Every finding on record at Rainier Rehabilitation

Based on interview and record review, the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASRR, a mental health screening tool) assessment was obtained prior to admission and was completed timely for 1 of 6 sample residents (Residents 49) reviewed for PASRRs or unnecessary medication use. This failure placed the resident at risk for unidentified mental health care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, PASRR screening for Mental Disorder/ Intellectual Disability, dated 01/22/2025 showed, The PASRR, process requires all individuals be screened for possible serious mental disorders or intellectual disabilities and related conditions. The initial pre-screening (PASRR level I) should be completed prior to admission to facility. A negative Level I requires no further action. Review showed, A positive Level I Screen (PASRR Indicates that individual requires a PASRR Level II Referral) necessitates an in-depth evaluation of the individual by the state-designated authority (PASRR Level II) which must be conducted prior to admission to a nursing facility OR upon identification that the individual may need a level II PASRR Referral while at the Nursing Facility. Review of the electronic health record (EHR) showed Resident 49 admitted to the facility on [DATE] with diagnoses to include post-traumatic stress disorder (PTSD, a mental health condition caused by an extremely stressful or terrifying event), cognitive (relating to the mental process involved in knowing, learning, and understanding things) communication deficit, and depression. Resident 49 was able to make needs known. Review of the level I PASRR form, dated 07/22/2025, showed Resident 49 was a current nursing facility resident that was admitted on [DATE] and had serious mental illness indicators marked on the form for PTSD and mood disorders. Review showed Resident 49 required a level II evaluation referral for their serious mental illnesses. During an interview on 08/11/2025 at 1:08 PM, Staff G, Social Services Director/Admissions Coordinator (SSD/AC), stated Resident 49 was admitted to the facility on [DATE] and did not admit to the facility with a level I PASRR completed. Staff G stated they completed a level I PASRR for Resident 49 on 07/22/2025 and was completed timely because they had completed it within 24 hours of admission. During an interview on 08/11/2025 at 1:25 PM, Staff A, Administrator, stated PASRRs were to be obtained prior to admission and/or if inaccurate they were to be completed on the date of admission. Staff A stated Resident 49's level I PASRR did not meet expectations because it should have been completed on 07/21/2025 (on admission). Reference WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview and record review the facility failed to obtain and/or ensure physician orders were followed for 1 of 24 sampled residents (Residents 47) reviewed for vision care related to medication administration. This failure placed the resident at risk for medical complications, substandard quality of care and unmet care needsFindings included .According to [NAME], Duell & [NAME], Clinical Nursing Skills, 6th Edition, page 4, paragraph Nurse Practice Act identified skills and functions that professional nurses perform in daily practice included, in part, to administer treatments per physician's orders. The Washington State Nurse Practice Act, WAC 246-840-710(2)(d), states nurses violate standards of practice by, Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards. Review of a document titled, Medication Administration / Standards and Principles - Eye drops, dated 04/2016, showed medications were to be accurately prepared, administered and documented per provider's order. Resident 47Review of Resident 47's quarterly minimum data set (MDS, a required assessment tool), dated 05/17/2025, showed Resident 47 admitted on [DATE] with multiple health conditions to include traumatic brain injury, respiratory failure, malnutrition, and depression. Review of the electronic health record (EHR) showed Resident 47 had visual impairment and was able to make their needs known. Review of Resident 47's current focus care plan, multiple dates, showed the resident was at risk for impaired visual function. Interventions included for licensed nurses (LNs) to administer medication as ordered by the provider. Review of Resident 47's medication administration record (MAR), dated August 2025, showed a provider's order dated 12/17/2024 for LNs to administer multiple ophthalmic (eye) medications to include carboxymethylcellulose sodium ophthalmic solution (an eye drop treatment that acts as a lubricant for dry eyes), two drops in the residents left eye four times a day and wait five minutes before the administration of another eye drop. An additional ophthalmic medication was ordered on 07/01/2025 for the LN to administer erythromycin ophthalmic ointment in the left eye four times a day and not to apply at the same time as the carboxymethylcellulose drops and to separate them (eye drop) administration by 60 minutes. Resident 47's MARs for the ordered eyes drops did not show the eye drops being held as ordered for 60 minutes between each eye drop administration. Observation and interview on 08/11/2025 at 9:18 AM showed Resident 47's left eye with small amount of secretion. Resident 47 stated the LNs administered their eye medications all at once throughout the day. During an interview on 08/11/2025 at 9:18 AM, Staff F, Licensed Practical Nurse/Unit Supervisor (LPN/US) stated the LNs were supposed to space out Resident 47s eye drops as per the providers' orders. During an interview on 08/11/2025 at 9:24 AM, Staff B, Director of Nursing Service, stated Resident 47 was being administered the eye drops by the LNs at the same time despite a provider's order to hold 60 minutes between each of eye drop medication. Staff B stated it was the expectation for the LNs to administer the eye drops as per the providers' orders. Reference WAC 388-97-1620(2)(b)(i)(ii), (6)(b)(i)

Based on observation, interview, and record review the facility failed to consistently implement and provide splints (device used to support, protect and immobilize body parts) for 1 of 4 sampled residents (Resident 2) reviewed for position/mobility. This failure placed the resident at risk for worsening contractures (condition when joint becomes permanently fixed in a bent or short-ended position due to the shortening of muscle, tendon, or skin), increased difficulties with dressing, grooming and decreased quality of life Findings included.Review of the electronic health record (EHR) showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include cerebral palsy (congenital or before birth disorder of brain with abnormal movement, muscle tone or posture), chronic respiratory failure and quadriplegia (paralysis that affects the ability to voluntarily move the upper and lower body). Review of the annual minimum data set (MDS, an assessment tool), dated 06/18/2025, showed Resident 2 could not communicate and had severely impaired decision-making skills. The MDS showed Resident 2 was dependent on staff for all the activities of daily living including nutrition and showed Resident 2 was using a splint or brace assistance for seven days of the week. Review of the care plan with focus area Restorative, dated 04/17/2017, showed Resident 2 was to have the following interventions Apply splints to Bilateral hands and elbows, splints alternating days on right and left side, Wear time up to 4 hours. Application time approx. 15 min [minutes] up to 7 days a week as tolerated by resident. Observation on 08/09/2025 at 10:35 AM, showed Resident 2 laid in bed, in a facility gown, with both elbows, wrists and fingers contracted without splints in place. Observation on 08/10/2025 at 10:30 AM, 12:10 PM and 1:44 PM showed Resident 2 in their wheelchair with no splints in place. Observation on 08/11/2025 9:23 AM and 10:30 AM showed Resident 2 in bed in a facility gown and hands folded without splints in place. Review of the EHR showed Resident 2 had documentation that showed splints application applied on 08/09/2025 at 10:14AM, 08/10/2025 at 10:00AM and 08/11/2025 at 9:19AM. During an interview on 08/11/2025 at 10:54 AM, Staff D, Restorative Nursing Assistant, stated they applied the splints and then signed for them. Staff D pulled the splints from the closet and applied them to Resident 2. Staff D stated the splints were to stay on for 6 hours. During an interview on 08/11/2025 at 10:58 AM, Staff C, Assessment MDS Nurse, stated the facility had two restorative nursing assistants. Staff C stated Resident 2 may have had a shower and restorative staff were to apply the splints back on. Staff C provided paper documentation that showed staff were signing for splints, and Resident 2 usually had their splints taken off between 10:20 AM and 12:15 AM from 08/01/2025 through 08/08/2025.Review of the paper splint documentation showed Resident 2 had nursing remove the splints on 08/09/2025 and on 08/10/2025 the time for the splint removal was unclear and the time was scribbled over and showed nursing written next to it. During an interview on 08/11/2025 at 12:51 PM, Staff E, Certified Nursing Assistant, stated they showered Resident 2 before 9:00 AM, and asked restorative staff to place the splints back on. Reference WAC 388-97-1060(1)

Based on observation and interview, the facility failed to use proper Personal Protective Equipment (PPE, equipment worn to minimize exposure to infectious diseases/illnesses) and follow hand hygiene practices to transport used gowns from resident rooms with Enhanced Barrier Precautions in 1 of 3 sampled Halls (100 Hall) when reviewed for Infection Control. This failure placed residents at risk for transmission of communicable diseases, hospitalization and diminished quality of life.Findings included. Observation on 08/11/2025 at 10:01 AM showed Staff H, Housekeeping Supervisor, in room [ROOM NUMBER] (a room with an Enhanced Barrier Precaution sign) transferring used gowns from the receptacle in the room to a large plastic bag on the floor. Staff H was not wearing any gloves; they proceeded to tie the plastic bag and threw it in a cart in the hallway. No hand hygiene was observed prior to Staff H pushing the cart to the next room. During an interview on 08/12/2025 at 9:45 AM Staff H, Housekeeping Supervisor, stated when the plastic bag was overfull in the receptacle, they would transfer all the gowns to another bag and refit the current bag in the receptacle. Staff H stated the expectation was to wear gloves; however, they did not have a pair in their pocket at the time. During an interview on 08/12/2025 at 11:45 AM, Staff A, Administrator, stated the expectation was staff would wear gloves when handling dirty gowns or linen. Reference WAC 388-97-1320(1)(a)

Based on record review and interview, the facility failed to provide a written bed hold notice at the time of transfer to the hospital for 2 of 3 sampled residents (Residents 109 and 56) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Findings included . Resident 109Review of the electronic health record (EHR) showed Resident 109's current admission to the facility was on 10/03/2024 with diagnoses that included kidney failure, diabetes (too much sugar in the blood) and chronic pain. Resident 109 was hospitalized on [DATE] with readmission to the facility on [DATE]. Resident 109 was hospitalized on [DATE] with readmission to the facility on [DATE]. There was no documentation showing the bed hold notice was provided in writing to the resident/resident representative. Resident 56Review of the EHR showed Resident 56 admitted to the facility on [DATE] with diagnoses that included diabetes and chronic obstructive pulmonary disease (COPD, an ongoing lung condition caused by damage to the lungs. Resident 56 was hospitalized with Return Anticipated on 05/28/2025 and readmitted to the facility on [DATE]. There was no documentation showing the bed hold notice was provided in writing to the resident/resident representative. During an interview on 08/11/2025 at 2:41 PM, Staff B, Director of Nursing Services, stated the facility did not provide residents with a written copy of bed holds at the time of transfer only upon admission. During an interview on 08/11/2025 at 2:43 PM, Staff A, Administrator, stated bed holds were communicated verbally, and the facility did not provide residents with a written copy. Reference WAC 388-91-0120(4).

Based on interview and record review, the facility failed to provide the necessary care and service following a post-surgical wound dehiscence (the incision, a cut made during surgery reopens) for 1 of 3 residents (Resident 1) reviewed for post-surgical care. This failure placed the resident at risk of not getting the appropriate treatment, worsening of the surgical wound that would require surgical repair, hospitalization , medical complications, and a diminished quality of life. Findings included . Review of Resident 1's quarterly Minimum Data Set (MDS, a required assessment tool) dated 11/07/2022, showed that Resident 1 admitted on [DATE] with diagnoses to include surgical repair of a left leg fracture and bacterial endocarditis (infection of the inner lining of the heart caused by bacteria entering the bloodstream). Review of Resident 1's progress note dated 08/01/2022 at 1:31 PM showed that Resident 1 arrived at the facility from the hospital status post-surgical repair of a leg fracture without evidence of complication. According to the progress note, Resident 1 had healing incisions to the left lower leg and left upper chest and a small open area covered with foam dressing on the back of the left lower leg. Review of the physician's note dated 08/02/2022 at 10:55 AM showed that Resident 1 was to be followed-up by orthopedics (branch of surgery dealing with conditions involving the musculoskeletal system). Review of the orthopedic consult report dated 09/08/2022 showed that Resident 1 had a follow-up consult with orthopedics and no surgical incision issues were noted. Review of Resident 1's progress note dated 09/17/2022 at 10:36 PM showed that Resident 1 asked the nursing assistant to request from the nurse a band-aid to cover the left lower leg incision. According to the progress note, the nurse assessed Resident 1's left lower leg incision and noted a pinpoint size open area with drainage. Review of the change in condition note dated 09/17/2022 at 11:41 PM showed that the facility notified the primary care clinician and Resident 1's family member regarding the small open area to the left lower leg incision. Review of the wound care service consult note dated 09/19/2022 showed that the in-house wound care service evaluated the dehisced wound and recommended to apply iodoform packing (a type of gauze packing with disinfecting properties) on the wound base and cover with dry dressing. The wound treatment was to be done daily and as needed for accidental removal, saturation or soiling. Review of the facility nurse practitioner's (NP) note dated 09/20/2022 showed that the plan was to consult orthopedics and Resident 1's infectious disease provider for recommendations. Review of Resident 1's orthopedic consult report dated 10/03/2022 showed that the reason for visit was for a wound check. The report showed Resident 1 with new drainage to the left leg incision for two weeks. The report indicated that the resident was being followed by the physician at the facility and the facility packed Resident 1's wound. The report further showed that orthopedics was not notified. The orthopedic surgeon recommended irrigation and debridement (removal of damaged tissue) to which Resident 1 agreed to proceed. In a phone interview on 11/28/2022 at 5:05 PM, Collateral Contact (CC) stated that orthopedics was not notified of Resident 1's wound dehiscence and the treatment recommended by the facility's wound care service. According to CC, orthopedics knew on 10/03/2022 during the consult visit. In a phone interview on 12/06/2022 at 11:48 AM, Staff C, Nurse Practitioner (NP), stated that on 09/20/2022 she ordered for a consult with orthopedics for Resident 1 for the wound dehiscence. According to Staff C, NP, the unit manager arranged Resident 1's consult with orthopedics and the visit was set for 10/03/2022. Staff C, NP, stated that she did not directly talk to the orthopedic surgeon or the surgeon's clinical associates. In an interview on 12/07/2022 at 1:00 PM, Staff D, Resident Care Manager (RCM), stated that she spoke with the receptionist at the orthopedic office and made arrangement for Resident 1's consult, indicating that Resident 1's incision dehisced. Staff D, RCM, stated that she did not speak directly to the orthopedic surgeon or other orthopedic clinicians at the orthopedic clinic. Review of Resident 1's electronic health records from 09/17/2022 through 10/03/2022 showed no documentation that the facility notified Resident 1's orthopedic surgeon or the surgeon's clinical associates about the dehiscence and the treatment recommended by the in-house wound care service. Review of Resident 1's hospital records dated 10/04/2022 through 10/08/2022, showed that Resident 1 admitted to the hospital on 10/04/2022 for irrigation and debridement of the dehisced wound. The hospital records further showed that Resident 1 discharged back to the facility on [DATE] with the dehisced wound sutured close and the resident placed on intravenous antibiotic therapy. In an interview on 12/07/2022 at 1:39 PM, Staff B, Director of Nursing Services, stated that the expectation from the facility staff was to notify directly the clinical professional providing the necessary care and service to the resident, of changes in the resident's condition and treatment, and to document in the resident's records that such notification was made. Reference WAC 388-97-1060(1)(3)(b)

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for six of 28 sampled residents (Residents 26, 5, 20, 44, 136 and 31) reviewed. The facility nurses' failure to follow and/or clarify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Please refer to F756 for additional information for Resident 136. Review of the facility's pharmacy's policy and procedure titled, 6.0 General Dose Preparation and Medication Administration, revision dated 01/01/2022 showed that prior to administration of medication, facility staff should take all measures required by facility policy and applicable law to include checking for allergies to medications. RESIDENT 26 Record review showed a 12/08/2021 PO for [MEDICATION(S)] (a pain medication) 5 milligrams (mg) via gastric tube, every six hours as needed (PRN) for a pain level of 4-7, on a scale to 10 (4-7/10). Review of the January and February 2022 Medication Administration Records (MARs) showed the resident was administered [MEDICATION(S)] 5 mg for a pain level of 8 (outside of the ordered parameters) 10 times in January and 5 times in February 2022. During an interview on 03/02/2022 at 12:10 PM, Staff B, Director of Nursing Services (DNS), confirmed in January and February 2022 facility nurses administered [MEDICATION(S)] 15 times outside of the physician ordered parameters. Staff B, DNS, reported the Resident 26 did not have a PRN pain medication order to treat a pain level of 8-10/10 and stated the parameters for the administration of the [MEDICATION(S)] should have been clarified. Review of Resident 26's current POs showed 02/11/2022 orders for: acetaminophen 650 mg every six hours PRN, for mild or moderate pain, 1-7/10; and [MEDICATION(S)] 5 mg every six hours PRN, for severe pain 8-10/10. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/02/2022 at 12:23 PM, Staff B, DNS, confirmed acetaminophen, not [MEDICATION(S)], should have been administered for reported pain level of 1-7/10. RESIDENT 20 Record review showed a 11/22/2021 PO for [MEDICATION(S)] (blood pressure medication) daily, with direction to hold the medication if the resident's systolic blood pressure (SBP) was less than 110, or heart rate (HR) was less than 60. According to the January 2022 MAR, on 01/02/2022 the nurse failed to hold the resident's [MEDICATION(S)], when the resident's HR was 58 and administered the [MEDICATION(S)] when the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 03/02/2022 at 11:17 AM, Staff B, DNS, acknowledged the nurse failed to hold the medication for a HR of 58, as ordered. RESIDENT 5 Record review showed the resident had two 02/04/2021 PO for water flushes as follows: water flush at 60 ml/hr per feeding tube (PFT) while on pump (20 hours a day) for a total of 1200 ml/24 hours. The order included direction to nurses to document the total water infused at time of disconnect; and water flush at 70 ml/hr PFT while on pump (20 hours a day) for a total of 1400 ml/24 hours. This order also included direction to nurses to document the total water infused at time of disconnect. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review also showed that the day shift nurses signed daily, for 24 consecutive days, that they verified the resident's water flushes were set and infusing at 60 ml/hr as ordered. In an interview on 03/04/2022 at 9:08 AM, Staff B, DNS, stated nursing should have identified the duplicate and conflicting flush orders, and clarified the order. RESIDENT 44 Review of the February 2022 Treatment Administration Record (TAR) showed a 02/23/2022 order that read Right arterial ulcer, paint with [MEDICATION(S)] every day shift for wound healing. The order did not identify the location of the arterial ulcer that required the treatment. During an interview on 03/04/2021 at 10:13 AM, Staff B, DNS, stated that the location of the arterial ulcer should be included in the order and that the order needed to be clarified. RESIDENT 136 During an interview on 03/01/2022 at 7:35 AM, when a request was made to observe the administration of Resident 136's 10:00 AM dose of intravenous (IV) [MEDICATION(S)] (an antibiotic), Staff EE, Licensed Practical Nurse (LPN), reported the 10:00 AM dose of [MEDICATION(S)] had already been administered. Staff EE, LPN, acknowledged the medication was not administered at the right time, in accordance with the resident's PO. Review of Resident 136's admission Minimum Data Set (MDS, a required assessment tool), dated 02/12/2022, showed that the resident admitted to the facility on [DATE]. Review of the admission record on 02/25/2022, showed that Resident 136 had an allergy to the medication [MEDICATION(S)], documented on 02/09/2022. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a copy of Resident 136's pharmacy document titled, Consultation Report, dated 02/10/2022, of the pharmacist recommendation related to Resident 136's allergy to the medication [MEDICATION(S)] that was prescribed, showed that the physician had signed the document on 02/11/2022. It further showed that the physician had handwritten on the document, OK to give. This was signed and documented by the physician after Resident 136 was provided [MEDICATION(S)] on 02/10/2022. During an interview on 03/01/2022 at 11:37 AM, Staff E, Registered Nurse/Resident Care Manager (RN/RCM), stated that Resident 136 was admitted with an allergy to the medication [MEDICATION(S)]. Additionally, Staff E, RN/RCM, stated that Resident 136's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff E, RN/RCM, further stated that the nurse should have consulted with the physician and documented prior to providing [MEDICATION(S)] to Resident 136. During an interview on 03/01/2022 at 12:24 PM, Staff B, DNS, stated that Resident 136's order for [MEDICATION(S)] should have been clarified with the physician. Additionally, Staff B, DNS, stated that clarification was needed to know if [MEDICATION(S)] was an allergy or an intolerance issue and should have been documented prior to providing the medication to Resident 136. RESIDENT 31 A review of the 01/18/2022 Admission 5-day MDS showed Resident 31 was cognitively intact, had clear speech, could make self understood and understand others. Resident 31 was assessed to have chronic pain and used opioid (narcotic) medication for seven days during the assessment period. In an interview on 03/01/2022 at 2:14 PM, Resident 31 stated their pain was not managed and the current pain plan was not working. Resident 31 stated they used pain medications including a [MEDICATION(S)] patch, [MEDICATION(S)], acetaminophen, and a pain gel. Resident 31 stated they had different pain locations, including lung pain, shoulder pain, leg pain, back pain and all over (generalized pain). Resident 31 stated, I just want to be comfortable until I die, and my pain cannot be managed. A review of Resident 31's 02/02/2022 PO showed [MEDICATION(S)] 1% gel with directions to apply to affected areas topically four times a day for pain in left shoulder, lower back, and right lateral thigh. The instructions did not state how much gel to apply to each area of pain. In an interview on 03/03/2022 at 12:45 PM, Staff O, RN, stated the [MEDICATION(S)] was administered to Resident 31 that morning to the left shoulder, low back, and right thigh. When asked how much gel was applied, Staff O, RN, stated there was a ruler then said, I applied one gram. Staff O, RN, was asked if the PO said to apply one gram total or one gram to each location. Staff O, RN, reviewed the PO and stated the dose was missing from the directions and the order needed to be clarified with the physician. In an interview on 03/03/2022 at 10:11 AM, Staff B, DNS, reviewed Resident 31's PO for [MEDICATION(S)] and stated the order was incomplete and needed to be clarified to identify how much gel to apply to all three different areas. Staff B, DNS, stated two nurses reviewed every order and the missing directions should have been identified and corrected. Reference WAC 388-97-1620(2)(b), (6)(b)(i)

