the feeding tube with a new one attached at the residen's stomach without confirming proper safe placement of the tube in the stomach (auscultate). While the resident's torso was flat and abdomen was lower than her hips, Staff LN B forced water from a syringe into the tube and into the resident's stomach. Staff LN B stated the water did not easily flow by gravity into the stomach. Staff LN B then restarted the pump to administer the tube feeding to provide 60 ml of formula per hour and 25 ml of water per hour. During interview on 3/4/13 regarding how staff would be alerted when the bag of formula was almost empty, Staff LN B stated she had been observing it that morning, then checked the pump and stated the nurse on the night shift had not set the pump with volume of the formula (1500 ml) so it would beep when near empty. Observation revealed after staff repositioned Resident #61 at 10:30 a.m. on 3/4/13 so her head and torso were up on the bed at an 80 degree angle, three hours later at 1:20 p.m., the resident was in an unsafe position with her torso lying flat with the tube feeding running. Similar observation was made an hour later at 2:25 p.m. of the same unsafe position. The resident's breathing sounded gurgling and rattling with wet vocalizations when she spoke. The Department required and accepted a safety plan for tube feeding regime from facility management that included retraining staff. Observation on 3/8/13 at 8:30 a.m. revealed Resident #61 was again lying in an unsafe position with her torso flat on the bed with the tube feeding running at 60 ml per hour of formula and 25 ml per hour of water. The resident was coughing and stated "I don't feel good. I feel like I have to heave." For Staff NA J, one of six sampled staff interviewed, she stated "No." when asked if received training in the past week on proper positioning of residents on tube feeding. The facility was unable to provide any documented evidence of this training that was a key part of the accepted tube feeding safe plan. Three other staff interviewed that replied negatively even though the facility provided documentation of training attendance on positioning during tube feeding. Facility's Tube Feeding Formula and Water Regime Treatment Did Not Minimize Risk for Dehydration or Poorly Managed Blood Sugar Levels related to Diabetes: Review of Medication Administration Records (MARs) between July 2012 and January 5th, 2013 for Resident #61's blood sugar (readings by finger stick) revealed significantly abnormally high levels as high as 502 (normal range 80 to 120). Staff RD 2 noted in nutrition assessment documentation the tube feeding formula was switched eight months ago on 4/25/12 to a product the manufacturer described was formulated for managing side effects of people with chronic kidney failure and on [MEDICAL TREATMENT] (labeled Nepro with Carb Steady) and contained simple sugars (corn syrup) as the carbohydrate. Resident #61 was not diagnosed with [REDACTED].#61's blood sugar readings (by finger stick) were above normal, above 248 at all four times of the day and Nepro with Carb Steady tube feeding regime was not able to lower the resident's blood sugar levels to an acceptable range. Staff RD 2 recommended changing to a different tube feeding formula (labeled Glucerna 1.5). The facility did not implement Staff RD 2's recommended change in formula. Review of manufacturer's product information revealed this recommended formula was formulated to manage blood sugar levels of people with insulin dependent diabetesand did not contain simple sugars. This matched Resident #61's [DIAGNOSES REDACTED]. Review of MARs between 1/15/13 and March revealed the resident's blood sugar readings (by finger stick) were significantly improved to a range of 125 to 220 (normal range 80 to 120) after tube feeding formula was switched to Glucerna 1.0 during recent hospitalization in January 2013. During interview on 2/27/13, Family stated when she visited the resident at the facility on 1/5/13, she could not arouse her from severe lethargy so requested facility staff assist in sending her to the hospital. She stated hospital medical staff identified the resident was dehydrated. Family also stated she felt her observation on the first day of hospitalization of urine (in the catheter bag) appeared like lemon sherbet; after the resident was given extra fluids, her urine became dark orange. It took several days of hydration before her urine was a normal light yellow, which confirmed for her the resident was very dehydrated from inadequate tube feeding regime at the nursing home. Family also expressed concern the resident's blood sugar levels had been high while in the nursing home. Review of nutrition assessment documentation by Staff RD 2 revealed Resident #61 was readmitted to the facility on [DATE] with newly placed gastrostomy tube (G tube) and a tube feeding formula (labeled Promote with Fiber) administered at a rate that provided 1680 ml of formula. Staff RD 2 incorrectly calculated that this amount of formula provided 2095 ml of free water when in fact it provided 400 ml less of water (1394 ml free water with calculations from the manufacturer's product information). This error of overestimating the amount of water provided by the tube feeding treatment was confirmed by interview via telephone with Staff RD 2 on 3/13/13. Further record review revealed Staff RD 2 noted family reported the resident had diarrhea. Fluid needs are increased with diarrhea to replace added water loss. The resident's pattern of abnormally elevated blood sugar levels for eight months may have also increased her fluid needs. During the resident's hospitalization in January, medical staff diagnosed she had an infection of the gall bladder which may have also increased her fluid needs. A [DIAGNOSES REDACTED]. water needs to minimize risk for dehydration.