Based on observation and interview, the facility failed to ensure multiple food items in the dietary department were properly stored, labeled, and that expired foods were identified and discarded. The facility also failed to ensure sanitary preparation of raw foods to prevent cross-contamination. The failure to properly store, label and prepare foods, including potentially hazardous foods, placed residents at risk for consuming expired/spoiled foods and at risk of exposure to food-borne illnesses. Findings included . CENTRAL KITCHEN STORAGE An observation of food storage in a small freezer on [DATE] at 10:37 AM, showed a chocolate cake and four pie crusts undated. Staff K, Dietary Supervisor (DS), took them and placed dates on the packaging when questioned. Staff K, DS, stated the items should have been dated when moved into the small freezer. An observation of food storage in the walk-in refrigerator on [DATE] at 10:43 AM, showed a container of fresh rosemary without a date and a container labeled chili con carne with a UB (use by) date of [DATE], expired 9 days. Staff K, DS, stated, That should be thrown away and took the items out of the walk-in. An observation in the dry storage room on [DATE] at 11:03 AM, showed 8 boxes of baking soda all with expiration dates of [DATE], expired over eight months. Staff K, DS, stated the baking soda should be thrown out because it was expired. There were two large storage bins labeled dry milk with a piece of tape dated ,d+[DATE] (no year). Staff K, DS, stated the powdered milk was put into the container on [DATE] and was good for six months. Staff K, DS, stated the powdered milk container was not labeled correctly, according to the expiration date on the original package. Staff K, DS, stated the staff would not know when the milk expired, and it should be thrown away. RESIDENT PERSONAL FOOD STORAGE An observation on [DATE] at 10:55 AM with Staff K, DS, showed the resident personal food refrigerator in the treatment room contained a bowl of lemon wedges without a name/date, two glass bowls of soup labeled 323 and no date, a styrofoam container in a plastic bag with contents of soup without a name or date, and a plastic take out container marked shrimp alfredo without a name or a date. In an interview on [DATE] at 11:00 AM, Staff K, DS, stated the facility policy required food in the resident refrigerator to contain the name of the resident and the date placed in the fridge. Staff K, DS, stated the kitchen staff checks the refrigerator and throws food away that was not labeled or dated. Staff K, DS, stated these items should be thrown away and took them out of the room and discarded. FOOD PREPARATION An observation on [DATE] at 10:13 AM showed Staff K, DS, cracking eggs and separating yolks and whites using bare hands. When finished with the eggs, Staff K, DS, took a pitcher to the sink, turned on the water faucet and put water in the pitcher, turned off the faucet, grabbed a whisk and started to mix water into the bowl with egg and dry ingredients. Staff K, DS, was not observed to wash their hands after touching the raw eggs and before touching the water faucet, pitcher, or whisk. In an interview on [DATE] at 10:24 AM, Staff K, DS, confirmed they did not wash their hands after cracking the eggs and before touching the faucet with raw egg on their hands. When asked if the raw eggs cross-contaminated the faucet, Staff K, DS, stated yes. An observation on [DATE] at 11:02 AM showed Staff L, Cook, scooping from a container of powdered thickener using a measuring spoon and bare hands. Staff L, Cook, placed the measuring spoon into the container with the powder and sealed the lid. In an interview on [DATE] at 11:40 AM, Staff K, DS, opened and looked in the container of thickening powder and saw the measuring spoon. Staff K, DS, said to Staff L, Cook, You cannot leave the spoon in the powder like that. Staff K, DS, removed the spoon from the container. Reference WAC [DATE](3), -2980.

Based on observation, interview and record review, the facility failed to ensure the resident environment did not pose a safety risk to residents from water temperatures exceeding 120 degrees Fahrenheit (F- a scale of heat measurement) for 1 of 2 hot water boilers reviewed for environmental concerns. Failure to routinely monitor, record and ensure safe water temperatures in resident rooms and bathrooms placed residents at risk for injury and uncomfortable living conditions. Findings included . Observation in room 320 on 02/24/2022 at 11:25 AM showed the hot water from the bedroom sink after running for two minutes was 121.2 degrees F. Observation in room 327 on 02/24/2022 at 11:27 AM showed the hot water from the bedroom sink after running for two minutes was 120.8 degrees F. Observation in room 321 on 02/24/2022 at 11:29 AM showed the hot water from the bedroom sink after running for two minutes was 126.7 degrees F and the bathroom sink was also 126.7 degrees F. Observation and interview in room 210 on 02/24/2022 at 11:36 AM showed the hot water from the bedroom sink was 120.7 degrees F. Resident 336 stated, That one [pointing to the bathroom sink] gets hot pretty fast, if you know how to put on the cold [water], it is ok, but if you don't, it is really hot. The hot water from the bathroom sink was 131.3 degrees F. During an interview on 02/24/2022 at 12:35 PM, Staff C, Maintenance Supervisor (MS), stated the water temperatures are checked weekly on Mondays and the expected temperature range was no higher than 120 degrees. Staff C, MS, explained there are two hot water boilers and each services water to half of the resident rooms on the [NAME] hallway and one boiler services Helens hallway, the other services the Baker hallway. Observation and interview on 02/24/2022 at 12:38 PM showed Staff C, MS, checked the water temperature in the bathroom sink of room 210. Staff C, MS, stated the water temperature was 132.4 degrees F. Observation and interview on 02/24/2022 at 12:40 PM showed Staff C, MS, checked the water boiler next to room 210 and stated that boiler serviced the Helens hallway of resident rooms and showers. Staff C, MS, explained the water in the boiler was calibrated with two thermometers, one on the tank and one on the regulator. Staff C, MS, stated the boiler was set to 115 degrees F, and the thermometer was showing 120 degrees F. Staff C, MS, looked at the regulator temperature and stated it was 126 degrees F. Staff C, MS, stated if room 210 was too hot, all the other resident rooms would be too hot. Staff C, MS, stated the thermostat needed to be replaced. During an interview on 02/24/2022 at 1:09 PM, Staff A, Administrator, stated there were no water temperature monitoring logs for any resident rooms. HELENS HALL Observation on 02/24/2022 at 10:41 AM of room 306 showed a water temperature out of a bedroom sink was 124.2 degrees F. Observation on 02/24/2022 at 10:50 AM of room 309 showed water temperature out of the bathroom sink after running for two minutes was 121.4 degrees F. Review of the maintenance logs from August 2021 through February 2022 showed that three boilers had been checked for water temperatures in the units of Helens, [NAME], Baker, and an additional boiler for the Kitchen/Laundry. The document further showed that the maintenance supervisor had recorded three separate temperatures, but no room numbers were documented on the form. During an interview on 02/24/2022 at 12:36 PM, Staff C, MS, stated that he did random checks of the resident rooms but just documented one temperature on the form for each of the boilers. During an interview on 02/28/2022 at 1:07 PM, Staff A, Administrator (ADM), stated that there was no set policy for the facility to check the water temperatures; however, Staff C, MS, was to ensure that the hot water was within the state guidelines for safe water temperatures. In addition, Staff A, ADM, stated that the electronic maintenance system would dictate to the maintenance supervisor when to check the water temperatures and if there were any issues from either the staff or residents then Staff C, MS, would adjust the boilers in order to keep the water at a safe temperature. BAKER HALL Observation on 02/24/2022 at 11:05 AM in room 128 showed water temperature out of the sink in the room after running for two minutes was 120.1 degrees F. Observation on 02/24/2022 at 12:16 AM in room 128 showed water temperature out of the bathroom sink after running for two minutes was 123.4 degrees F. Observation and interview on 02/24/2022 at 12:42 PM in room 128 showed Staff Z, Certified Nursing Assistant (NAC), turned on the bathroom sink faucet and stated that the water was almost too hot to wash hands in and was hotter than the water out of the sink in the room. During an interview on 02/24/2022 at 1:16 PM, Staff A, ADM, stated that there were two boilers in the facility that provided water to the resident hallways (resident care areas). Staff A, ADM, further stated that the thermostat to the boiler that provided hot water to Baker and Helens hallways needed to be replaced. Reference WAC 388-97-0880.

Based on observation, interview, and record review the facility failed to ensure proper consistency and nutritional value was maintained to meet the nutritional needs for four of four residents (Residents 58, 26, 49 and 286) who required their food in a pureed texture. The failure to follow the written recipe did not ensure the proper consistency or flavor of food served, and placed the residents at risk for a diminished dining experience, less than adequate nutritional intake potentially leading to a decreased quality of life. Findings included . RESIDENT 58 A record review showed Resident 58 had a 11/15/2021 physician order for a pureed diet texture. RESIDENT 26 A record review showed Resident 26 had a 02/21/2022 physician order for a pureed diet texture. RESIDENT 49 A record review showed Resident 49 had a 02/03/2022 physician order for a pureed diet texture. RESIDENT 286 A record review showed Resident 286 had a 02/24/2022 physician order for a pureed diet texture. In an observation on 03/01/2022 at 10:22 AM, Staff L, Cook, was preparing pureed Mediterranean (white cod) fish. The cooked fish combined with cooked tomatoes, onions and cucumbers and some liquid from the pan, had not been measured, was placed in the blender and pureed. Staff L, Cook, added six plastic spoons full of thickening powder and blended again. The texture of the fish and vegetables and thickener was comparable to paste. Staff L, Cook, added a partial ladle of brown gravy to the white fish and blended again. When finished, the fish was a light brown pudding texture, not a pureed texture and there were red strings of tomato skin in the pureed fish. In an interview on 03/01/2022 at 10:22 AM, Staff L, Cook, confirmed the red strings were tomatoes. When asked to look at the recipe, Staff L, Cook, obtained a large binder and searched for the recipe for the fish, as they were not using the recipe for preparation. Review of the pureed Mediterranean fish recipe showed 10 servings of 5 ounces each should contain 2 tablespoons and 1 ½ teaspoons of food thickener powder with 1 ¼ cup of fish stock or water. The recipe showed, puree texture modification, omit tomatoes. Staff L, Cook, confirmed the tomatoes were supposed to be omitted for the pureed texture and brown gravy was not in the recipe. In an interview on 03/01/2022 at 11:55 AM Staff K, Dietary Supervisor (DS), stated the cook did not measure the thickening powder and should not have added brown gravy. Staff K, DS, stated the cook did not follow the puree recipe for the fish as expected. Reference WAC 388-97-1100 (1)(2)

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than five percent (%). Failure of two of two nurses (Staff EE & FF) to properly administer seven of 25 medications for two of two residents (Residents 136 and 26) observed during medication pass, resulted in a medication error rate of 28% percent. These failures placed the residents at risk for adverse side effects and/or reduced medication effectiveness due to improper administration. Findings included . For further information for Resident 26 refer to F658. RESIDENT 136 Observation of medication pass on 03/01/2022 between 7:12 AM and 7:35 AM showed Staff EE, Licensed Practical Nurse (LPN), prepared and administered 14 medications to Resident 26 which included: [MEDICATION(S)] Beysylate 5 milligrams (mg) by mouth (PO); [MEDICATION(S)] 10 mg PO; [MEDICATION(S)] [MEDICATION(S)] capsule 67 mg, PO; [MEDICATION(S)] tablet 75 micrograms (mcg) PO; and [MEDICATION(S)] two sprays inhale orally. Resident 136 took the PO medications independently with fluids and self-administered the two sprays of [MEDICATION(S)]. Review of Resident 136's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview 03/01/2022 at 7:35 AM, Staff EE, LPN, acknowledged they failed to administer the five above listed medications at the correct time, as specified by the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] RESIDENT 26 Observation of medication pass on 03/03/2022 between 8:56 AM and 9:33 AM, showed Staff FF, LPN, prepared and administered 10 medications to Resident 26 via PEG tube (Tube placed through the abdominal wall into the stomach or small intestine. Commonly used for feeding patients unable to safely swallow or meet nutritional needs orally) including [MEDICATION(S)] five mg (anticoagulant, blood thinning medication). Staff FF, LPN, was observed to crush the [MEDICATION(S)] tablet and pour the powder into a medication cup. Prior to administration, Staff FF, LPN, poured five ml of water into the medication cup, swirled it around dissolving the medication, and administered it via PEG tube. After administration, Staff FF, LPN, flushed the tube with an additional five ml of water. While Staff FF, LPN, was administering Resident 26's medications, the resident complained of pain to their legs, and rated it as a four on a pain scale to 10. At 9:29 AM after administering the resident's medications, Staff FF, LPN, restarted the resident's enteral feeding and exited the room. Review of Resident 26's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Okay to crush tablet and suspend in 60 ml of Water and promptly give via gastrostomy tube, and a 01/19/2022 order for [MEDICATION(S)] Sodium Gel 1 %, apply topically to both knees four times a day for knee pain, which Staff FF, LPN, omitted. On 03/03/2022 at 9:33 AM, Staff FF, LPN, was observed signing for the medications that were administered and indicated they were done with medication administration. In an interview at that time, Staff FF, LPN, acknowledged the failure to suspend the crushed [MEDICATION(S)] tablet in 60 ml of water, prior to administration as ordered. When queried about the failure to administer the resident's [MEDICATION(S)] gel (scheduled for administration between 7:00 AM and 9:00 AM) Staff FF, LPN, stated that they still planned to get something for [Resident 26's] legs. Reference WAC 388-97-1060 (3)(k)(ii)

Based on observation, interview and record review, the facility failed to ensure the consultant pharmacist's Medication Regimen Review (MRR) recommendations were followed up on for one of five residents (Resident 136) reviewed for unnecessary medication use. This failure placed the resident at risk of being uniformed of medication risks and benefits, medical complications, and a diminished quality of life. Findings included . Review of Resident 136's admission Minimum Data Set (MDS, a required assessment tool), dated 02/12/2022, showed that the resident admitted to the facility on [DATE]. Review of the admission record on 02/25/2022, showed that Resident 136 had an allergy to the medication [MEDICATION(S)], documented on 02/09/2022. During an interview and observation on 02/28/2022 at 9:29 AM, when asked if allergic to any medications, Resident 136 stated, Yes, [MEDICATION(S)] and another med [medication] I can't remember the name of it but they [the staff] are aware of it and was notified of them. Resident 136 had on white gloves and stated that they were to prevent injury from scratching skin and that the resident had a habit of scratching skin while sleeping but received medications that helped. Review of Resident 136's pharmacy document titled, Consultation Report, dated 02/10/2022, showed that Resident 136 had an allergy to the medication [MEDICATION(S)], yet had an order for the medication to be given every day. Additionally, the report showed, Recommendation: Please clarify the status of this allergy, and contact prescriber with recommendations for [MEDICATION(S)] discontinuation if reaction is significant i.e. [in example], hives, itching, trouble breathing, tingling lips, severe musculoskeletal pain etc. If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. Review of a copy of Resident 136's pharmacy document titled, Consultation Report, dated 02/10/2022, of the pharmacist recommendation related to Resident 136's allergy to the medication [MEDICATION(S)] that was prescribed, showed that the physician had signed the document on 02/11/2022. It further showed that the physician had handwritten on the document, OK to give. During an interview on 03/01/2022 at 11:37 AM, Staff E, Registered Nurse/Resident Care Manager (RN/RCM), stated that Resident 136's Medication Administration Record dated February 2022 showed that the resident received the medication [MEDICATION(S)] on 02/10/2022 and continued to receive the medication daily. Additionally, Staff E, RN/RCM, stated that she was unable to locate in Resident 136's medical record the following documentation: -Documented rational by the physician for the continued use of [MEDICATION(S)] despite the resident's allergy. -Documented risk and benefits provided to Resident 136 and/or responsible party related to the resident being provided the medication [MEDICATION(S)]. -A care plan that showed that Resident 136 had an allergy to the medication [MEDICATION(S)] and what signs and symptoms to monitor for. During an interview on 03/01/2022 at 12:24 PM, when asked if able to locate documentation of the rationale for giving [MEDICATION(S)] to Resident 136 with a known allergy to it, Staff B, Director of Nursing Services (DNS), stated, I cannot. Additionally, Staff B, DNS, was unable to locate documentation to show that risk and benefits were discussed with Resident 136. Reference WAC 388-97-1300(4)(c)

Based on observation, interview and record review, the facility failed to ensure medications were secured in a locked storage area and inaccessible to unauthorized staff and residents for one of 26 sampled residents (Resident 37) observed with medications at bedside. This failure placed the resident at risk for incorrect utilization of the medications and cognitively impaired residents at risk for ingestion of potentially harmful substances. Findings included . RESIDENT 37 According to the 12/27/2021 Quarterly Minimum Data Set (MDS, an assessment tool), the resident was cognitively intact and able to understand and be understood in conversation. On 02/23/2022 at 2:04 PM, observation showed Resident 37 had the following medications sitting on their overbed table: a bottle of [MEDICATION(S)] A (an antihistamine-decongestant combination) eye drops; [MEDICATION(S)] (a anti-[CONDITION(S)] medication) nasal spray; an eight ounce jar of Blue Ice pain relieving gel; and a bottle of [MEDICATION(S)]-Iodine (an antiseptic) solution. Similar observations were made on: 02/24/2022 at 11:18 AM; 02/25/2022 at 9:40 AM and 1:18 PM; and 03/01/2022 at 7:40 AM. Observation on 03/02/2022 at 7:49 AM, showed the medications had been removed from the resident's bedside table. During an interview on 03/02/2022 at 9:28 AM, Staff A, Administrator, and Staff F, Licensed Practical Nurse/Resident Care Manager, indicated they had inventoried and secured the medications at Resident 37's bedside. Staff B, DNS, expressed that the medications were found on the resident's overbed table in plain view, and should have been identified and secured by staff. Reference WAC 388-97-1300 (2)

Based on observation, interview, and record review the facility failed to accurately assess three of 26 residents (Residents 31, 50 and 75) reviewed for accurate Minimum Data Set (MDS, an assessment tool). Failure to ensure accurate assessment of resident care requirements placed residents at risk for unidentified and/or unmet needs. Findings included . RESIDENT 31 A review of the 01/18/2022 Medicare 5-day MDS showed Resident 31 to have no dental issues, including no missing or broken teeth. In an interview and observation on 02/24/2022 at 2:54 PM, Resident 31 stated they had multiple broken teeth and only had four whole teeth on the top front of their mouth. Resident 31 opened their mouth and was observed to have broken back teeth on the upper and lower jaw, and four front teeth which were discolored and chipped. A review of the 10/11/2021 dentist notes showed Resident 31 had broken and missing teeth. Dental notes on 01/29/2021 and 05/17/2021 also showed broken and missing teeth. In an interview on 03/02/2022 at 12:01 PM, Staff G, MDS Nurse, stated the resident denied dental issues during the assessment. Staff G, MDS Nurse, stated they did not examine Resident 31's mouth. In an interview on 03/03/2022 at 11:11 AM, Staff B, Director of Nursing Services (DNS), stated the MDS was expected to represent the assessment of the resident and the nurse was expected to look into the resident's mouth to assess dental status. RESIDENT 50 A review of the 01/07/2022 Quarterly MDS showed Resident 50 was administered an antidepressant medication for seven days during the assessment period. The MDS did not show that Resident 50 was diagnosed with depression. An 11/25/2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 03/02/2022 at 11:36 AM, Staff G, MDS Nurse, confirmed Resident 50's MDS was coded as receiving an antidepressant, and the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G, MDS Nurse, stated Resident 50's MDS was not coded correctly and should have been. In an interview on 03/03/2022 at 11:11 AM, Staff B, DNS, stated the MDS was expected to be completed accurately and represent the accurate assessment of the resident. RESIDENT 75 A review of the 01/31/2022 Quarterly MDS showed Resident 75 to have no dental issues. The MDS also showed Resident 75 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview and observation on 02/23/2022 at 1:46 PM, Resident 75 was observed edentulous (no teeth). Resident 75 stated they had dentures and a denture cup was observed at the sink. In an interview on 03/03/2022 at 11:55 AM, Staff G, MDS Nurse, stated Resident 75 did not have any natural teeth and did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G, MDS Nurse, stated the MDS was coded incorrectly. In an interview on 03/03/2022 at 11:11 AM, Staff B, DNS, stated the MDS was expected to be coded correctly and represent the accurate assessment of the resident. Reference WAC 388-97-1000(1)(b)

Based on observation, interview and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) for two of six residents (Residents 50 and 75) reviewed for ADLs. The failure to assist with nail care and showers placed residents at risk for unmet needs, poor hygiene, and a diminished quality of life. Findings included . Resident 50 A review of the 01/07/2022 Quarterly Minimum Data Set (MDS, a required assessment tool) showed Resident 50 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 50 was assessed to be totally dependent in the ADL of bathing. In an observation on 02/24/2022 at 10:25 AM, Resident 50 was observed to have long thick toenails extending past the end of the toes on both feet. A review of Resident 50's ADL care plan showed no directions to staff on the type and frequency of showers or instructions for nailcare to provide to Resident 50's feet. A review of the 02/2022 and 03/2022 bathing log showed Resident 50 did not receive a shower, bed bath or sponge bath between the dates of 02/22/2022 and 03/04/2022, 11 days. The shower record also did not show the resident refused a shower or bath during this timeframe. In an interview on 03/01/2022 at 11:51 AM, Staff B, Director of Nursing Services (DNS), stated nail care was provided with showers and could be done by the shower aide if the resident asked. Staff B, DNS, stated that if the resident was not able to ask, nail care was done as needed. In an interview on 03/03/2022 at 2:53 PM, Staff E, Registered Nurse/Resident Care Manager (RN/RCM), stated the nurse was expected to look at the resident's nails when doing the weekly skin check. The nurse could cut nails for residents with diabetes or could arrange for the podiatrist on hard to cut nails. Staff E, RN/RCM) looked at Resident 50's toenails and stated Oh, these could use some TLC [care] and asked Resident 50 if they would like to see the foot doctor on the next visit. Resident 50 stated, Yes. In an interview on 03/03/2022 at 11:11 AM, Staff B, DNS, stated the nurses are expected to identify when a resident needed toenail care from the podiatrist and the nurse should place the resident on the podiatrist list. Staff B, DNS, stated Resident 50's nails needed to be managed by the podiatrist. RESIDENT 75 A review of the 01/31/2022 Quarterly MDS showed Resident 75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 75's ADL care plan dated 08/27/2021 showed no directions to staff on the type and frequency of showers or instructions for nailcare to provide to Resident 75's feet. An observation and interview on 02/25/2022 at 9:29 AM showed Resident 75's great toe with a nail extending past the end of the toe. The four other toes had long nails that were growing over the end of the top of the toes. Resident 75 stated the nails were much longer than they preferred, and the resident wanted them cut. Resident 75 stated their nails had not been cut since before Thanksgiving 2021. Resident 75 stated they were scheduled for bed baths on Wednesdays, did not have the nails cut this week and would ask the aide to cut the nails next Wednesday. In an observation and interview with Staff E, RN/RCM, on 03/02/2022 at 2:53 PM (a Wednesday), Resident 75 stated I have not had my bed bath, they [toenails] are getting so long, that is the longest I have ever seen them. Staff E, RN/RCM, confirmed the nails were long and needed to be cut. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to ensure one of two residents (Resident 288) reviewed for activities received an ongoing program of activities to meet the individual resident's interests and needs. Failure to provide activities to meet the needs of the resident placed them at risk for diminished quality of life. Findings included . Review of a facility policy titled, Diversional Activity Programming, dated 05/2016, showed that the facility must provide activities meaningful to the resident at various times throughout the day and evening based on each resident's need and preference. RESIDENT 288 Resident 288 was most recently readmitted from the hospital on 02/11/2022. Their diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment of resident care needs), dated 01/18/2022, showed the resident did not speak and was rarely understood. The MDS also indicated that listening to music and being involved in favorite activities was very important to Resident 288. Review of Resident 288's care plan showed that staff were to invite resident to scheduled activities. The care plan showed that Resident 288's preferred interests were arts/crafts, parties/social events, puzzles, talking/conversing, bingo, wheeling outdoors and music. Staff were to engage resident in music on facility's electronic assistant device. In an interview and observation of care on 03/01/2022 at 9:29 AM, Staff U, Certified Nursing Assistant (NAC), was talking to Resident 288 about Hawaii and told them Mahalo. Resident 288 was noted to smile. Staff U, NAC, stated that Resident 288 had a decline in condition recently, but prior to the decline they liked to talk about Hawaii and music was very important to them. Staff DD, Registered Nurse (RN), stated that Resident 288 could not communicate verbally but they did make facial expressions during interactions to communicate. Prior to the staff entering room to provide care, Resident 288 was lying in bed. Room had been dark except for a light by the sink. Resident 288's TV was not on and there was no music on in the room. In an observation on 03/01/2022 at 3:49 PM, there was a parade with music and dancing in the hallway outside of Resident 288's room. Resident 288 was lying in bed. Other residents were sitting in their doorways to watch the parade. The parade passed by Resident 288's doorway but did not stop. The parade outside of Resident 288's room lasted less than two minutes. Review of Resident 288's activity log on this date showed that he participated in a social event. In an observation on 03/02/2022 at 8:41 AM, Resident 288 was lying in bed. Resident's TV was not on and there was no music on in the room. In an observation on 03/02/2022 at 10:20 AM, Resident 288 was lying in bed. Resident's TV was not on and there was no music on in the room. In an observation on 03/02/2022 at 2:56 PM, Resident 288 had their eyes open and was tracking the surveyor. Resident 288's TV was not on and there was no music on in the room. In an interview and observation on 03/03/2022 at 10:11 AM, Resident 288 was lying in bed. Resident 288's TV was not on and there was no music on in the room. Staff V, NAC, stated that Resident 288 liked music. No radio or stereo was noted in the room. Staff V, NAC, stated that they had not seen a stereo or radio in the room when asked how staff played music for resident. In an observation on 03/03/2022 at 12:10 PM, an electronic assistant device was noted at roommate's bedside, although it was not playing music. In an observation on 03/04/2022 at 8:34 AM, Resident 288 was lying in bed with their eyes open and tracking surveyor. Resident 288's TV was not on and there was no music on in the room. In an observation on 03/04/2022 at 9:50 AM, Resident 288 was lying in bed. Resident 288's TV was not on and there was no music on in the room. An electronic assistant device was noted at roommate's bedside. In an observation on 03/04/2022 at 10:20 AM, Resident 288 had the TV monitor in front of them, but the TV was not turned on. No music was on in the room. In an interview on 03/03/2022 at 11:49 AM, Staff H, Activity Supervisor (AS), stated that Resident 288 should have three activities a week of either group activity and/or one on one activity. Staff H, AS, also stated that Resident 288's main activity preference was TV and music and that those should be provided in their room every day from nine AM until five PM. Staff H, AS, stated that there was an electronic assistant device in Resident 288's room that was to be shared by both residents in that room. Review of Resident 288's activity log for the week of 02/18/2022-02/24/2022 showed that other than TV, Resident 288 was provided a church streaming activity on 02/20/2022 and a social activity on 02/23/2022. Review of Resident 288's activity log for the week of 02/25/2022-03/03/2022 showed that other than TV, Resident 288 was provided a church streaming activity on 02/27/2022, an entertainment activity on 03/01/2022 which was a parade [MEDICATION(S)] less than 2 minutes and one to one activity on 03/03/2022. Reference WAC 388-97-940 (1)

Based on observation, interview, and record review, the facility failed to provide bowel care in accordance with the facility bowel protocol and residents' physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These failures resulted in a delay of treatment, and placed residents at risk for pain, discomfort, and unmet care needs. Findings included . According to the facility's undated Bowel Care Protocol, each resident's bowel monitoring will be completed in the Electronic Health Record (EHR). The day shift licensed nurse will review the bowel movement (BM) alert report. If a resident has not had a BM for three consecutive days, the day shift nurse administers [MEDICATION(S)] (a [MEDICATION(S)]) per the POs. If the resident does not have a BM after administration of [MEDICATION(S)], a Dulcolax suppository (sup) should be administered per PO, on day shift of day four. RESIDENT 26 During an interview on 02/24/2022 at 1:46 PM, the resident stated they had bouts of constipation all the time. Record review showed Resident 26 had 12/08/2021 bowel care orders for: [MEDICATION(S)] as needed (PRN), if no BM for three days; and Dulcolax sup PRN, if no results after [MEDICATION(S)], administer on day shift of the fourth day without a BM. Review of Resident 26's bowel monitor showed the resident went three days or greater without a BM on the following occasions: 01/09/2022-01/12/2022 (four days); 01/24/2022- 01/27/2022 (four days); 02/02/2022- 02/04/2022 (three days); 02/13/2022- 02/16/2022 (four days); and 02/20/2022 -02/22/2022 (three days). Review of the January and February 2022 Medication Administration Records (MAR) showed facility nurses failed to administer [MEDICATION(S)] on the third day of no BM as ordered on: 01/11/2022; 01/26/2022; 02/04/2022; 02/15/2022; and 02/22/2022. During an interview on 03/02/2022 at 11:51 AM, Staff B, Director of Nursing Services (DNS), acknowledged on the above referenced dates nursing should have administered the resident's PRN [MEDICATION(S)] as ordered, but failed to do so. RESIDENT 20 During an interview on 02/24/2022 at 1:29 PM, Resident 20 complained of experiencing episodic upper abdominal pain believed to be related to kidney stones but indicated it could be constipation. Record review showed Resident 20 had 11/22/2021 bowel care orders for: [MEDICATION(S)] PRN, if no BM for three days three days; and Dulcolax sup PRN, if no results after [MEDICATION(S)], administer on day shift of the fourth day of no BM. Review of Resident 20's bowel monitor showed the resident went three days or greater without a BM from 01/06/2022- 01/09/2022 (four days). Review of the January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 03/02/2022 at 11:51 AM, Staff B, DNS, acknowledged [MEDICATION(S)] should have been administered on 01/08/2022, but was not. RESIDENT 75 A review of the 01/31/2022 quarterly MDS showed Resident 75 was cognitively intact, was able to speak clearly, was understood and was able to understand others. Resident 75 was assessed to require extensive assistance with toileting, was frequently incontinent of bowels, was not on a toileting program and did not have constipation. In an interview on 02/25/2022 at 9:23 AM, Resident 75 stated they had a very hard BM the prior day. Resident 75 stated the staff helped resident to lay on their left side, staff spread the resident's hips and told the resident to push the BM out. Resident 75 stated it felt like having a baby and the staff collected a handful of BM. A review of Resident 75's 02/2022 BM record showed the resident did not have a BM on 02/22/2022 thru 02/24/2022, three days with no BM. A review of Resident 75's POs showed a bowel protocol of three laxatives including a 12/21/2021 order for [MEDICATION(S)] every three days No BM, a 11/12/2021 order for a Dulcolax sup if no results from [MEDICATION(S)], on day four if no BM and a 12/01/2021 order for a Fleet enema every 24 hours as needed for constipation. A review of Resident 75's 02/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 03/02/2022 at 3:04 PM, Staff E, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 75 should have, and did not, receive a [MEDICATION(S)] on day three without a BM and the BM protocol was not followed. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Failure to administer the ordered volume of enteral formula, to identify/clarify conflicting water (H2O) flush orders, and to accurately document tasks completed, placed residents at risk for inadequate nutrition, hydration and potential adverse outcomes. Findings included . RESIDENT 26 Resident 26 admitted to the facility on [DATE]. According to the 02/03/2022 Quarterly Minimum Data Set (MDS, a required assessment tool), the resident was cognitively intact, able to understand and be understood in conversation, had a significant weight loss of greater than 5 % in a month or 10% in 6 months, was not on a prescribed weight-loss regimen, and received greater than 51% of total calories through enteral nutrition (EN). During an interview on 02/24/2022 at 12:55 PM, Resident 26 expressed concern about the management of their EN and reported that staff, shut it off and forget to turn it back on. Review of the [Resident 26] has nutritional problem . care plan (CP), with a goal date of 05/22/2022, showed nurses were directed to Provide and administer enteral nutrition and hydration as ordered. Record of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was to provide 1800 ml/ kilocalories (Kcal) per day; and an order to Document the daily total of formula infused, when volume to be delivered is complete. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the daily total of formula infused documentation showed on eight occasions the resident received less than 1620 ml of the ordered 1800 ml, and four times received less than 1530 ml. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 26s electronic health record (EHR) on 03/02/2022 showed no documentation or indication why facility nurses were not administering enteral feedings as ordered. During an interview on 03/02/2022 at 10:52 AM, Resident 26 reported facility nurses continued to forget to restart the enteral feeding at 4:00 PM. The resident stated, The other day it was off until past five and another day until past seven. Resident 26 stated that they had to call for the nurse each time to remind them to restart the enteral feeding. Observation and interview on 03/02/2022 at 2:36 PM, showed Resident 26's enteral feeding was not infusing, but remained attached to the resident's gastric tube. The enteral pump display was flashing restart in 86 minutes the pump had been programmed to restart the residents enteral feeding at 4:00 PM as ordered. Resident 26 stated that on the days where staff leave the pump connected (to the resident's gastric tube), the enteral feeding starts on time; however, clarified that it was on the days the EN was disconnected from the enteral pump that staff forgot to come and restart the enteral feeding. During an interview on 03/04/2022 at 8:56 AM, Staff B, Director of Nursing Services (DNS), stated that the nurse could not always control the amount of enteral feeding administered, as residents may have outings, therapy, appointments etc. Additionally, Staff B, DNS stated that the required enteral feeding had to be turned off during that time. Staff B, DNS, further stated it was likely care issues that prevented the nurses from administering residents' EN as ordered, not nurses failing to initiate the feedings at the correct times. A copy of Resident 26's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No further information was provided. RESIDENT 5 Review of the 12/01/2021 hospital discharge summary showed one of the resident's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident 5s EHR on 03/04/2022 showed that the resident had a 12/10/2021 order for: [MEDICATION(S)] Renal infuse at 50 ml/hr, via gastric tube, for 20 hours a day, to provide 1000 ml of formula and 2000 Kcal per day; and to Document daily total of formula infused, when volume to be delivered is complete. Review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10 occasions facility nurses documented the resident received less than 800 ml, indicating the resident missed greater than two hours of their ordered infusion. Review of Resident 5s EHR on 03/04/2022 showed no documentation or indication why the facility nurses failed to administer enteral feedings as ordered. Review Resident 5s February 2022, MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (Two conflicting orders). During an interview on 03/04/2022 at 9:08 AM, Staff B, DNS, stated that the nurses should have identified that they signed duplicate and conflicting flush orders. RESIDENT 40 Review of Resident 40's January 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not indicate the duration of the infusion (how many hours), the amount of ml and Kcal the resident required in a day, or what time the enteral feeding should be started or stopped. Review of the January and February MARs showed facility nurses signed twice daily between 01/13/2022-02/16/2022, that they carried out the order. Reference WAC 388-97-1060 (3)(f)