Based on interview and record review the facility failed to ensure that 1 of 10 sampled residents (#1) received care and services necessary to maintain optimal health and prevent the deterioration of health and/or receive timely emergency services. The facility failed to recognize Resident #1's decline in health as an emergent concern. This failure resulted in harm to Resident #1. Findings include: All interviews took place [DATE] or [DATE] Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. He had recently had a [MEDICAL CONDITION] infarction (MI or [MEDICAL CONDITION]). He was assessed by the facility as being alert and oriented and able to make his needs known. Documentation in the Progress Notes dated [DATE] stated, "At (approximately) 2:00 a.m. resident came out into hall complained of SOB (shortness of breath) and chest pain. O2 (oxygen) saturation 77% on room air. On O2 at 2 liters (O2 saturation) went to ,[DATE]%. Resident wished to go to hospital. Doctor (called) at approximately 2:30a.m., Doctor agreed. Called AMR (non-urgent response) at approximately 2:45 a.m. Gave resident 4 - 81 mg chewable ASA (aspirin). AMR arrived at approximately 3:10a.m. resident unresponsive. CPR started, EMT's called. Family called. EMT's pronounced resident deceased at 3:30a.m. Doctor called and informed. Family informed." In an interview with Director of Nurses (DNS) she stated she had been alerted the morning of [DATE] when she came to work there was concern because the LN called a non-urgent medical response service and had not initially called 911 to send Resident #1 to the hospital when experiencing SOB and chest pain. Resident #1 had expired. DNS began an investigation. During the investigation by the DNS, it was noted the Resident actually came from his room between 2:30 and 2:40 a.m. to state he had chest pain and difficulty breathing. The call to the physician was at 3:05 a.m. The call to AMR was at 3:09a.m. Per AMR records they directed the nurse to give the resident 4 baby aspirin. The resident was unresponsive when the AMR crew arrived and he was coded (CPR was performed) for approximately ,[DATE] minutes before the Emergency Medical Response Team pronounced him deceased at 3:45a.m. Documented interview between the DNS and LN F concerning the incident involving Resident #1 on [DATE] indicated her assessment was not completely documented and was incomplete. She stated she should have called 911. She denied completing vital signs or checking on the resident every 15 minutes, she denied having someone stay with the resident. In an interview with LN F she stated she was responsible for Resident #1 the night of [DATE] into the morning of [DATE]. She related the events of the night as written above. LN F stated she competed an assessment and vital signs. She stated the resident was checked on by herself or an aide at least every 10 minutes. When asked why she did not document her assessment or call 911 she replied, "I did not believe it was cardiac." She said she called AMR and they did not suggest she call 911 but stated they were in the area and would be there within 10 minutes. She stated she should have documented her assessment and she should have called 911. She stated she did not use the tools available to her to make critical decisions. She had no explanation to why she did not recognize the situation as emergent, except she was tired and she did not know the resident. In interviews with the Director of Nurses and the Assistant Director of Nurses, they stated LN F should have followed facility procedures when dealing with an acute change of condition. LN F was suspended during the investigation and had been brought back and provided 1:1 education on following procedures, making critical decisions and recognizing an acute change in condition. LN F will work on shifts where she can have assistance and supervision in making critical decisions.