Based on interview and record review, the facility failed to ensure that gradual dose reductions (GDR) for [CONDITION(S)] medications were presented to the physician for the need to attempt a GDR in the absence of identified and documented clinical contraindication for one of five residents (Resident 31) reviewed for unnecessary [CONDITION(S)] medications. This failure placed residents at risk of receiving unnecessary [CONDITION(S)] medication with side effects and a diminished quality of life. Findings included . Review of the 12/16/2021 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident 31 admitted to the facility on [DATE]. Resident 31 had diagnoses of depression, anxiety, and chronic pain. Resident 31 was administered antidepressant and antianxiety medications during the assessment period. A 09/16/2020 physician order (PO) showed Resident 31 started an increased dose of [MEDICATION(S)] (an antidepressant medication) 50 milligrams (mg) by mouth daily at bedtime for [CONDITION(S)]. A 09/30/2020 PO showed Resident 31 started an increased dose of [MEDICATION(S)] (an antidepressant medication) 300 mg by mouth daily for depression. There was no further documentation in Resident 31's record to attempt a GDR or obtain a clinical contraindication statement from the physician for [MEDICATION(S)]. A 04/08/2021 PO showed Resident 31 started an increased does of [MEDICATION(S)] (an antianxiety medication) 1 mg by mouth daily at bedtime and 0.5 mg by mouth three times daily for anxiety related to shortness of breath. There was no further documentation in Resident 31's record to attempt a GDR or obtain a clinical contraindication statement from the physician for [MEDICATION(S)]. A 02/03/2021 PO showed Resident 31 started an increased dose of [MEDICATION(S)] (an antidepressant medication) 90 mg by mouth daily for depression with pain symptoms. There was no further documentation in Resident 31's record to attempt a GDR or obtain a clinical contraindication statement from the physician for [MEDICATION(S)]. A review of the 11/2021, 12/2021, 01/2022, 02/2022 Medication Administration Records showed Resident 31 continued to be administered [MEDICATION(S)] 50 mg daily, [MEDICATION(S)] 300 mg daily, [MEDICATION(S)] 1 mg daily and 0.5 mg three times daily and [MEDICATION(S)] 90 mg daily. Review of a 11/24/2021 interdisciplinary psychoactive medication assessment/review showed a recommendation to GDR decrease [MEDICATION(S)] and continue the other psychoactive medications as ordered. A review of resident 31's medical records after this assessment from 11/24/2021 showed no initiation of the decrease of the [MEDICATION(S)]. A review of the medical record showed no other evaluations of the antidepressant medications or antianxiety medication to attempt a GDR. The medical record did not show documentation of the physician declaration of clinical contraindication to decrease or discontinue the psychoactive medications dosages. In an interview on 03/03/2022 at 10:03 AM, Staff B, Director of Nursing Services (DNS), stated psychoactive medications were reviewed monthly for a GDR. Staff B, DNS, stated they thought a contraindication statement was on record for Resident 31's [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. A copy of the contraindication statement completed by the physician was requested, and none was provided. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure residents were comprehensively assessed for the use of seatbelts for one of three residents (Resident 40) reviewed for restraints. This failure placed the resident at risk for injury, unmet needs, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set (MDS, a required assessment tool), dated 02/08/2022 showed that Resident 40 had upper and lower extremity (shoulder, elbow, wrist, hand, hip, knee, ankle, and foot) impairment on both sides, used a wheelchair (manual or electric), did not utilize a restraint and was able to make needs known. Observations on 02/23/2022 at 3:01 PM and 02/28/2022 at 2:53 PM showed Resident 40 sat in an electric wheelchair with a seatbelt attached to the wheelchair and placed around the resident's waist. Review of Resident 40's care plan on 02/25/2022 at 12:46 PM showed no documentation for the use of a seatbelt while up in a wheelchair. During an interview on 03/01/2022 at 9:33 AM, Staff Z, Nursing Assistant Certified (NAC), stated that Resident 40 utilized a seatbelt when up in the wheelchair and that the resident was unable to remove it once applied. During an interview on 03/01/2022 at 11:04 AM, Staff Y, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that Resident 40 did not have an evaluation completed for the use of a seatbelt and thought that there should have been. During an interview on 03/01/2022 at 11:12 AM, Staff B, Director of Nursing Services (DNS), stated that she was unable to locate documentation in Resident 40's medical record for the use of a seatbelt. Additionally, Staff B, DNS, stated that residents that utilized a seatbelt needed to be assessed, an enabler restraint assessment completed, and care planned. Reference WAC 388-97-0620 (1)

Based on observation, interview and record review the facility did not have evidence of thorough investigations for 6 of 12 residents (Resident #s 1, 24, 30, 75, 77, & 91), reviewed for incidents and accidents. Failure to conduct a thorough investigation to identify root cause and all contributing factors related to accident hazards, and report any significant injuries to the state agency, placed residents at risk for unidentified abuse or neglect. Inappropriate corrective actions and recurrent falls resulted in harm to Resident #24. Findings included . RESIDENT #24 Refer to F609 and F689 for additional information and resident history. Review of the Face Sheet showed Resident #24 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set, (MDS, a required assessment tool), dated 12/18/17, indicated the Resident #24's vision was adequate, required supervision for mobility and transfers due to impaired balance, and was one person physical assistance with toileting. The resident was incontinent of bladder and bowel. The Brief Interview for Mental Status (BIMS) showed the resident scored 15 out of 15, which indicated the resident was able to recall time and date, repeat words correctly, and had adequate memory recall. The care plan reviewed on 03/15/18 showed Resident #24 was independent with transfers and required assistance with toileting every two hours at night. In an observation and interview on 03/07/18 at 12:16 PM, Resident #24's left elbow had a healing skin tear. The resident reported she had fallen, but she did not remember when it happened. The resident had dark purple areas around both eyes, consistent with bruising. Resident #24 was not able to explain why her eyes appeared bruised. In an interview at 12:30 PM, Staff G, CNA, said the bruising was from a fall. Review of the Incident Report Log and the nursing notes, showed Resident #24 sustained 18 unwitnessed falls on the following dates: 11/14/17 at 12:47 AM, 11/23/17 at 1:08 AM, 11/26/17 at 5:30 AM, 12/04/17 at 2:10 AM, 12/20/17 at 11:45 PM, 01/04/18 at 2:50 PM, 01/04/18 at 4:05 PM, 01/05/18 at 4:30 AM, 01/06/18 at 3:14 PM, 01/14/18 at 12:00 AM, 02/02/18 at 12:45 AM, 02/07/18 at 10:50 PM, 02/10/18 at 9:30 AM, 02/16/18 at 8:00 AM, 02/21/18 at 3:15 PM, 02/28/18 at 6:00 AM and 9:50 PM, and 03/02/18 at 8:28 AM. The first fall on 02/28/18 resulted in injury. Review of the incident reports showed Resident #24 fell four times in two days between 01/04/18 and 01/06/18. Review of the incident reports showed Resident #24 fell two times on 02/28/18. The first fall resulted in a head injury. The second fall investigation showed the resident had increased confusion, as evidenced by forgetting the location of the bathroom, only wore one shoe, and was restless. Review of the incident reports showed nine of the 18 falls, Resident #24 felt urgency to use the bathroom as she did not want to pee on herself, and attempted to get to the bathroom on her own. Three falls occurred in the bathroom. Review of the incident reports showed six of the falls, Resident #24 ambulated independently and without her front wheeled walker. The front wheeled walker placement, condition and why the walker was not used was not investigated. Review of the incident reports showed eight of the falls, Resident #24 fell at bedside. The investigations did not consider the resident's normal routine and why she got out of bed on her affected side. Review of the incident reports showed four falls involved Resident #24 wearing improper footwear. The resident was found only wearing one flip-flop, no shoes at all, and was attempting to get her shoes. Review of the incident reports showed three falls did not have investigations to identify the circumstances that may have contributed to the fall. Review of the incident reports showed two of the falls Resident #24 was reaching for items, such as a purse and shoes. The facility did not consider that commonly used items were not within reach. Review of the investigations showed the facility did not consider vision impairment as a possible contributing factor, as Resident #24 used a magnifying glass to read. Some incident reports did not investigate or identify the lighting in the room. Review of the 18 incident reports showed Resident #24 did not use her call light to request staff assistance, or use her walker consistently. The investigations did not consider footwear, lighting, assistive device, ability to use the call light, the last time the resident used the bathroom, if the resident was not able to empty her bladder, or what medication was given before the fall. The investigations did not explore the Resident #24's toileting needs related to falls or ensure the care plan was followed. The facility did not consider level of supervision as a factor to protect the resident from repeat falls. Review of Resident #24's investigations showed assessments and witness statements were incomplete. Review of the incident reports showed Resident #24 fell 12 times before a bladder assessment was performed. The bladder assessment dated [DATE] identified the resident as continent and marked that further evaluation was not needed, however, the nursing assessment dated [DATE] at 1:58 PM, stated she was incontinent several times a week. The documents titled, Nursing Post Fall Assessment, dated 11/14/17, 12/12/17, 12/20/17, 01/04/18, and 01/06/18 did not include orthostatic blood pressure readings or blood sugar levels. Some of the blood pressure readings were abnormal. Some of the neurological assessments recorded less than the 72 hour requirement. The investigation summary did not address the abnormal vital signs as a possible contributing factor to the fall. The facility did not consistently put Resident #24 on alert charting after each fall. Resident #24's post-fall neurological checks were not consistently completed. The facility did not to rule out mental status changes, abnormal vital signs, and possible unidentified internal injuries. Resident #24's medication regimen was not reviewed or considered as a factor as she received routine [MEDICATION NAME] (anti-anxiety medication), twice a day between 01/04/18 and 01/10/18. Review of the nurse's progress notes (NPN) dated 11/23/17 at 1:08 AM, and 11/26/17 at 5:30 AM, showed Resident #24 had two unwitnessed falls. The falls were not recorded on the Incident Reporting Log. On 03/21/18 at 2:00 PM, Staff E, Administrator, did not provide the investigations. Without the investigations, the facility could not rule out neglect and/or abuse. Review of the incident investigations dated 12/20/17 at 11:45 PM, 01/04/18 at 2:50 PM, and 01/04/18 at 4:05 PM, showed duplication of the investigative documentation for Resident #24's falls. Duplication of documents resulted in unclear course of events that occurred. It was undetermined if a separate investigation took place for each event. During an interview on 03/16/18 at 11:28 AM, Staff P, LPN, stated that Resident #24 had a shuffling gait, and the left foot dragged on the floor while she walked. In an interview on 03/16/18 at 12:23 PM, Staff F, DNS, said Resident #24's Optometry appointment had not happened yet, and there was no change or modification of interventions after the falls on 02/02/18, 02/10/18, 02/16/18, 02/21/18, both falls on 02/28/18 and 03/02/18. Staff F, DNS stated the facility had done everything they could to prevent Resident #24's falls. The incident summaries of the unwitnessed falls did not include facts and/or contributing factors surrounding the circumstances of the falls. The conclusion of the investigations were based on incomplete information, and did not explain how the patient-centered care plan was followed. Resident #24's incident investigations showed information was not thoroughly collected and analyzed. Relevant interventions were not identified, based on root cause, to protect the resident. Failure to thoroughly investigate incidents, and collect adequate information prevented substantiation of possible abuse and neglect. Resident#24 continued to experience repeat falls with significant injury that were potentially avoidable. RESIDENT #75 Refer to F689 for additional information and resident history. Review of the admission MDS dated [DATE] showed Resident #75 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required supplemental oxygen 24 hours a day by nasal cannula. The Brief Interview for Mental Status (BIMS) showed the Resident #75 scored 12 of 15, to indicate the resident had mild short memory deficit. The MDS further showed the resident had short term memory loss, impaired judgement, required one-person physical assistance with toileting, transferring, and locomotion on the unit. He used a wheelchair and had bladder incontinence. During an interview on 03/08/18 at 12:38 PM, Resident #75 stated that he fell in here (in the facility) and broke my hip. Record review of the incident log for the months of (MONTH) (YEAR) through (MONTH) (YEAR) showed two falls: 01/01/18 at 2:45 PM and 01/12/18 at 11:30 PM. FALL #1 The incident report for the fall dated 01/01/18 at 2:45 PM, showed Resident #75 had a fall in the shower room that resulted in an abrasion on the right knee. Staff V, Shower Aide was in the room, but the resident was using the toilet behind a privacy curtain, and not in direct line of sight of the shower aide. The aide told the resident to notify her when he was done. The aide hear a knock on the wall and found Resident #75 squatting on the floor holding the grab bar. The investigation did not include why the aide was not present to assist Resident #75 with personal hygiene after toileting, if the floor was wet, if the resident was wearing his oxygen, what his oxygen saturation levels were at the time of the fall, and if there were any additional environmental hazards. The investigation did not thoroughly rule out abuse and neglect. FALL #2 The incident report showed Resident #75 ambulated without assistance in the hallway looking for a bathroom. Staff V NAC redirected him to a bathroom, where he had an incontinent episode on the way. The resident slipped and fell to the bathroom floor, resulting in a [MEDICAL CONDITION] and skin tears to the right forearm and elbow. This fall with injury resulted in a three-day hospitalization and surgery. Review of NPN dated 01/10/18 at 11:11 AM, showed Resident #75 required 24-hour supervision and was able to ambulate only 20 feet with a front wheel walker (FWW) with supervision for safety. Review of the investigation and the Incident Report Log, showed the facility did not report the fall with [MEDICAL CONDITION] to the state agency. The incident report did not identify the last time Resident #75 was toileted, if staff anticipated his needs, if any additional staff may have seen the resident get out of bed or exiting his room prior to looking for the bathroom, why the resident didn't use his own bathroom or urinal, how far the resident ambulated into the hall, how far staff walked with him to the bathroom, what medications he was given prior to the fall, and if staffing level or supervision was a contributing factor. During an interview on 03/16/18 at 11:28 AM, Staff P, LPN, stated post fall orthostatic blood pressures were not required. We do that once a month if the resident was on antipsychotic medication. The investigation did not thoroughly rule out abuse and neglect. RESIDENT #77 Review of the admission Minimum Data Set (MDS, a required assessment tool), dated 01/15/18, showed Resident #77 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #77 was incontinent, wore glasses, and required artificial nutrition via gastrointestinal tube ([DEVICE]), a wheelchair for mobility, two person total assistance for dressing, bathing, mobility, and transfers. The MDS further showed Resident #77 had short term memory loss, usually made needs known and usually understood what was communicated to him. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The Care Area assessment dated [DATE], showed Resident #77 triggered for being at risk for cognitive loss, pain, activities, falls, alteration in psychosocial well-being Review of the (MONTH) (YEAR) through (MONTH) (YEAR) Incident and Accident Log, showed Resident #77 sustained four unwitnessed falls out of bed on 01/20/18 at 10:30 PM, 01/25/18 at 6:40 PM, 02/26/18 at 6:13 PM, and 03/11/18 at 6:46 PM. 01/20/18 FALL Review of the incident report showed Resident #77 sustained an unwitnessed fall on 01/20/18 at 10:30 PM. An aide found the resident on the floor at bedside lying on his stomach on the right side of the bed, with a sheet and two pillows under him. The resident did not appear in distress, was breathing fine, and denied pain. The investigation showed the resident was confused, unclear if a this was a new onset or baseline, and the call light was not on. One staff witness statement said the resident was last toileted at 9:30 PM, and last seen at 10:15 PM watching television and asked about food. The aide did not elaborate in her statement, why the resident asked for food, what her response was to Resident #77, as the resident was not able to safely eat or drink anything by mouth (NPO). The investigation did not consider the resident being bored, as he had watched television for at least an hour. The witness statement also did not show if the resident was asked if he needed anything at 10:15 PM, 15 minutes prior to the fall. It was unclear in the investigation if the assigned aide was familiar with the resident, or was a new staff. The investigation did not determine if the resident was hungry, thirsty, if he experienced discomfort, what position he was last seen in prior to the fall, and if the care plan was followed. The incident was not thoroughly investigated, root cause was not identified, and did not thoroughly rule out abuse and neglect. 01/25/18 FALL Review of the unwitnessed fall that occurred on 01/25/18 at 6:40 PM, showed Resident #77 was found with his feet and bottom in the bed and his upper torso and head on the floor mat on the right side of his bed. The resident appeared sad, was frowning, as if he might have wanted company. The investigation did not state if staff provided Resident #77 with company. Prior to the fall at 6:30 PM, the investigation showed Resident #77 was observed as calm, but was banging his remote on the table, pressing his remote control buttons and call light repeatedly. When asked if he needed anything, the resident shrugged his shoulders and shook his head. It was unclear if staff provided Resident #77 with the dry erase board to encourage communication. After staff left the room, Resident #77 continued to put his call light on repeatedly, and banged the controls on the table/Respiratory Therapy cart, for an uncertain period of time, to get staff attention for help. Staff responded, and found the resident with his head and torso on the mat on the floor. Resident #77 complained of seven out of 10 on the pain in his head and neck. An abrasion was found on the top of his scalp. The resident was also changed and found he had a small bowel movement. The incident report did not determine what the resident was attempting to communicate when banging his remote and using the call light. It was unclear if the banging was purposeful or due to agitation. The investigation did not clarify the conflicting information the investigation that described Resident #77 as experiencing agitation, but was identified as calm. The investigation did not describe Resident #77's daily routine, to include time he normally fell asleep, if pain increased in the evening, and his regular routine prior to hospitalization and the stroke. It was unclear if Resident #77 may have been reaching for something that staff should have known to have available to the resident. It was unclear if staffing was considered, as a copy was included and showed changes made to the schedule. It was not determined Resident #77's bowel pattern, if he was experiencing constipation or a painful bowel movement. It was unclear if staff followed the care plan or anticipated the resident's needs. The incident was not thoroughly investigated, root cause was not identified, and did not thoroughly rule out abuse and neglect. 02/26/18 FALL Review of the incident report for the 02/26/18 fall, showed Resident #77 sustained an unwitnessed fall at bedside on 02/26/18 at 7:13 PM. The Respiratory Therapist (RT) found the resident face down on the floor mat on the right side of the bed. The call light was not on. One witness statements showed the resident was last toileted at 5:30 PM. Resident #77 did not provide information as the resident is non-verbal. The staff member was assisting another resident to eat at the time the resident was found on the floor. Resident #77 had nothing on his feet as he was in bed. Another witness statement said Resident #77 was last seen at 6:00 PM lying in bed agitated and calm and had on non-skid socks. When asked what the resident said, staff left the section blank. An additional witness stated Resident #77 was last seen at 5:30 PM sleeping in bed and was toileted at that time. The resident was calm. Another staff included in the investigation stated the resident was last seen by her at 6:15 PM. The resident was exit seeking at that time. The staff member did not elaborate what that looked like for Resident #77 as he was dependent on staff for mobility. The investigation did not include the resident's continence status at the time of the fall, in addition to pain level before and after the fall. It was unclear if staff followed the care plan or anticipated the resident's needs. The investigation did not consider if all frequently used items were within view and reach, or if the resident attempted to reach for something The incident was not thoroughly investigated, root cause was not identified, and did not thoroughly rule out abuse and neglect. 03/11/18 FALL Review of the incident report of the fall sustained on 03/11/18 at 7:30 AM, showed Resident #77 was found on the floor at bedside. The incident was determined to be reasonably related to the resident being high risk for falls due to poor safety awareness and forgetfulness secondary to stroke. Resident #77 remained on 15 minute checks. Staff interviews showed inconsistent stories and conflicting information. It was unclear if the resident's needs were anticipated and the care plan was followed. The incident was not thoroughly investigated, root cause was not identified, and did not thoroughly rule out abuse and neglect. RESIDENT #91 Review of the History and Physical dated 11/09/17 showed Resident #91's [DIAGNOSES REDACTED]. Resident #91 no longer lived at the facility. Resident #91 sustained eight falls between 12/09/17 and 12/20/17. Seven of the eight falls were not thoroughly investigated. Review of the incident investigation for the fall on 12/09/17 at 9:30 PM, showed Resident #91 fell when she tripped over her walker. The incident investigation did not include thorough information gathering to rule out neglect. The investigation did not evaluate the resident's physical environment to determine if it accommodated her vision deficit. Additionally, the investigation also lacked assessment of lighting, footwear, presence of environmental hazards, medication regimen, blood sugar levels immediately after a fall, and condition of the assistive device(s). The investigation summary stated that the fall was reasonably related to no vision in the right eye. Review of the incident investigation for the fall on 12/11/17 at 4:10 PM, showed Resident #91 fell and hit her head against the footboard of her bed. The incident investigation identified Resident #91's oxygen tubing was 50 feet long. The investigation failed to determine if the tubing contributed to the fall, or identify other potential contributing factors such as medication regimen, lighting, footwear, blood sugar levels and orthostatic blood pressure immediately after the fall. The facility concluded the fall was related to no vision in the right eye and poor safety awareness. Review of the incident investigation for the fall on 12/12/17 at 1:00 AM, showed Resident #91 fell on the wet floor in her room. The incident investigation summary stated that the fall was reasonably related to no vision to the right eye, and poor safety awareness. Although, facility repeatedly identified Resident #91's vision as the cause of repeat falls, the investigation did not contain evidence of a thorough environmental assessment to determine if it adequately accommodated visual impairment. Review of the incident investigation for the fall on 12/16/17 at 8:10 PM, showed Resident #91 was found on the floor. The resident said she lost her balance when trying to sit on the edge of the bed. The incident investigation did not identify and evaluate potential contributing factors. The witness statements did provide a through description of the circumstances surrounding the fall. Review of the incident investigation for the fall on 12/17/17 at 7:10 PM, showed Resident #91 fell again, less than 24 hours following the prior fall. The resident was found on the floor mat next to her bed. The incident investigation did not include a review of potential contributing factors. Review of the incident investigation for the fall on 12/17/17 at 9:35 PM, showed Resident #91 fell two and a half hours later. The facility's incident investigation indicated the resident was hallucinating. Prior to the fall Resident #91 received a combination of sedating medications; [MEDICATION NAME](narcotic), [MEDICATION NAME] (sedative), and [MEDICATION NAME] (anti-anxiety medication,) between 6:19 PM and 8:20 PM. The investigation showed the facility failed to consider the side effects of the high-risk medications and the likelihood of increased falls. The nursing notes did not contain an assessment to consider what the hallucinations were and rule out mental status changes. The incident report showed the physician was not notified until 12/18/17 at 7:13 AM. Review of the incident investigation for the fall on 12/20/18 at 2:10 AM, showed Resident #91 fell when she lost her balance. The incident report did not show evidence of a thorough investigation. The summary stated that abuse and neglect was ruled out despite lack of thorough post-fall assessment. The neurological assessment form had holes in documentation, the resident's blood sugar were not obtained immediately after the fall, concurrent use of sedating medication was not addressed and the physician was not notified right away. In interview on 03/15/18 at 4:31 PM, Staff F, Director of Nursing Services (DNS) stated the facility was in the process of reviewing fall prevention through the Quality Assurance Program. Without a thorough investigation, the facility could not rule out abuse/neglect and implement relevant interventions to protect the resident from repeat falls based on root cause analysis. RESIDENT #1 Review of the Quarterly Nursing assessment dated [DATE], Resident #1 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident also had severe contractures. According to progress notes dated 03/06/18, Resident #1 required two person total assist for all cares including transfers and bed mobility. Nursing notes dated 03/08/18 at 2:23 PM, indicated Resident #1 is forgetful/confused, and has paralysis. An observations on 03/06/18 at 11:11 AM, showed Resident #1 was in bed on a low air-loss mattress. Review of the incident investigation of the fall on 03/08/18 at 2:30 AM, Resident #1 was found on the floor next to the bed. The investigation concluded the fall was reasonably related to resident coughed then expelling upper body forward .unable to correct forward movement, and propelled onto the floor. The investigation failed to assess resident's low air loss mattress following the fall to determine if it potentially contributed to the fall and/or if it malfunctioned or was not properly set up. Reference WAC 388-97-0640(6)(a)(b)