Based on document review and interview the facility failed to ensure professional standards of practice were followed for 1 of 10 (#2) residents, reviewed for orders, and for 1 of 10 (#1) reviewed for accuracy of documentation and assessment. These failures placed the residents at risk for delay in treatment and worsening condition. Findings include: All interviews took place [DATE] The Fundamentals of Nursing, 7th Edition, (Taylor, Lillis & LeMone) documented, "Nurses are legally responsible for carrying out the orders of the physician in charge of a patient." The Fundamentals of Nursing, 7th Edition, (Taylor, Lillis & LeMone) p. 327 stated, "documentation should be consistent with professional and agency standards; complete, accurate, concise, factual, organized, and timely; legally prudent; and confidential." 1) Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. He was assessed by the facility as being alert and oriented and able to make his needs known. Documentation in the Progress Notes dated [DATE] stated, "At (approximately) 2:00 a.m. resident came out into hall complained of SOB (shortness of breath) and chest pain. O2 (oxygen) saturation 77% on room air. On O2 at 2liters (O2 saturation) went to ,[DATE]%. Resident wished to go to hospital. Doctor (called) at approximately 2:30a.m., Doctor agreed. Called AMR (non-urgent response) at approximately 2:45 a.m. Gave resident 4 - 81mg chewable ASA (aspirin). AMR arrived at approximately 3:10a.m. resident unresponsive. CPR started, EMT's called. Family called. EMT's pronounced resident deceased at 3:30a.m. Doctor called and informed. Family informed." Documented interview between the DNS and the LN caring for Resident #1 on [DATE] indicated her assessment was not completely documented and was incomplete. She stated she should have called 911. She denied completing vital signs or checking on the resident every 15minutes, she denied having someone stay with the resident and she did not complete the Situation Background Assessment Recommendation (SBAR) communication tool as required by facility policy. In separate interviews with LNs A, C, D, and E they stated they would document the assessment completely and accurately. They stated they would use the SBAR communication tool to assist them in preparing their call to the physician. They also stated if a person was complaining of SOB and chest pain and their O2 saturation was low (below 90%) even on oxygen they would call 911 to send the resident to the hospital. 2) Resident #2 was alert and oriented and able to make her needs known. On [DATE] an order was received to obtain a urine sample to rule out UTI. Resident was incontinent so a straight cath (insert tube into bladder to obtain urine) had been ordered. There was no evidence the order had been carried out. No lab report was found. Refer to F157

Based on record review and interview, the facility failed to ensure an allegation of abuse and neglect for 1 of 10 residents (#1) was thoroughly investigated. This failure placed residents at risk for future abuse and neglect. Findings include: All interviews took place ,[DATE] or [DATE] Resident #1 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. He had recently had a [MEDICAL CONDITION] infarction (MI or [MEDICAL CONDITION]). He was assessed by the facility as being alert and oriented and able to make his needs known. Documentation in the Progress Notes dated [DATE] stated, "At (approximately) 2:00 a.m. resident came out into hall complained of SOB (shortness of breath) and chest pain. O2 (oxygen) saturation 77% on room air. On O2 at 2 liters (O2 saturation) went to ,[DATE]%. Resident wished to go to hospital. Doctor (called) at approximately 2:30a.m., Doctor agreed. Called AMR (non-urgent response) at approximately 2:45 a.m. Gave resident 4 - 81 mg chewable ASA (aspirin). AMR arrived at approximately 3:10a.m. resident unresponsive. CPR started, EMT's called. Family called. EMT's pronounced resident deceased at 3:30a.m. Doctor called and informed. Family informed." In an interview with the Director of Nurses (DNS) she stated she had been alerted the morning of [DATE] when she came to work there was concern from AMR because the LN called a non-urgent medical response service and had not initially called 911 to send Resident #1 to the hospital when he was experiencing SOB and chest pain. Resident #1 had expired. DNS began an investigation. In the summary of investigation outcome provided by the facility it stated, "Based off initial nurse documentation and subsequent interviews, resident condition was pointing to a significant change, showing s/sx (signs and symptoms) of cardiac vs. respiratory distress. Facility protocols and residents code status would indicate that such symptoms would be cause for 911 transfer to ER for evaluation. Nurse failed to utilize appropriate transfer method." Review of the incident review provided by the facility indicated an interview was done with two different certified nursing