Based on observation, interview, and record review the facility did not fully operationalize its abuse prevention policy and procedure. The facility failed to recognize potential abuse, protect the resident, investigate, and immediately report to all appropriate agencies. Multiple facility staff knew about rape allegations and/or presence of significant injuries of unknown source but did not take immediate action and follow the abuse prevention policy as soon as Resident #1 reported sexual assault. Resident #1 did not receive immediate care and services for sexual assault and was not protected. The failure to implement abuse policy and procedure placed all residents in the facility at imminent risk for unrecognized abuse/neglect, constituting an Immediate Jeopardy situation on 09/20/17. Findings included . According to the facility's policy/ procedure dated 05/2016, and titled Abuse Prevention & Investigation, It is the policy of this facility that all suspected, alleged or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to the State and Federal regulations. The same policy described seven components for abuse prevention; screening, training, prevention, identification, investigation, protection and reporting/response. The policy stated it is the responsibility of all staff members to report abuse. The policy specified the investigation should be completed within five days. Resident #1 was observed on 09/19/17 at 3:35 PM in bed on her left side. Resident's right leg was wrapped with soft long padding from the ankle to the middle of the high. Resident was not interviewable. Resident #1 had [DIAGNOSES REDACTED]. According to facility investigation dated 09/21/17, Resident #1 had redness, swelling and pain to the right knee on 09/07/17. A portable x-ray completed on the same day did not show an injury. On 09/10/17 around dinner time, Resident #1 told Staff F, Nursing Assistant and Staff U, Licensed Nurse she was raped. In less than 24 hours of making rape allegations Staff I, Registered Nurse/Charge Nurse identified bruise measuring 7 cm x 9 cm on the right inner thigh. The bruise was from an unknown cause. After Resident #1 alleged rape and staff identified bruising of unknown source, the facility staff took resident to the fair on 09/11/17 from 10:00 AM to 1:00 PM, as documented in the progress notes and a witness statement by Staff E, Social Services. A second x-ray on 09/12/17 identified Resident #1 had a broken right thigh bone. The emergency room notes dated 09/12/17 confirmed Resident #1 had a right distal femur and right femoral neck fracture. The facility failed to identify potential abuse when resident reported rape allegation and in less than 24 hours developed substantial bruising of unknown source to the inner thigh (an area generally not vulnerable to trauma.) The resident was not protected during and following reports of sexual assault and concurrent presence of bruising of unknown source. Based on staff witness statements and/or staff interviews conducted from 09/19/17 through 09/26/17, Staff F, Nursing Assistant, Staff G, Licensed Nurse, Staff I, Registered/Charge Nurse, Staff U, Licensed Nurse, B, Registered Nurse/Director of Nursing, Staff Q, Nursing Assistant, Staff W, Registered/Charge Nurse, & Staff H, Registered/Charge Nurse, had knowledge of rape allegations on 09/10/11 and/or on 09/11/17.The identified staff members were mandatory reporters and were involved in Resident #1's care directly or indirectly. The staff did not follow facility's abuse policy and procedure and failed to demonstrate effective communication. Refer to F490 for additional information related to ineffective communication system and facility administration. On 09/22/17 at 3:42 PM in an interview, Staff F said around dinner time on 09/10/17, Resident #1 told her she was raped. Staff F said she informed Staff G and Staff H. Staff F said she documented resident's report on a COMPLAINTS/GRIEVANCES form and gave it to Staff G. On 09/26/17 at 5:52 PM Staff G said he was assigned to Resident #1 on 09/10/17 in the evening. Staff G said after Staff F made him aware of rape allegations he informed Staff H, a charge nurse. Staff G said he did not notify the police or state agency because he knew Staff H was contacting Staff B, DNS. Staff G said a female nurse was asked to assess the resident. On 09/26/17 at 5:48 PM Staff U (female nurse) said she worked the evening shift on 09/10/17 and spoke with Resident #1 about rape allegations. Staff U confirmed that Resident #1 reported she was raped on 09/10/17. Staff U said she did not call the police or make other reports because she thought it was covered. During an interview on 09/19/17 at 1:40 PM Staff B, Director of Nursing confirmed she knew about rape allegations on 09/10/17 because the charge nurse contacted her. Staff B said that 09/10/17 was her last day prior to taking time off work. The DNS said on 09/10/17 she thought Staff W, Registered Nurse (on-call charge nurse) was handling it. The DNS did not notify the administrator as soon she learned about rape allegations. Staff I, was the charge nurse on duty on 09/10/17 from 6 PM to 6 AM, according to the facility staffing schedule. On 09/26/17 at 5:20 PM, Staff I said she knew about the rape allegations when she took over as a charge nurse on 09/10/17 sometime in the evening. Staff I said she had no idea about what was done on the previous shift related to the rape allegations. Staff I said she did not notify the state or the police. On 09/25/17 at 7:15 AM, Staff W said Staff H, called her sometime during the evening of 09/10/17. Staff H inquired about how to proceed with rape allegations. Staff W said she advised Staff H to send the resident to the emergency room . Staff H responded he would also contact the Director of Nursing. Staff W said the next day (09/11/17) in the morning she followed up with the DNS about rape allegations. Staff W said she was informed by Staff B the allegations were not reportable. Staff Q was aware of rape allegations on 09/11/17 at 5:00 AM when she provided care to Resident #1 with Staff I, as documented on the grievance/complaint form dated 09/10/17. Additional witness statements identified three other facility staff who were aware of bruises from unknown source located in the area generally not vulnerable to trauma, but did not follow mandatory reporter requirements and/or facility abuse policy. -Staff X provided care to Resident #1 on 09/11/17 and saw inner thigh bruising dark and purple. Staff X stated she saw bruising before and after breakfast and noticed the bruising was getting worse and notified a nurse. -On 09/11/17 when Resident #1 returned from the fair, the redness and bruising became worse, according to Staff S' statement. -Staff R was aware of right upper and inner thigh bruising according to statement dated 09/11/17. The grievance/complaint form dated 09/10/17, identified Staff F assisted Resident #1 to dinner on 09/10/17. The resident said she could not go to dinner because she was raped. On 09/19/17 at 3:15 PM, Staff E, Social Services said he found a grievance form on the floor under his office door on 09/14/17, but did not read it at the time. Staff E said the following day (09/15/17) the same form was in his inbox. Staff E said the form contained rape allegation. Staff E said at that time he informed the Administrator. Staff E said he should have been checking concern/grievance forms daily. On 09/15/17 at 10:02 PM, five days after the rape allegation, Staff D, Licensed Nurse contacted the police department, as indicated in the police report. According to the police report, and interviews with Collateral Contacts 1 &2 on 09/21/17 at 2:30 PM and 09/29/17 at 6:13 PM, the facility did not inform the police about presence of significant injuries of unknown source around at the time of rape allegations. Review of the police report showed rape allegations notification took place on 09/15/17. Facility reported to the police that rape allegations came up during an unrelated investigation. In the police report, staff informed the officer/dispatcher that Resident #1 had [MEDICAL CONDITION] and was known to make up stories. On 09/20/17 at 3:59 PM, the DNS was interviewed about delay in investigating rape allegations and failure to protect the resident. The DNS said there was a communication breakdown. Interviews were conducted with Staff BB and Staff AA on 09/22/17 at 4:25 PM. Staff BB said the process for rape allegations is to start investigation immediately, contact the police and notify the state within 24 hours.

Based on observations interview and record review the facility was not administered efficiently and effectively to ensure highest practicable well-being of each resident. The facility failed to have effective clinical oversight that ensured effective and functioning communication system among direct care nursing staff, nursing supervisors and Director of Nursing Services (DNS). The ineffective transfer of essential information among multiple staff in various positions, on different shifts resulted in failure to identify abuse, protect, report and investigate according to facility policy and federal regulations. This failure created a situation of Immediate Jeopardy, placing all residents in the facility at risk of ongoing and unrecognized abuse/neglect. Substandard Care was identified in the following areas: 42 CFR 483.12(a) (b) (c) Investigate/Report Allegations 42 CFR 483.12(b) (1) (2) Develop and implement policies and procedures to prohibit abuse/neglect. Refer to F225 Report/Investigate Abuse and Neglect. The facility failed to report alleged violations, conduct a thorough investigation of all alleged violations. Refer to F226 for facility failure to implement its abuse prevention policy/procedure. Findings included Due to failure of multiple staff members including the Director of Nursing to identify and report allegations to the administrator, law enforcement and the stage agency resulted in Resident #1 not receiving protection and immediate services following sexual assault allegation and concurrent presence of significant injuries of unknown source in area generally not vulnerable to trauma. Resident #1did not have an opportunity to have forensic evidence collected immediately following the rape allegation. A rape kit (package of items used by medical personnel for gathering evidence) was done at the hospital on [DATE], (six days after reported rape.) According to facility incident investigation dated 09/21/17, and Staff interviews between 09/19/17 and 09/26/17 revealed seven nursing staff members who were involved in caring for Resident #1 on 09/10/17 and 09/11/17 had knowledge of rape allegations. The investigation showed the Administrator was notified of allegations until 09/15/17. The Administrator initiated full investigation on 09/15/17. The information exchange among multiple staff members demonstrated repeated gaps in communication including failure to clarify the plan, failure to delegate duties, relying on assumptions, and lack of clarity about who was in charge when the Director of Nursing was going to be on leave starting on 09/11/17. On 09/10/17 Resident #1 reported she was raped to Staff F, Nursing Assistant, Staff F informed Staff G, a licensed nurse who was assigned to care for Resident #1. Staff G informed Staff H, Registered Nurse/Charge Nurse. Staff G thought Staff H was taking care reporting/investigating. Staff U, was a female nurse and was asked to speak with Resident #1. Staff U, wrote a statement and handed it to Staff G. Staff H consulted by phone with Staff W, Registered Nurse/Nurse Manager on call who advised sending resident to the hospital. Staff H also called Staff B, Director of Nursing. Staff H received conflicting guidance on how to proceed with rape allegations. Staff I, took over as a charge nurse for the night shift. Staff I was aware of rape allegations but did not know what was done on the prior shift. Staff W followed up with the DNS on 09/11/17 and was told the allegations were not reportable. On 09/10/17 and 09/11/17 Staff G, H, W, F, U, I and the DNS were aware of rape allegations but did not effectively transition the knowledge and responsibility from one staff member to another. During the interviews multiple staff members reported they thought or assumed that another nursing staff besides them was responsible for reporting allegations and notifying the police. The Administrator was made aware on 09/15/17 after a grievance card dated 09/10/17 was discovered in social services box describing rape allegations documented by Staff F on 09/10/17 and Staff I on 09/11/17. On 09/15/17 at 10:02 PM, five days after the rape allegation, Staff D notified the police department about rape allegations, but did not report concurrent substantial injuries of unknown source.

Based on observations, interview, and record review, the facility failed to immediately report rape allegations and presence of concurrent injuries of unknown source to the facility administrator, law enforcement and the state agency for Resident #1. Additionally, the facility failed to timely initiate and conduct thorough investigations for 3 out of 19 Sample Residents (#'s1, 2, 3) reviewed for abuse/neglect allegations. This failure placed residents in immediate jeopardy situation for ongoing unrecognized abuse/neglect. Findings Included . Facility's policy and procedure on Resident Rights and grievances indicated that residents could voice concerns related to care using Grievance Resolution Forms. The policy and procedure included, The Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source as required by law. Record review and interview identified three allegations of abuse/neglect reported and processed via grievance forms instead completing a full investigation to rule out abuse and neglect. RESIDENT #1 SEXUAL ASSAULT ALLEGATION: On 09/10/17, at dinner time, Resident #1 said she was raped by a male. Shortly after rape allegations on 09/11/17 at 4:56 AM, a 7cm x 9 cm bruise of unknown source was observed on the left inner thigh, according to nurse's notes. On 09/19/17 at 1:40 PM, Staff A, Administrator and Staff B, Director of Nursing (DNS) were interviewed. Staff A, said the rape allegations were documented on a grievance/concern form on 09/10/17. Staff E, Social Services found the grievance on 09/15/17 in his inbox, five days later. The police department and the state agency were notified on 09/15/17. Staff A said he initiated a full investigation as soon as he became aware on 09/15/17. During the same interview Staff B, DNS confirmed she was aware of rape allegations on 09/10/17 and thought Staff W, Registered Nurse/Charge Nurse was handling the situation. The DNS did not inform the Administrator immediately about rape allegations. Based on staff witness statements and/or staff interviews conducted from 09/19/17 through 09/26/17, Staff F, Certified Nursing Assistant, Staff G, Licensed Nurse, Staff I, Registered Nurse/Charge Nurse, Staff U, Licensed Nurse, Staff B, Registered Nurse/Director of Nursing, Staff Q, Certified Nursing Assistant, Staff W, Registered Nurse/Charge Nurse, & Staff H, Registered Nurse/Charge nurse had knowledge of rape allegations on 09/10/11 and/or on 09/11/17. The identified staff members were directly or indirectly involved in Resident #1 care at the time of allegations. The eight staff members, including the Director of Nursing failed to immediately report the rape allegations and/or concurrent development of injuries of unknown source in area generally not vulnerable to trauma to the administrator, law enforcement and the state agency. In an interview on 09/22/17 at 3:35 PM, Staff V, Licensed Nurse/Staff Development verified that all staff had received mandatory reporter and abuse prevention training at the time of hire and at least annually. Staff V said all staff were mandatory reporters and allegations of abuse/neglect must be reported to the supervisor(s) and the state. On 09/22/17 review of facility rape investigation dated 09/21/17 showed a full investigation was initiated five days after the initial sexual assault report. During an interview, Staff A on 09/19/17 at 2:10 PM confirmed delay in initiating the investigation. The facility did not conclude the investigation and summarized findings within five days. Staff BB on 09/22/17 at 4:25 PM confirmed the investigation summary should have been done within five days. Facility completed separate investigations related to fracture of unknown origin and rape allegations and failed to rule out if there was a connection. On 09/11/17 the facility staff accompanied Resident #1 to the fair after there was alleged raped and identified significant bruising of unknown source as indicated in witness statement by Staff X on 09/12/17 and nursing notes dated 09/11/17. On 09/12/17 an x-ray showed Resident #1 had a broken thigh bone. INJURIES OF UNKNOWN SOURCE Facility's evidence of investigation for fracture of unknown source dated 09/16/17 contained four witness statements with abuse/neglect allegations that were not either clarified or investigated: 1. Statement dated 09/12/17 described Resident #1 screamed in pain during a transfer in a mechanical lift, the staff stopped the transfer, notified the nurse and indicate that the nurse allowed the transfer to continue. The facility did not clarify this statement and/or initiate an investigation to rule out abuse/neglect. 2. In an undated statement with illegible signature, the writer indicated an x-ray technician was alone with the resident for 5-10 minutes and had to stop when resident complained of discomfort. The facility did not explore whether nursing assessed the patient following the procedure. The facility did not determine why the x-ray tech was in the room alone with Resident #1 when the care plan specified This resident requires 2 person care at all times with minimum of 1 female. No male care givers to be alone with resident. The facility investigation did not investigate why the care plan was not followed to determine what part of the process needed to be corrected. 3. Information in a statement dated 09/12/17 alleged Resident #1 was complaining of pain during transfer but staff continued to provide care because the resident allowed it. 4. Staff X documented a witness statement dated 09/12/17. Staff X, a Nursing Assistant, described that she saw a dark purple bruise on the right inner thigh on 09/11/17 before and after breakfast. Staff X documented that resident was in pain and bruising was getting worse. The statement showed Staff X notified the nurse on duty. The information in the statement alleged the nurse responded by saying she was already aware of the bruises and the bruises were old. The facility staff took Resident #1 to the fair after staff noted the bruising was getting worse. The facility did not explore this statement to rule out if the nurse demonstrated serious disregard for consequences or was neglectful. The statements with potential allegations were reviewed with Staff A and Staff T on 09/26/17 at 8:36 PM. Staff A said the statements will be investigated. Refer to F226 for additional information for Resident #1. ALLEGATIONS REPORTED USING GRIEVANCE/COMPLAINT FORMS RESIDENT #2 Resident # 2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to facility's MDS (Minimum Data Set, comprehensive assessment tool) dated 08/31/17, Resident #2 was able to make self-understood, understood others and had no problems with cognition. A COMPLAINT/GRIEVANCES form dated 05/04/17, showed Resident #2 did not want a nurse around her or taking care of her, because the nurse yells at her and bullies her. During interview and record review on 09/26/17 at 6:27 PM, Staff Z said this should have been investigated as abuse allegations to rule out emotional abuse. RESIDENT #3 Resident #3 admitted on [DATE] with [DIAGNOSES REDACTED]. According to MDS dated [DATE] resident was able to make self-understood, had ability to understand others and had no problems with cognition. The same assessment indicated resident experienced frequent pain. A COMPLAINT/GRIEVANCES form dated 07/02/17 with attached witness statement described Resident #3 asked Staff L for pain medications three different times within 30 minutes. The writer alleged the nurse did not respond to the resident, he became angry and started yelling asking for the nurse. The resident yelled multiple times calling the nurse. The statement alleged Staff L, Licensed Nurse was ignoring the resident. In an interview on 09/19/17 at 3:15 PM, Staff E, Social Services indicated that prior to 09/15/17 the grievance/complaint forms were not reviewed daily.