assistants (NACs) to ascertain the time the event took place. One of the NACs reportedly stated she obtained "vital signs for the nurse and did not notice resident to be sweating and denied him complaining of N/V (nausea and vomiting)." The 2nd NAC interviewed appeared to verify the time of the incident. There was no indication the facility questioned the NAC who allegedly obtained the vital signs what she did with the documentation or where they were documented. There was no indication the NACs were asked if they stayed with the resident, monitored the resident or if someone was with the resident when AMR arrived. There were no written statements by the NACs to be reviewed. There was no evidence the facility interviewed the other LN who was working during the shift when Resident #1 expired, even though LN F stated she had conferred with the other LN. The investigation did not show evidence staff working that night when Resident #1 expired were interviewed and asked questions regarding the condition of the resident, what were the vital signs or how often they were obtained, where were they recorded, who stayed with the resident, how long was he unresponsive, etc. The facility did not investigate what led the LN to her decisions to include why a non-emergent transport service was summoned instead of the Emergency Medical Response Team. Why did she not recognize the signs and symptoms of classic cardiac distress in a resident with a history of [MEDICAL CONDITION]. The investigation did not include why the LN did not follow the facility protocol. The facility concluded, "abuse ruled out at this time. There was no willful intent to harm. Aspirin was given at the direction of emergency personal per the ALS (advanced life support) protocols." There was nothing to indicate how the facility arrived at their conclusion. The facility investigation of an unexpected death relayed some of the events surrounding the death of this resident but failed to get detailed information regarding why staff did not immediately call 911 for a resident with a history of [MEDICAL CONDITION] who was complaining of chest pain. There was no evidence of vital signs being taken and there was no continuous monitoring of the resident until transport arrived. In addition it was known that the primary LN involved with the original assessment of the event was working her first night shift which was not her regular schedule. The facility failed to review if there were extenuating circumstances being new to the night shift routine that had an impact on the performance and decisions that were made by the LN. Without a thorough review of why things happened as they did, the facility would be unsure of what steps to take to effectively prevent recurrence of similar future incidents. .

Based on observation, interview and record reviews, the facility failed to ensure that their infection control interventions were consistently put into practice when there was an outbreak of intestinal type virus spreading through the facility infecting residents and staff alike. Observations of failure staff 's failure to wash hands when exiting rooms of residents who were symptomatic; failure to disinfect equipment used on infected before use on non infected residents; failure to have sufficient supplies needed to protect staff when working with infected residents; failure to have proper signage on all doors that visitors use to come and go from the facility alerting them of the intestinal virus outbreak; and interviews with visitors who were an aware of the intestinal outbreak and who took no precautions to protect themselves or others created an environment where the intestinal virus could spread and cause residents harm. On entry to the facility on [DATE], thirteen residents and two staff members were symptomatic of the intestinal outbreaks. The failure of the facility infection control system to be consistently implemented by all staff in the presence of an intestinal viral outbreak demonstrated immediate jeopardy situations. A safety plan was obtained 12/14/11. The facility was notified on 12/16/11 that these failed practices were found to be immediate jeopardy. Findings include: 12/14/11 at 10:15 a.m., the survey team entered the facility. The receptionist notified the survey team to read and sign an article describing a virus in the building. The Administrator met the survey team and stated his concerns about the survey team spreading the flu virus around the building. The Administrator was asked to clarify what symptoms were being experienced with the "flu". The Administrator said it was "vomiting and diarrhea." The Administrator stated the facility had cancelled activities and residents were being kept in their rooms to prevent the spread of infection. He indicated staff were staying in the units assigned to them, to prevent the spread of the virus. The Administrator indicated the majority of the infected residents were in unit A, and there were a few cases on Unit B. Unit A was toured at 10:27 a.m. A folding chair or metal cart was observed outside ten rooms with gloves, masks, and/or yellow disposable gowns. Five of the 10 rooms identified isolation rooms did not have the disposable yellow gowns. 