Based on observation, interview and record review, it was determined the facility failed to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for facility residents. This failure created an unsafe environment for all residents and caused harm to Residents #3, #2 and #17 and represented Immediate Jeopardy for Resident #21, #22, #23 and #6. Findings include: On 4/19/16 at 3:00 p.m., during interview with the Administrator, she said the Medical Director (MD) participated in the Quality Assurance Meetings. There was no available documentation to support more than discussions/attendance at the meetings related to the MD's involvement in the oversight of the facility with one specific topic now pertaining to hospital re-visits. There was no supporting documentation to indicate the MD was participating to the extent necessary for adequate resident care and services as described in his duties that included but not limited to: Participated in administrative decisions related to policies and procedures; Performs annual review of the policies and procedures manual; Participates in the quality assurance, pharmacy, infection control, safety and other clinical committees; Participates in the management of unusual occurrences and unexpected events both within and outside the facility; Assures adequate documentation of health care delivered at the facility; Responds appropriately to all reported Changes of Condition; Responds to staff inquiries regarding admissions, orders, and/or transfers; Participates in monitoring the care within the facility through a QA program that encourages self-evaluation, anticipates and plans for change; Ensures that the QA program addresses issues germane to patient care; Actively engages and develops performance management initiatives to enhance the provision of nursing and medical care in the facility as identified in conjunction with the Interdisciplinary Team . At 4:00 p.m., when asked, the Director of Nursing Services (DNS) said she did not have any recent concerns shared with the MD. 1) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for lack of sufficient, qualified staff to perform nursing services to provide care to residents in the facility to help them attain or maintain their highest practicable level of function and resulted in harm to Residents #2, #3, #17; failure to perform timely medication management for Residents #2, #3, #17, #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and 1 former Resident (#21) and 2 discharged Residents (#22, #23) who failed to receive timely assessments and/or staff intervention in a timely manner for Resident #6, 1 former Resident (#21), 2 discharged Residents (#22, #23) who experienced harm and resulted in Immediate Jeopardy. 2) Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to protect Resident #21, 322, #23 and #6 from neglect when physician intervention was warranted; when emergent care was needed or when the resident/family requested to go to the hospital for evaluations and were not sent, resulted in Immediate Jeopardy. 3) Refer to 42CFR483.20(k)(3)(i) F 281 Service Meets Standards for facility failure to ensure staff performed duties per accepted professional standards of practice for Residents (#6, #9, #8, #10, #11, #13, #14, #29, #15), 1 former Resident #21 and 2 discharged residents (#22 and #23) who needed assessments and timely intervention /accurate documentation for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk of the same/similar deficient practices and for Residents #6, #21, #22 and #23 was determined to represent Immediate Jeopardy. 4) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility to obtain emergent, immediate assistance for sampled Residents (#6), former Resident #21, discharged Residents #22 and #23 who were found to experience conditions that warranted emergency/physician interventions. The failure to obtain emergent, immediate help was determined to be an Immediate Jeopardy. 5) Refer to 42CFR 483.25(g)(2) F 322 NG Treatment/Services for facility failure to ensure Residents (#10, #11); 1 former Resident (#21) and 1 discharged Resident (#24) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with the resident's written plan of care and standards of safe clinical practice. This avoidable failed practice placed all residents with gastric tube feedings at risk of harm and represented Immediate Jeopardy. 6) Refer to 42CFR483.25(h)(2) F 323 Prevention of Accidents for facility failure to ensure the safety of Resident #17 that resulted in harm after she was found after sitting on her hand for approximately 6 hours. 7) Refer to 42CFR483.25(m)(2) F 333 Medication Errors for failure to ensure Residents #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and discharged Resident #21 were free of significant medication errors when staff failed to administer medications as ordered. This avoidable failed practice demonstrated system breakdown and placed all residents at risk of prolonged pain and/or worsening of their health conditions and was determined to represent Immediate Jeopardy. 8) Refer to 42CFR483.75(l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards and practice to ensure complete and accurately documented records for sampled Residents (#1 #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15 reviewed for sufficient, accurate information in the clinical record. In addition his failure resulted in the inability to identify the physical and psychosocial needs and relevant outcomes to Residents #17, #6, #21, #22, #23 who experienced significant changes in condition/decline in health status. Lack of accurate and timely information in the clinical record had the potential to affect all residents in the facility when records were not complete and accurately documented.

Based on observations, interview and record review, it was determined the governing body failed to ensure sufficient policies and procedures were in place so facility staff had clear guidance related to specific care issues such as the need for emergent/immediate care required by Residents #6, #21, #22 and #23 who either repeatedly asked/demanded to go to the hospital and/or did not have assessments/timely interventions for their medical conditions. This failure resulted in harm to 4 current Residents (#6, #2, #3, #17); 1 former Resident (#21) who passed away without intervention after significant bleeding occurred; and for 2 discharged Residents (#22 and #23) that were in critical condition and required hospitalization and resulted in a finding of substandard care. The governing body's failure to provide oversight of the facility's operation allowed findings of substandard care throughout the facility. This represented an Immediate Jeopardy. Findings include: The governing body failed to ensure the facility was effectively administered to ensure sufficient qualified staff members were available to avoid negative outcomes for these residents. 1) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for lack of sufficient, qualified staff to perform nursing services to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function and resulted in harm to Residents #2, #3, #17; failure to perform timely medication management for Resident ##2, #3, #17, #9, #8, #10, #11, #13, #14, #20, #29, #15); failed to intervene in a timely manner for Resident #6, 1 former Resident (#21), 2 discharged Residents (#22, #23) who experienced harm and resulted in Immediate Jeopardy. 2) Refer to 42 CFR 483.75 F-490, Effective Administration, Resident Well-Being for facility was not administered effectively to utilize resources to attain and/or maintain the highest practicable well-being of residents in the facility and failed to have sufficient qualified nursing staff and address staff knowledge to meet resident needs to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the regulatory requirements which affected and had the potential to affect all residents in the facility. Failure to ensure compliance resulted in harm to Resident #2, #3 and #17 referenced in F 241, F 312 and F 323 and represented Immediate Jeopardy for Resident #21, #22, #23 and #6, referenced in F 224, F 281, F 309, F 322, F 353. 3) Refer to 42CFR483.75(i) F 501 Responsibilities of Medical Director for facility failure to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for facility residents. This failure created an unsafe environment for all residents and caused harm Residents #2, #3, #17 and resulted in Immediate Jeopardy for Residents #21, #22, #23 and #6. 4) Refer to 42CFR 483.75 (o)(1) F 520 QAA Committe for failure of the facility to ensure an effective Quality Assessment and Assurance Program (QA&A) self-identified deficiencies and failed to develop/implement effective plans of action and to develop policies and procedures to review resident care and services in view of the facility's high acuity residents (of the 104 residents, 55 had gastric feeding tubes; 46 had tracheostomies and 25 of them were on ventilators. This failure placed all residents at risk for less than optimal care and services and resulted in harm to Resident #2, #3 and #17 and Immediate Jeopardy for Resident #21, #22, #23 and #6. Failure to have an effectively functioning QAA program that consistently self-identified deficient practices placed residents at risk and repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. .

Based on interview and record review, it was determined the facility failed to ensure a Quality Assessment and Assurance Program (QA&A) self-identified deficiencies and failed to develop/implement effective plans of action and to develop policies and procedures to review resident care and services in view of the facility's high acuity residents (of the 104 residents, 54 had gastric feeding tubes; 46 had tracheostomies and 25 of them were on ventilators. This failure placed all residents at risk for less than optimal care and services and resulted in harm to Resident #2, #3 and #17 and Immediate Jeopardy for Resident #21, #22, #23 and #6. Failure to have an effectively functioning QAA program that consistently self-identified deficient practices placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care. Findings include: On 4/19/16 at 3:00 p.m., during interview with the Administrator, she stated there was a Quality Assurance Committee that met quarterly. Although no documents were provided for review, the facility had recently been reviewing re-hospitalization of residents related to the national statistics. According to the Director of Nursing Services (DNS), she was not aware of any self-identified staffing related or training issues currently or recently presented to QA for review. 1) Refer to 42CFR 483.10(b)(11) - F 157 Notify Of Changes (injury/decline/room, Etc) The facility failed to ensure nursing staff followed professional standards of practice in identifying and monitoring the residents' acute medical symptoms with timely notification to the physician to prevent medical emergencies and/or resident complications and to include notification of family members for Resident #21. 2) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for lack of sufficient, qualified staff to perform nursing services to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function and resulted in harm to Residents #2, #3, #17; failure to perform timely medication management for Resident ##2, #3, #17, #9, #8, #10, #11, #13, #14, #20, #29, #15); failed to intervene in a timely manner for Resident #6, 1 former Resident (#21), 2 discharged Residents (#22, #23) who experienced harm and resulted in Immediate Jeopardy. 3) Refer to 42CFR483.20(k)(3)(i) F 281 Service Meets Standards for facility failure to ensure staff performed duties per accepted professional standards of practice for Residents (#6, #9, #8, #10, #11, #13, #14, #29, #15), 1 former Resident #21 and 2 discharged residents (#22 and #23) who needed assessments and timely intervention /accurate documentation for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk of the same/similar deficient practices and for Residents #6, #21, #22 and #23 was determined to represent Immediate Jeopardy. 4) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility to obtain emergent, immediate assistance for sampled Residents (#6), former Resident #21, discharged Residents #22 and #23 who were found to experience conditions that warranted emergency/physician interventions. The failure to obtain emergent, immediate help was determined to be an Immediate Jeopardy. 5) Refer to 42CFR 483.25(g)(2) F 322 NG Treatment/Services for facility failure to ensure Residents (#10, #11); 1 former Resident (#21) and 1 discharged Resident (#24) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with the resident's written plan of care and standards of safe clinical practice. This avoidable failed practice placed all residents with gastric tube feedings at risk of harm and represented Immediate Jeopardy. 6) Refer to 42CFR483.25(m)(2) F 333 Medication Errors for failure to ensure Residents (#9, #8, #10, #11, #13, #14, #20, #29, #15) were free of avoidable medication errors. This failed practice demonstrated system breakdown and placed all residents at risk of prolonged pain and/or worsening of their health conditions. This avoidable failed practice placed all residents at risk of harm and represented Immediate Jeopardy.

Based on observation, interview and record review, it was determined the facility failed to have sufficient, qualified staff to provide and supervise care for Residents #2, #3, #17, #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and 1 former Resident (#21) and 2 discharged Residents (#22, #23). Observations, interviews with residents and staff, combined with record reviews, revealed inadequate supervision of residents to ensure the care needs of these residents were met by licensed staff or certified nursing assistants in accordance with established clinical standards and their care plans. This failure placed all residents at risk of harm from lack of qualified staff to meet residents' needs and represented Immediate Jeopardy. Findings include: Review of the 4/5/16 resident census revealed 104 total residents; 46 residents with tracheostomies (holes in throat) and 25 of those residents were on ventilators (mechanical breathing machine). In addition, an average of 54-56 residents required medications/nutrition support via gastric (stomach) tubes. All of these residents required substantial time and care from qualified staff. According to the actual daily staffing schedule, the facility assignments were divided into work zones for day and evening shift but not on night shift. During interview with the staffing coordinator (SC) on 4/14/16, she stated it was hard to get the night charge nurse to complete the assignment so each Nursing Assistant (NA) was not identified with the assigned residents on the documents she provided. Review of the nightly assignments indicated some of the nights were frequently missing assigned rooms/aides on the units to indicate the responsible staff member and to whom the charge nurse could ask for detail about residents' care needs. 1) Refer to Revised Code of Washington/RCW 74.42.360, January 1, 2016 that in part requires: (3) Large nonessential community providers must have a Registered Nurse (RN) on duty, directly supervising resident care twenty-four (24) hours per day, seven days per week . Review of the staffing schedules indicated lack of RN coverage to meet this requirement on 3/5/16; 3/6/16; 3/7/16 and 4/11/16. 2) Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to protect Resident #21, 322, #23 and #6 from neglect when physician intervention was warranted; when emergent care was needed or when the resident/family requested to go to the hospital for evaluations and were not sent, resulted in Immediate Jeopardy. 3) Refer to 42CFR 483.15(a), F241, Quality of Life, Dignity for facility failure to ensure dignity was protected for Resident #2 and #3 that resulted in harm when they were found in soiled beds/clothes for a prolonged period of time. 4) Refer to 42CFR483.20(k)(3)(i) F 281 Service Meets Standards for facility failure to ensure staff performed duties per accepted professional standards of practice for Residents (#6, #9, #8, #10, #11, #13, #14, #29, #15), 1 former Resident #21 and 2 discharged residents (#22 and #23) who needed assessments and timely intervention /accurate documentation for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk of the same/similar deficient practices and for Residents #6, #21, #22 and #23 was determined to represent Immediate Jeopardy. 5) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility failure to obtain emergent, immediate assistance for sampled Residents (#6), former Resident #21, discharged Residents #22 and #23 who were found to experience conditions that warranted emergency/physician interventions. The failure to obtain emergent, immediate help and/or when family/resident asked to transfer to the hospital was determined to be an Immediate Jeopardy. 6) Refer to 42CFR 483.25(a)(3), F312 Care for Dependent Residents for facility failure to provide care to dependent Resident #2 and #3 that resulted in harm when they failed to receive timely bowel and urinary incontinence care. 7) Refer to 42CFR 483.25(g)(2) F 322 NG Treatment/Services for facility failure to ensure Residents (#10, #11); 1 former Resident (#21) and 1 discharged Resident (#24) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with the resident's written plan of care and standards of safe clinical practice. This avoidable failed practice placed all residents with gastric tube feedings at risk of harm and represented Immediate Jeopardy. 8) Refer to 42CFR483.25(h)(2) F 323 Prevention of Accidents for facility failure to ensure the safety of Resident #17 that resulted in harm after she was found after sitting on her hand for approximately 6 hours. 9) Refer to 42CFR483.25(m)(2) F 333 Medication Errors for failure to ensure Residents #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and discharged Resident #21 were free of significant medication errors when staff failed to administer medications as ordered. This avoidable failed practice demonstrated system breakdown and placed all residents at risk of prolonged pain and/or worsening of their health conditions and was determined to represent Immediate Jeopardy. 10) Refer to 42CFR483.75(l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards and practice to ensure complete and accurately documented records for sampled Residents (#1 #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15 reviewed for sufficient, accurate information in the clinical record. In addition his failure resulted in the inability to identify the physical and psychosocial needs and relevant outcomes to Residents #17, #6, #21, #22, #23 who experienced significant changes in condition/decline in health status. Lack of accurate and timely information in the clinical record had the potential to affect all residents in the facility when records were not complete and accurately documented.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to Resident #2, #3 and #17 referenced in F 241, F 312 and F 323 and represented Immediate Jeopardy for Resident #21, #22, #23 and #6 referenced in F 224, F 281 and F 309. Findings include: 1) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for lack of sufficient, qualified staff to perform nursing services to provide care to residents in the facility to help them attain or maintain their highest practicable level of function and resulted in harm to Residents #2, #3, #17; failure to perform timely medication management for Residents #2, #3, #17, #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and 1 former Resident (#21) and 2 discharged Residents (#22, #23) who failed to receive timely assessments and/or staff intervention in a timely manner for Resident #6, 1 former Resident (#21), 2 discharged Residents (#22, #23) who experienced harm and resulted in Immediate Jeopardy. 2) Refer to 42CFR 483.13(c) F 224 Prohibit Mistreatment/Neglect for facility failure to protect Residents #2, #3, #17 from harm and to ensure Resident #21, 322, #23 and #6 from neglect when physician intervention was warranted; when emergent care was needed or when the resident/family requested to go to the hospital for evaluations and were not sent, resulted in Immediate Jeopardy. 3) Refer to 42CFR483.20(k)(3)(i) F 281 Service Meets Standards for facility failure to ensure staff performed duties per accepted professional standards of practice for Residents #2, #3, #17, #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15; 1 former Resident #21 and 2 discharged residents (#22 and #23) who needed assessments and timely intervention /accurate documentation for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk of the same/similar deficient practices and for Residents #6, #21, #22 and #23 was determined to represent Immediate Jeopardy. 4) Refer to 42CFR483.25 F 309 Care and Services/Highest Practicable for facility to obtain emergent, immediate assistance for sampled Residents (#6), former Resident #21, discharged Residents #22 and #23 who were found to experience conditions that warranted emergency/physician interventions. The failure to obtain emergent, immediate help was determined to be an Immediate Jeopardy. 5) Refer to 42CFR 483.25(g)(2) F 322 NG Treatment/Services for facility failure to ensure Residents (#10, #11); 1 former Resident (#21) and 1 discharged Resident (#24) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with the resident's written plan of care and standards of safe clinical practice. This avoidable failed practice placed all residents with gastric tube feedings at risk of harm and represented Immediate Jeopardy. 6) Refer to 42CFR483.25(m)(2) F 333 Medication Errors for failure to ensure Residents #2, #3, #17, #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15 were free of avoidable medication errors. This failed practice demonstrated system breakdown and placed all residents at risk of prolonged pain and/or worsening of their health conditions. This avoidable failed practice placed all residents at risk of harm and represented Immediate Jeopardy. 7) Refer to 42CFR483.75(i) F 501 Responsibilities of Medical Director for facility failure to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for facility residents. This failure created an unsafe environment for all residents and caused harm Residents #2, #3, #17 and resulted in Immediate Jeopardy for Residents #21, #22, #23 and #6. 8) Refer to 42CFR483.75(l)(1) F 514 Clinical Records Meet Standards for facility failure to maintain medical records in accordance with professional standards and practice to ensure complete and accurately documented records for sampled Residents (#1 #5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15 reviewed for sufficient, accurate information in the clinical record. In addition his failure resulted in the inability to identify the physical and psychosocial needs and relevant outcomes to Residents #17, #6, #21, #22, #23 who experienced significant changes in condition/decline in health status. Lack of accurate and timely information in the clinical record had the potential to affect all residents in the facility when records were not complete and accurately documented. 9) Refer to 42CFR483.75(o)(1) F 520 QAA Committee-Members for facility failure to ensure a Quality Assessment and Assurance Program (QA&A) self-identified deficiencies and failed to develop/implement effective plans of action to correct identified concerns or deficiencies related to notification of change in condition that resulted in harm to Resident #21; neglect for Residents #2, #3; professional practice standards related to assessments and medication administration and to develop policies and procedures to review resident care and services in view of the facility's high acuity residents (of the 104 residents, 54 had gastric feeding tubes; 46 had tracheostomies and 25 of them were on ventilators. This failure placed all residents at risk for less than optimal care and services and resulted in Immediate Jeopardy when the facility failed to intervene and/or seek emergency help for Residents #21, #22, #23 and #6.