12/14/11 at 10:29 a.m., NA G was observed in resident number # 136 and 131's room which was identified as being in isolation. Personal Protective equipment in isolation cart was outside the room for use. NA G was observed not wearing any gown, mask or gloves. Dirty linens and a soiled bed pan were in a garbage bag on the floor. Staff A was observed as she removed the garbage bags from the floor with her ungloved left hand, and [MEDICATION NAME] the bed linens with her ungloved right hand while holding the dirtied linens/bed pan. She took the dirty linens across the hall and discarded them. Staff A went from the dirty utility room, back into room with no protective gear, touched the resident then used the alcohol based hand rub (ABHR) as she left the room. Resident #64 room was observed at 10:31 a.m., with isolation equipment outside the door for use. The garbage bin in the room was overflowing with a gown observed partially in the can and partially on the floor. At 10:33 a.m.,RCM B Resident Care Manager (RCM),was interviewed. She was asked to clarify what the protective isolation gear outside the residents rooms meant. She stated the gloves and gowns outside the residents rooms indicated those residents were in isolation and was currently experiencing symptoms of nausea, vomiting and diarrhea. She stated it was not the flu but a [MEDICATION NAME] (stomach and intestinal) virus. She indicated the facility had a list of all the residents who were having the illness. Rooms A1, 3, 5,7,10,12,16,26, 28 and 29 were identified by the RCM B being in isolation on Unit A. At 10:15 a.m., in the entrance meeting, the Administrator informed the survey team staff were being kept on a specific unit and requested the survey team members not cross between the different units while doing the survey. At 10:42 a.m., the Rehabilitation Director, was interviewed. She stated all therapies in the facility gym were on hold. A resident was observed sitting on a mat, working with a therapist in the gym. The rehabilitation director stated all residents were being treated in their rooms with the exception of outpatient therapies. She clarified the client in the gym was an outpatient. The Rehab director indicated the outpatient therapy clients entered the building at a separate entrance. There was no signage or indication to outpatient client to indicated client that the facility is experiencing a gastroentro virus outbreak. At 12:08 p.m., NA G was observed taking the mechanical lift after transferring Resident #2 directly into Resident #8 and used the mechanical lift for Resident #8. NA G was interviewed at 12:13 p.m., after using the mechanical lift for transfer of Resident #8. NA G stated "I was just there with Resident #2, and came in here (pointing to the resident room) and got up Resident #8." The shared mechanical lift was observed not being cleaned as it went from a designated isolation room to a non-isolated room. When Staff A was asked what should be done to shared equipment when it was used for infected resident and prior using it for another resident, she stated "I just take it from one room to another, nothing special is done to it." When the Director of Nursing was interviewed at 3: 34 p.m., about the cleaning policy of resident shared equipment, mechanical lifts, she stated it is "to be cleaned with one of those bleach wipes or disinfectant wipes in between each resident use " At 12:18 pm lunch trays were observed being delivered on unit A. Staff members from Nursing, housekeeping, the business office, activities and the unit clerk were delivering lunch trays. The same staff members were observed delivering trays in unit B at 12:45 p.m. At 12:19 p.m., RCM B was observed passing a lunch tray. She took a room tray into resident # 1room (an Isolation room) not wearing gown, gloves or mask precautions. She placed the tray in front of the resident in the room and asked the resident if she wanted a clothing protector. RCM B was observed leaving the room without washing her hands or using the ABHR. She returned to resident # 1 room at 12:23 p.m., and entered the room wearing no isolation equipment, and did not wash her hands or use the ABHR. She put the clothing protector on the resident in the first bed, then was observed not washing her hands, or using ABHR, and went to the resident in Bed 2 and assisted her to eat. Facility staff who were distributing the lunch trays began discussing that Resident # 88's tray was delivered to the wrong room,(Resident # 1) who was in isolation. At 12: 23 p.m., Activity Director (AD) took the lunch tray that was on Resident #1's over -bed table out of the room across the hall to Resident # 118(from isolation room to non isolation room)and placed it in front of the resident while not wearing isolation equipment or washing hands/using ABHR. Maintenance Director (MD) was observed at 12:23 p.m, delivering a tray into Resident #132's room (isolation room)without a gown, gloves or a mask. When he left the room he used ABHR. MD obtained a second lunch tray from cart and went back into the designated isolation room to deliver the lunch tray. No precautions of hand washing or ABHR were used before he preceded to delivery another tray to another resident in a different room. At 12:24 p.m., NA G was observed taking a lunch tray into isolation room Resident #55 not wearing a gown, mask or gloves. NA G did not wash her hands or use ABHR after or before entering the room. At 12:34 p.m., Resident #3 came down the hallway and announced she was back from the beauty shop and was ready to have her lunch. An overhead announcement was heard at 12:37 p.m., that a B wing resident was ready to be transferred back to her room from the beauty shop. At 12:40 p.m., the beauty shop which was in a common area, was observed with a resident awaiting services, and a staff person identified herself as the beautician. The beautician was interviewed at 12:41 p.m. She stated she just finished with Resident #3 and the B wing resident. The beautician stated if she knew of any resident who had a virus, she would have them wear a mask. At 12:47 p.m., a gentleman was observed using a side entrance to Unit A. He indicated he was the son of Resident #61. He stated his mother called him because she was distressed because she had been very ill with a headache, nausea, vomiting and diarrhea. She asked him to come to the facility because she was "very upset and having some serious health problems and no one here is listening to her " and "she is worried as she keeps getting her usual meds, but nothing else is being done." Upon further observation, six additional visitors came through that entrance where there was no posted notification of the infectious outbreak. At 3:28 p.m., the DNS and Administrator were interviewed. The DNS stated the first call to notify Public Health of the facility illness was made Tuesday 12/13/11 and a voicemail was left. The DNS stated she called again 12/14/11 and spoke with the public health nurse (PHN) approximately 7:30 a.m., and was directed by the PHN to use log in forms, culture one stool sample, notify the facility Medical Director and let the two infection control nurses at both hospitals know about the facility illness. The DNS stated she talked to the Medical director twice a day. The Administrator and DNS stated they were " holding voluntarily all admissions, except for 3 residents who left the facility, were admitted to the hospital, and now returning." At 3:34 pm the DNS was asked to clarify what the facility's " isolation" precautions were. She stated " it's actually symptomatic contact precautions with mask, gloves, and gown that are to be worn with direct contact" and "shared equipment is cleaned in between use with bleach wipes." She was asked to clarify who in the facility was ensuring those precautions were being followed. She stated the " RCM's are supposed to be watching that precautions are being followed." At 3:51 p.m., yellow gowns were observed tied in a garbage bag tucked into the hand railing by isolation room of Resident #55. LN E was asked to explains what was in the bags. He stated " um, that is a good question " and called to NA I. NA I stated "it's NA J's way of securing them to use later". Both were unable to state how they knew if these gowns were clean or dirty. NA I said "I'll get rid of them". The surveyor shared the observations of several rooms with no gowns but other equipment gloves and masks with NA I who stated "we are running out of gowns really fast, we really don't have enough stuff." The following rooms were observed at 3:53 p.m., as having no isolation gowns: Room # A 3, 7, 10, 16, and 21. On 12/15/11 at 12:00 p.m., an interview with persons at the local health departments (PHN) reported receiving a call from the infection control nurse (ICN) from the facility on 12/14/11 at approximately 12:00 p.m. The ICN reported facility residents started getting sick on 12/11/11. The ICN reported on 12/14/11 that the facility identified 13 residents and two staff who were sick. When questioned by the health department staff about preventative measures, the ICN stated the facility had reported the outbreak to the state and preventative measures were implemented, including suspension of admissions. The ICN had reported the outbreak to the state at 10:24 a.m., on 12/14/11 ten minutes after the survey team entered the facility. The facility had not reported the outbreak to the state or the health department for 48 hours after it was identified. A safety plan was requested from the facility on 12/14/11 at 5:00 p.m., and by the end of the survey on 12/23/11, the facility had put sufficient steps in place to mitigate the immediate risk to residents.