Based on observation, interview and record review, it was determined the facility failed to ensure 23 of 23 sampled Residents (#5. #28, #35, #36, #40, #25, #37, #7, #38, #4, #39, #31, #41, #23, #9, #10, #11, #13, #14, #19, #20, #29, #15) and discharged Resident #21 were free of significant medication errors when staff failed to administer medications as ordered. This avoidable failed practice demonstrated system breakdown and placed all residents at risk of prolonged pain and/or worsening of their health conditions and was determined to represent Immediate Jeopardy. Findings include: Review of the facility Census Reports between 4/2/16 and 4/19/16 indicated an average daily census of 104 residents who received multiple medications daily with between 54 to 56 residents who had various types of inserted tubes in the stomach (gastric/enteral) for nutritional support, hydration and medications. According to nursing literature, Safety is the main concern in medication administration .preparing medications carefully and recording their administration. Use of the Medication Administration Record (MAR) ensures timely and safe medication administration (Fundamentals Nursing Skills and Concepts, 9th Ed. (2009) Lippincott, Williams and Wilkens, Chapter 32, page 771). Medication administration includes the 8 Rights: Right patient; Right medication; Right dose; Right route; Right time (double-check that you are giving the ordered dose at the correct time and confirm when the last dose was given); Right documentation AFTER giving the ordered medication, site of injections, vital signs checked before giving the drug; Right reason and Right response. (Nursing 2012 Drug Handbook. Lippincott Williams & Wilkins, 2012. Philadelphia, PA). The Washington State Nurse Practice Act, WAC 246-840-710 (2) in part indicates nurses violate standards by: (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly: (d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards (c) Willfully or repeatedly failing to make entries .pertaining to the giving of medication, treatments, or other nursing care . (i) Failure to protect clients from unsafe practices or conditions . and (8) The nurse shall have knowledge of the statutes and rules governing nursing practice . <Medications Administration> On 4/2/16 at 11:00 a.m., during interview with Resident #5, who needed a ventilator and gastric tube, said his medications/treatments had not been administered on time and sometimes were missed completely. His Medication Administration Record (MAR) had frequent areas of no documentation of medications being administered. Review of Licensed Nurse (LN) E's documented explanation of the missed medications/treatments for 14 of 18 dependent residents on this unit, dated 3/11/16 was: This LN was unable to complete medication pass due to extreme busyness of the floor. It was unclear to this LN just how far behind on med pass I was. Many of the lesser treatments were skipped and important medications that were missed were passed on to the oncoming nurse (evening nurse) . Some examples follow: 1) Resident #28 was to receive medications via his gastric (stomach) tube. He did not receive either of his blood pressure medications, tube feeding bolus and did not receive tube care as ordered. Licensed Nurse (LN) E said he could not provide the medications as the Nursing Assistants (NA) had not done the vitals and he could not find the medications. He was far too busy to do the site care and the gravity tube feeding. 2) Resident #35 did not receive her pain patch ([MEDICATION NAME]) and other care and services as ordered. Licensed Nurse (LN) E told the facility he was far too busy . 3) Resident #36 did not receive his [MEDICAL CONDITION] medication or the amount totaled for his tube feeding. LN E documented he could not find the medication and was far too busy to total tube feedings. 4) Resident #40 did not receive his combination high blood pressure/diuretic medication, wound care to his shoulder, medication patch for his [MEDICAL CONDITION], stomach medication and did not have his tube feeding formula documented. LN E documented he was unable to locate the items as far to busy. 5) Resident #25 had no documentation to indicate how much tube feeding was tolerated, did not receive eye medication, respiratory medication or flushes to the feeding tube or tube site care. LN E documented: Far too busy to do. 6) Resident #37 did not receive his antibiotic as LN E was unable to locate the medication, LN E failed to provide ordered ointment, yeast infection power, feeding tube care and did not document tube feeding formula as he was unable to do, far too busy. 7) Resident #7 did not receive his eye drops; his blood sugar was 55 and the physician was not notified. 8) Resident #38's feeding tube totals were not documented as LN E was unable to do, far too busy . 9) Resident #4 had no totals of his tube feeding documented on the MAR as LN E was far too busy to do. 10) Resident #39 did not have tube feeding formula documented on the MAR as LN E was too busy to do . 11) Resident #31's total feeding tube formula was not documented on the MAR as LN E was far too busy . 12) Resident #41 did not have his tube feedings documented as LN E was unable to do, far too busy. 13) discharged Resident #23 did not receive his high calorie nutritional supplement or prescribed ointment for his nose and LN E documented unable to do, far too busy. 14) On 4/7/16 at 9:35 a.m., Resident #10 was observed for medication administration by Licensed Nurse (LN) B. She placed all the Resident's pills into the same cup, transferred them to a plastic envelope, crushed all medications together in the same envelope, poured crushed pills into a cup, added water from the hot water dispenser on the beverage cart, swirled meds to try to dissolve them, then add ice water from pitcher on beverage cart. She was unable to identify medications that should not be given together due to possible interactions. She was unable to demonstrate how to unplug the gastric tube. The following medications were documented by a check mark as given at the times on the pre-printed MAR rather than the time actually administered. 15) At 9:45 a.m., Resident #11 was observed for medication administration by LN B. She measured the [MEDICATION NAME] [MEDICATION]) solution, poured it directly into the cup with [MEDICATION NAME] (laxative) liquid. She crushed all meds together in the same envelope. Mixed in hot water first from Hot Water Dispenser from beverage cart, then ice water from pitcher and followed the same procedure as observed with Resident #10. She was unable to identify medications that should not be given together. 16) Former Resident #21 was ordered to have nutritional feedings through his gastric tube. The Comprehensive Care Plan indicated the Resident is independent and prefers to do the feedings himself. Although the nurses documented administering the medications, nutritional formula and flushes, there was no documentation to indicate the number of cans and when the feedings should be given or to indicate how staff monitored his feedings and stoma site or that the resident demonstrated the ability to perform these services for himself and how well he was following procedures. Refer to F 176 and F 309 for more details regarding this resident. 17) On 4/13/16 at 3:30 p.m., LN L was observed to administer medication to Resident #20. The resident requested a medication for pain, which she stated was an 8 on a 0-10 pain scale. The order for the medication requested by the resident read, [MEDICATION NAME] HCl tablet 5 mg. Give 1 tablet via PEG Tube every 3 hours as needed for pain. The order was dated 6/17/15, nearly a year ago. LN L stated, She (Resident) takes her meds in applesauce. LN L gave the medication to the resident orally with a spoonful of applesauce. (The surveyor found the discrepancy in route of administration when doing the medication reconciliation) 18) On 4/14/16 at 10:15 a.m., LN A was observed to administer medications to Resident #13. The LN took the poured medications to the Dining Room. The LN administered oral meds first, then an inhaler, then another [MEDICATION NAME] inhaler with 2 puffs in rapid succession, less than 5 seconds apart. At 10:26 a.m., when the LN returned to cart, he was asked if there was a specific amount of time that is recommended to wait in between puffs of [MEDICATION NAME]. The nurse replied, a few seconds. The surveyor and LN checked the prescription label that read: Wait 1 minute between puffs. The LN said, I did not know that. 19) At 10:33 a.m., medication administration by LN A was observed for Resident #14. The LN said an aide told him the resident requested a pain med. The LN removed a dose of [MEDICATION NAME] (narcotic) from the locked drawer and then signed it out in the narcotic book. The LN did not perform a pain assessment and did not sign in the MAR that the medication was given. At 12:46 p.m., nearly two hours later, the printed MAR did not indicate the medication had been given or what the pain level was prior to administering the medication. <Signing Off Meds At a Time Different Than When Given> 20) On 4/13/16 at 3:20 p.m., LN L was observed to administer medications to Resident #19. While preparing the medications, LN L stated regarding Clobazam, an anti-[MEDICAL CONDITION] medication, He only gets it once in 24 hours so I can give it now. The MAR time period to give the Clobazam was between 8:00 p.m. and 10:00 p.m. At 4:25 p.m., LN L was asked whether the MAR would show what time the medication was given to the resident today or on a previous day. The nurse opened the resident's MAR and stated, It's not going to show because I haven't signed it out yet. The nurse acknowledged that the Clobazam (anti-[MEDICAL CONDITION]) medication was one of the medications given to the resident at 3:20 p.m. and stated, I gave it but I'll sign it out later. The nurse reviewed the time period the medication was due to be given, five hours later than the time it was administered, and stated, If you want me to sign it out now I can do that. While the MAR for Resident #19 was open, LN L was observed to click the Yes button (electronically signing that a medication was given) for [MEDICATION NAME] acid (another medication given for [MEDICAL CONDITION]), was timed in the MAR to be given at 5:00 p.m. The LN acknowledged that she had given these and the other anti-[MEDICAL CONDITION] medication at 3:20 p.m. when she gave the other medications, but she was signed these two out as though each had been given at the correct time. 21) On 4/7/16 after administering medications to Resident #14 at 10:33 am, LN A was observed to click medications on the MAR as given while not removing them from the cart. The LN clicked through the medications and said: Already gave that, and that, and that. Surveyor asked, Aren't you supposed to sign them out when you take them out when they are given? The LN stated, Yes but I didn't have time earlier. When asked is it to do a double check to know when you're pulling the meds that you're giving so it is the right one at the right time? The LN paused before answering and then stated: I think I'm pretty reliable. 22) At 10:50 a.m., LN G was observed to administer medications to Resident #15. Without taking the medication cart to the room, the LN carried a plastic tray with medications on it into resident's room and placed it on resident's overbed table. The LN told the resident, I have your meds. The Resident asked: Which ones? The LN paused then started to recite some medication names from memory then stopped and asked the resident: Do you want the list? The resident answered, No, that's okay. The LN administered [MEDICATION NAME] (nasal spray) without gloves and assisted the resident by occluding each nostril. The LN gave 2 inhaled meds (Qvar and [MEDICATION NAME]), then asked the NA to bring a cup of water from the med cart, handed it to resident and asked her to rinse and spit after the last does. The LN stated to the resident, Sorry, she (surveyor) is going to make me do that. During these observations the following problems were identified related to lack of nurses providing care and services according to accepted professional practice standards: Combining crushed meds and giving all at one time via tube feedings without checking for placement; knowing if there could be any adverse interactions; Giving narcotics and anti-anxiety medications without assessments. Timing medication administration for times noted on the MARs rather than the times actually administered or combining all medications together and giving them at one time but failing to accurately document the time which would not be known to the following nurses who may also document the medications in the same manner. This avoidable failed practice placed all residents at risk for medication errors and potential for harm. 23) On 4/7/16 At 9:20 a.m., LN B was observed to administer medications to Resident #9. Without taking the medication cart to the room she carried an exposed needle filled with insulin to the room and injected into the resident's Left Upper abdomen. On return to the cart, the LN was asked about the exposed needle and not twisting a shield to cover over it. She stated, I must have forgot. She documented the site as the abdomen. At 1:30 p.m., LN B was asked about documenting injection sites in their MAR system. She was asked if the expectation was to rotate injection sites? The nurse answered Yes and showed it was possible to select among numerous sites including each 4 abdominal quadrants, right/left rear arms, thighs, etc. Asked if she can tell where the site the last injection was given, the nurse stated, I don't know, why you would you do that? The nurse pulled up the insulin administration record for Resident #9, which documented the administration site of every dose of Insulin was given at 9 a.m. was abdomen without indication of location on the abdomen. 24) At 9:20 a.m., LN B was observed to administer Medications to Resident #9. Without taking the medication cart, she carried an exposed needle filled with insulin to the room. and Injected into the resident's Left Upper abdomen. On return to the cart, the LN was asked about the exposed needle and not twisting a shield to cover over it. She stated, I must have forgot. She did not document the site of injection which would prevent the following nurse from knowing where to give the next injection. At 1:30 p.m., LN B was asked about documenting injection sites in their MAR system. She was asked if the expectation was to rotate injection sites? The nurse answered Yes and showed it was possible to select among numerous sites including each 4 abdominal quadrants, right/left rear arms, thighs, etc. Asked if she can tell where the site the last injection was given, the nurse stated, I don't know, why you would you do that? The nurse pulled up the insulin administration record for Resident #9, which documented the administration site of every dose of Insulin was given at 9 a.m. was abdomen without indication of location on the abdomen. .

Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 2 current sampled residents (#10, #11); 1 former Resident (#21) and 1 discharged Resident (#24) received gastric (stomach) tube feeding (TF) services by qualified persons in accordance with the resident's written plan of care and standards of safe clinical practice. This failure placed all residents with gastric tube feedings at risk of harm and was determined to represent Immediate Jeopardy. Findings include: Review of the facility Census Reports between 4/2/16 and 4/19/16 indicated an average daily census of 104 residents with between 54 to 56 residents who had various types of inserted tubes in the stomach (gastic/enteral) for nutritional support, hydration and medications. When asked for the facility policy, the Medication Administration Policy - Feeding Tube (Revised 11/2007) was provided and showed #8. Different medications should not be mixed together for administration; #12. Check for correct placement of feeding tube prior to administration of medication; #15. If administering several medications, administer each one separately. The tube should be flushed with at least 5 ml of water between medications . 1) On 4/7/16 at 9:35 a.m., Resident #10 was observed for medication administration. Licensed Nurse (LN) B was observed to place all the Resident's pills into the same cup, transfer to a plastic envelope, crushed all medications together in same envelope, poured crushed pills into a cup, added water from the hot water dispenser on the beverage cart, swirled meds to try to dissolve them, then add ice water from pitcher on beverage cart. The LN disconnected the gastric tube feeding and without listening for tube placement, removed the plunger from the syringe, poured fluid with medications into the syringe. The medications would not flow. The LN then placed the plunger in the syringe and applied pressure three times more and was still unsuccessful in unplugging the tube. She removed the plunger and poured the medication solution back into the cup. 2) At 9:45 a.m., Resident #11 was observed for medication administration. After LN B measured the [MEDICATION NAME] [MEDICATION]) solution, she poured it directly into the cup with [MEDICATION NAME] (laxative) liquid. She crushed all meds together in the same envelope. Mixed them in hot water first from Hot Water Dispenser from beverage cart, then added ice water from the pitcher and followed the same procedure as observed with Resident #10. During observations the following problems were identified related to lack of nurses providing care and services according to accepted professional practice standards for [DEVICE] medication administration. Combining crushed meds and giving all at one time via tube feedings without checking for potential interactions of the medications and for tube placement. 3) Former Resident #21 was ordered to have nutritional feedings through his gastric tube. Facility documentation dated 3/20/16 at 10:00 a.m. indicated the LN found the feeding tube on the bedside table. The resident reported: It happened last night and He notified the NA and the nurse. The LN was unable to reinsert the tube because the stoma was closed. The resident wanted the tube replaced. After obtaining approval from the provider and Hospice, the resident was sent to the ER. The facility records dated 3/22/16 around 8:00 p.m. indicated: Patient walked up to nurse's station and asked for a cup of ice and scheduled medications, noted to have his own cup and straw. Told he was not supposed to have food or liquid by mouth as he was NPO (nothing by mouth). Went to Patient's room to educate about the risks of taking liquids by mouth, noticed to have soda bottles on his table .removed . A Hospice Nursing Note (NN) dated 3/26/16 indicated the resident was observed sitting on the edge of his bed and able to dress himself .gastric feeding tube that he manages and does have a whitish discharge with a malodorous (offensive/bad) smell. He delivers the 6 cans of formula a day per his gastric tube. He reports and wants 10 cans a day. The Comprehensive Care Plan indicated the Resident is independent and prefers to do the feedings himself. Although the nurses documented administering the medications, nutritional formula and flushes, there was no documentation to indicate the number of cans and when the feedings should be given or to indicate how staff monitored his feedings and stoma site or that the resident demonstrated the ability to perform these services for himself and how well he was following procedures. Refer to F 176 and F 309 for more detail regarding this resident. 4) Review of discharged Resident #24's record indicated on 3/3/16, he was found at 9:30 a.m.with his gastric tube pulled out of his stomach and the gauze stuck to his skin around the stoma. The LN was unable to reinsert the tube because the stoma was closed. The note continued: Resident insisted to go to the hospital to get it replaced. The nurse practitioner approved the transfer to the ER. Refer to F 333 for more details regarding medication via gastric tubes.

Based on observation, interview and record review, it was determined the facility failed to recognize the need for emergency care for 4 of 4 residents reviewed for necessary care and services and included current Resident #6, former Resident #21 and discharged Residents #22 and #23 to ensure they received timely emergency care for pain, lethargy, [MEDICAL CONDITION] (hole/stoma in throat to breathe) blockage, low oxygen level, low blood pressures and profuse bleeding. Facility failure to recognize the need for emergency care for these residents who were harmed and for former Resident # 21, who was not assessed or treated for [REDACTED]. Findings include: 1) Former Resident #21 was admitted to the facility on [DATE] with multiple medical conditions including a [MEDICAL CONDITION] (stoma/hole in throat) inserted following [MEDICAL CONDITION] surgery on 2/2/16 for mechanical/ventilator support to breathe when needed. He chose to have a [DEVICE] (gastric/stomach tube) inserted for nutritional feeding support since losing about 45 pounds over the last 6 months. He was alert, oriented and could make his needs known. He was independent with ambulation/walker and managed his own [DEVICE] including giving himself intermittent feedings. According to Resident #21's Comprehensive Care Plan (CCP), initiated on 2/26/16 through 3/18/16, the resident's care interventions included: monitor for difficulty breathing, [MEDICAL CONDITION] care, suction as necessary, 4-wheel walker for self ambulation, follow fall protocol and allow resident to make decisions about treatment. The discharge plan initiated on 3/1/16 included referral numbers for community resources and evaluate motivation to return to the community. A POLST (physician's orders [REDACTED].other measures to relieve pain and suffering. Use oxygen, oral suction and manual treatment of [REDACTED]. Facility records dated 3/31/16 at 11:30 p.m., indicated the resident approached the nurse's station with his [MEDICAL CONDITION] in his hands asking what he should do with it. RT (Respiratory Therapist) placed a new trach, noted blood-tinged secretions. The care plan was updated to include: will have no abnormal drainage around [MEDICAL CONDITION] .if tube is coughed out, open stoma with hemostat. (Using a hemostat is NOT the recommended way to reinsert this tube). If tube cannot be reinserted, monitor for signs of respiratory distress, elevate Head of Bed (HOB) 45 degrees, stay with resident. Obtain medical help IMMEDIATELY. According to RT notes dated 4/9/16 at 5:00 a.m., the resident was stable and no respiratory distress. The Nursing Note (NN) at this time dated 4/9/16 at 5:00 a.m. by the Licensed Practical Nurse (LPN) indicated: This morning resident had been resting quietly in his room during the night shift and he came out to the nurse's station (no time) with blood dripping down his arms and had mouth covered saying that he was bleeding. Frank red blood noted by the RT. They came to inform this writer of the bleeding and stated it was a large amount. This writer told the RT to ensure that resident went back to his room and that I would be there as soon as I was done passing the medication that I had poured. Upon entering the room (no time), there was a significant amount of blood on the toilet, walls, resident and on the floor. Approximately 1 liter (4 cups of the 5 liter/20 cup average in the human body) of blood in total. Floor of room, bathroom, couch, resident's clothing and body had blood on it . The NN on 4/9/16 continued: 5:30 a.m. Hospice notified of situation and made note in case the resident passes today. A 5:47 a.m., the nurse manager was contacted and informed .Resident presently in bed and a huge clot is forming in the front of his mouth. Resident wants to be suctioned, however, bleeding slowing down and if clot dislodged, resident will start bleeding profusely again, [MEDICAL CONDITION] airway is not compromised at this time. Other than the LPN's appraisal of the situation, no further documentation was found to determine the cause of the bleeding and if the resident wanted to go to the emergency room (As he requested when his feeding tube came out on 3/21/16. See [DEVICE] below) where he could be suctioned as he requested and per his comfort wishes. The NN dated 4/9/16 at 8:30 a.m. indicated: Doctor in house and informed of situation .no new orders. On 4/9/16 at 12:10 p.m., the RT wrote the resident's oxygen saturation and heart rate were unobtainable. Resident on toilet seat, conscious, bleeding out of his mouth. Nurse notified. At 3:33 p.m. the NN indicated: (oxygen) saturations and heart rate unable to obtain, resident unstable, bleeding from mouth breathing and responding and resident refused tube feeding fluids. On 4/10/16 at 12:20 a.m., the RT noted:Resident refused [MEDICAL CONDITION]. Resident's inner ([MEDICAL CONDITION]) cannula was plugged and at 4:00 a.m., unable to obtain oxygen saturation and heart rate, resident sleeping. According to the NN dated 4/10/16 at 5:50 a.m., RT walked to room to check on resident and found him on the floor in front of his couch with head on the floor. Head to toe assessment showed no new marks .continue to monitor. There was no documentation to indicate comparison of old marks to no new marks or that a thorough assessment had been done. Review of the POS [REDACTED]in bed, sleeping. After the resident fell on [DATE], the LPN wrote a note on the fall report at 5:30 a.m. unable to get neuro's; resident starting to agonal (gasp) breathe, in active process of dying after bleeding significant amount yesterday. On 4/10/16 at 8:50 a.m. the NN revealed: Staff went to check on resident and came to get the nurse on shift .found resident without vital signs . Although the resident asked to be suctioned on 4/9/16 when the profuse bleeding occurred and the NN indicated he was responding, there was no documentation to indicate a thorough assessment was completed by a qualified person to determine the cause of the bleeding and what occurred when [MEDICAL CONDITION] found plugged or if the resident wanted to go to the hospital for treatment over the two days to include assessments to determine the cause of the bleeding and after the fall when the facility documented the resident refused neurological checks. <Gastric (stomach) Tube/[DEVICE]> Resident #21 also had a gastrostomy tube for nutrition and fluids. A Hospice Nursing Note (NN) dated 3/26/16 indicated the resident was observed sitting on the edge of his bed and able to dress himself .gastric feeding tube that he manages and does have a whitish discharge with a malodorous (offensive/bad) smell. He delivers the 6 cans of formula a day per his gastric tube. He reports and wants 10 cans a day. The Comprehensive Care Plan indicated the Resident is independent and prefers to do the feedings himself. There was no documentation to indicate the number of cans and when the feedings should be given or to indicate staff monitored his feedings and stoma site or that the resident demonstrated the ability to safely perform these services for himself. Refer to F 176 for more detail regarding this resident. 2) discharged Resident #22 was admitted to the facility on [DATE] for rehabilitation services following a 4-month hospital stay. He had multiple medical conditions including history of [MEDICAL CONDITION]/heart failure, [MEDICAL CONDITION], stroke, irregular heat beat ([MEDICAL CONDITION]), diabetes and urinary obstruction. The resident received nutritional support via the [DEVICE]. He required extensive assistance from staff for all care. He was alert and oriented and could make his needs known. He wanted all heroic, life-saving measures implemented. According to the facility NN dated 3/19/16 at 2:00 p.m., the resident was alert and oriented. Oxygen saturation was 97% on room air. He had no complaints of pain or discomfort, stable. The NN dated 3/20/16 at 11:00 p.m., indicated the resident was anxious, restless, agitated, confused and observed with long periods of sleep .Pulses in both feet were absent with [MEDICAL CONDITION], unable to obtain because of the [MEDICAL CONDITION]. Bowel tones present .decreased movement of both the right and left upper extremities and both lower extremities. His oxygen saturation was now 92% on 3 liters of oxygen per nasal cannula. The NN dated 3/21/16 at 7:00 p.m. indicated, family here and believe resident has had another stroke and demand he be sent out to the ER. The NN indicated: 911 called due to two hour delay for the contracted transport company to come and transport. Resident did open his eyes and give 1 word response. Slight wheezing noted. Oxygen on at 4 liters per nasal cannula. 911 transported resident via stretcher. According to the ER admission note, the resident was transported from the facility to the ER for Altered mental status (AMS) over the last three days and for nausea, vomiting, constipation and [MEDICAL CONDITION] over the last week with coughing and possible aspiration. The ER assessment dated [DATE] revealed: Constipation related to severe rectal fecal impaction .massive bladder distention; Acute Kidney Injury (AKI) as evidenced by the resident's lab results showing a BUN of 153 (normal range 8- 24); Creatinine was 6.68 (normal range 0.7- 1.5); a potassium level of 7.1 (normal range 3.6 -5.3). A urinary catheter was inserted with an initial output of 3600 cc (15 cups). The resident was also found to have ESBL (Extended spectrum beta-lactamase-superbug) urine infection and aspiration pneumonia. The resident was to have the wound team provide care to his sacrum. The resident was admitted to the Intensive Care Unit (ICU) on a ventilator with heavy return of respiratory secretions. On 4/12/16 at 4:00 p.m., during interview with the resident's family members, it was learned they visited every day. He got really sick the week he was to come home. There was just something wrong. We kept asking them to get a UA (urine analysis). He kept saying he couldn't pee or poop. Why did he keep saying these things? We weren't getting any help for him .he smelled and he was not clean. Just disgusting .he started having [MEDICAL CONDITION] and they refused to send him to the hospital. We felt his belly the night before and it was hard as a rock. There was something more wrong. I had to get him to the hospital. He needed to see the doctor. Kept telling staff he needed to go (to the hospital). They kept telling us his vitals are fine. LN G said oh you just can't take him to the hospital .both of us said we are going to call the ambulance. We threatened that if they did not call 911 we would. 3) discharged Resident #23 was admitted to the facility 12/22/15 with multiple medical conditions including the need for post surgical care following a laryngectomy (removal of voice box due [MEDICAL CONDITION]). As a result of the surgery, the resident could breathe only through the permanent [MEDICAL CONDITION] (stoma) with ventilator support. He had difficulty swallowing. He was alert, deaf and relied on writing for all communication. He was to have assistance when eating/drinking. According to the facility clinical record NN dated 3/26/16 at 2:02 p.m., the resident was alert, oriented and stable. His blood pressure was 130/62. The next NN dated 3/27/15 at 5:14 a.m. indicated the resident's blood pressure was 100/68 and his pulse was 58. The night nurse documented she held the 4:00 a.m. blood pressure medication due to the low pressure and pulse per physician orders. Review of the Medication Administration Record [REDACTED]. The next NN dated 3/27/16 at 7:47 a.m. indicated: Respiratory therapy (RT) reports the resident having difficulty with eating with food particles [MEDICAL CONDITION]. Will put in orders for speech evaluation and notify physician. Placed on alert charting for nutrition and intake. At 12:02 p.m., the NN indicated the Resident was unable to eat or drink, lethargic, restless and his blood pressure was 74/49 (normal reference range 120/70). Another note at 12:49 p.m. indicated the respiratory therapist (RT) reported: Resident noted to bypass food through [MEDICAL CONDITION] while eating nurse practitioner in house and saw the resident today. Received orders to transfer to hospital via 911 for evaluation and treatment .resident left the facility at approximately 1:30 p.m. According to the hospital records, the resident was evaluated in the emergency room (ER) on 3/27/16 at 2:00 p.m. with irreversible expansion .changes in the lungs .there is hyperinflation (can cause tracheal mucosal injury) of the (trach) balloon cuff moderate mass effect and posterior displacement of the esophagus .balloon protruding through the stoma. The resident was placed on a ventilator and transferred to a larger acute care hospital for [MEDICAL CONDITION] and post-surgical care. 4) Resident #6 was admitted to the facility on [DATE] with multiple medical conditions. He was alert and oriented, wanted all life-saving measures (full code) and made his own care decisions. He required extensive assistance of staff for all care and services. On 4/2/16 at 10:25 a.m., Resident #6 was heard from the hallway calling out for help. When asked what was wrong, the resident said: No one listening. Terrible pain whole right side. Look! The leg was swollen with redness up the leg. He said he had been in terrible pain for days and nobody is helping me. I need to go to the hospital, please! At 10:30 a.m., when asked about the resident's condition, Licensed Nurse (LN) A said: I just gave him some pain medication. He (resident) is insisting on going to the hospital, so I am calling the doctor now. Review of the resident's pain medication record indicated he received pain medication at 10:00 a.m., for excruciating pain. Review of the resident's record indicated on 3/31/16 at approximately 3:23 a.m., the resident complained of right side pain with a level of 8 of 10. The documention at 2:46 p.m., indicated: Resident was lethargic this morning and hard to arouse for breakfast .LN checked vitals and oxygen saturation, 79% on room air (reference range 92-100%). Oxygen administered and saturation was 86% and after a couple of minutes was 94%. Tylenol was given for low grade temperature and cold wash rag to forehead. No assessment of the right leg/side was found. According to the record, on 3/31/16 at 6:00 p.m., Redness to his right lower extremity found by NA .hot to touch with [MEDICAL CONDITION] present. On 4/1/16, the resident continued to complain of severe pain. On 4/2/16 at 10:45 a.m., the record indicated: Resident insisted upon going to the hospital related to severe pain to entire right side of body .right lower leg swollen, reddened and warm to touch. Nurse practitioner notified and gave okay to send to hospital .resident in too much pain to decide on bed hold . The hospital records indicated the resident arrived in the emergency room (ER) on 4/2/16 at 11:00 a.m., with an oxygen saturation of 75% on room air. Right lower leg with severe 3 to 4+ [MEDICAL CONDITION], redness and induration (firmness/hardness) all the way up the thigh to the hip and down to the toes. White blood count was 35,700 (reference range 4-12,000) indicating a severe infection. The note continued: Right lower leg [MEDICAL CONDITION] (swelling/infection);[MEDICAL CONDITION] (life-threatening condition secondary to [MEDICAL CONDITION]); need to rule out necrotizing (process of dying tissue) infection and monitor the demarcation (border) area of redness up to hip, monitor for any progression . No pain assessment was found in the records and on 4/7/16, the DNS provided an assessment which she stated she performed on 4/1/16, the day before the resident was admitted to the hospital. No description of the resident's leg was documented on the assessment other than RLE (right lower extremity) [MEDICAL CONDITION]. Failure to ensure timely and accurate assessment of the resident's pain and condition of his right leg/right side and to send him to the hospital at his request resulted in the resident's decline, pain and delay in treatment.

Based on observation, interview and record review, it was determined the facility failed to ensure nursing staff followed accepted professional standards of practice for 10 of 12 sampled Residents (#6, #9, #8, #10, #11, #12, #13, #14, #29, #15) reviewed for medication administration; and for 1 former Resident (#21) and 2 discharged Residents (#22 and #23) who needed assessments and timely intervention /accurate documentation for significant changes in condition. This failure represented a lack of vigilance, quality of care and system error breakdown that placed all residents at risk of the same/similar deficient practices and for Residents #6, #21, #22 and #23 represented Immediate Jeopardy. Findings include: The Washington State Nurse Practice Act, WAC 246-840-710 (2) in part indicates nurses violate standards by: (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly: (d) Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards (c) Willfully or repeatedly failing to make entries .pertaining to the giving of medication, treatments, or other nursing care . (i) Failure to protect clients from unsafe practices or conditions . and (8) The nurse shall have knowledge of the statutes and rules governing nursing practice . Facility nursing staff repeatedly failed to assess, monitor, intervene and evaluate and accurately time and document when changes in condition, vital signs, mentation and/or function occurred. 1) Resident #21. Nursing staff failed to assess for the cause and respond to profuse bleeding from his mouth and failed to perform a nursing assessment, implement interventions or obtain a provider's onsite evaluation and/or send the resident to the emergency room (ER) when his condition clearly warranted some type of intervention the facility could not provide. 2) discharged Resident #22. Nursing staff failed to assess the resident when a significant change in condition occurred. Upon arrival to the hospital, the resident was placed on a ventilator and admitted in critical condition to the Intensive Care Unit (ICU). 3) discharged Resident #23. The nursing staff failed to adequately monitor the resident's vital signs and administered anti-hypertensive medication without checking blood pressure (BP) and pulse first as per physician's orders [REDACTED]. 4) Resident #6. Nursing staff failed to identify and respond to a significant change of condition when he complained of excruciating right sided pain and experienced a change in mentation. Nursing staff failed to honor the resident's request to go to the ER in a timely manner. He was admitted to the hospital with [REDACTED]. Refer to F 309 for more detail regarding these residents. <Medication Administration> According to nursing literature, Safety is the main concern in medication administration .preparing medications carefully and recording their administration. Use of the Medication Administration Record (MAR) ensures timely and safe medication administration (Fundamentals Nursing Skills and Concepts, 9th Ed. (2009) Lippincott, Williams and Wilkens, Chapter 32, page 771). Medication administration includes the 8 Rights: Right patient; Right medication; Right dose; Right route; Right time (double-check that you are giving the ordered dose at the correct time and confirm when the last dose was given); Right documentation AFTER giving the ordered medication, site of injections, vital signs checked before giving the drug; Right reason and Right response. (Nursing 2012 Drug Handbook. (2012). Lippincott Williams & Wilkins: Philadelphia, PA). The facility's Policy/Procedure - Nursing Clinical regarding Injections, Insulin (Revised 5/2007), indicated after withdrawing ordered dosage of insulin, to place protector on needle. Item #10 was Select injection site based on planned site rotation. Rotate insulin injections between the different sites. 5) On 4/7/16 at 7:35 a.m., LN J was observed to administer medications. She drew up insulin at the cart and left the needle exposed and without taking the cart to the room, walked into room [ROOM NUMBER]. The LN was asked who she gave the insulin to and she was not able to say. After looking at her notes, she pointed to Resident #8's name as the resident who received the insulin. The LN did not consult the MAR to recall which resident received the medication. When informed by the Surveyor that she had walked down the hallway with an open needle rather than covering it with the retractable cover, the nurse said, I thought I did that. 6) At 9:20 a.m., LN B was observed to administer Medications to Resident #9. Without taking the medication cart, she carried an exposed needle filled with insulin to the room. and Injected into the resident's Left Upper abdomen. On return to the cart, the LN was asked about the exposed needle and not twisting a shield to cover over it. She stated, I must have forgot. She did not document the site of injection. LN B was asked to show where the expiration dates were located on some of the medications. She said, Oh. Sorry and pulled Resident #9's insulin back out of drawer, looked at the vial for a few moments until she found the expiration date. At 1:30 p.m., LN B was asked about documenting injection sites in their electronic MAR system. She was asked if the expectation was to rotate injection sites? The nurse answered Yes and showed it was possible to select among numerous sites including each 4 abdominal quadrants, right/left rear arms, thighs, etc. Asked if she can tell where the site the last injection was given, the nurse stated, I don't know why you would do that? The nurse pulled up the insulin administration record for Resident #9, which documented the administration site of every dose of Insulin was given at 9 a.m. was abdomen without indication of the location of the injection. <Gastric (stomach) Tube> According to Residents' MARs: Enteral Feed Order, every shift PLACEMENT VERIFICATION VIA AUSCULTATION AND ASPIRATION PRIOR TO FEEDINGS / FLUSHES / MEDS. DOCUMENT #CC'S ASPIRATED & REPLACE. 7) At 9:35 a.m., Resident #10 was observed for medication administration. In reviewing the MAR and pulling medications, LN B stated, She usually likes [MEDICATION NAME]. Let me see if she can have it. Yes, she can have it. The LN was observed to place all the Resident's pills into the same cup, transfer to a plastic envelope, crush all meds together in same envelope, poured crushed pills into a cup, added water from the hot water dispenser on the beverage cart, swirled meds to dissolve them, then add ice water from pitcher on beverage cart. On entering the room, the LN spoke with resident telling her that she had brought her medications and told her she had [MEDICATION NAME] (anti-anxiety) medications. No discussion or assessment about resident's level of anxiety was done. The LN then disconnected the gastric tube feeding and without listening for tube placement, removed the plunger from the syringe, poured fluid with medications into the syringe. The medications did not flow. The LN then placed the plunger in the syringe and applied pressure twice and was still unsuccessful. She removed the plunger and poured the medication solution back into the cup. 8) At 9:45 a.m., Resident #11 was observed for medication administration. After LN B measured the [MEDICATION NAME] [MEDICATION]) solution, she poured it directly into the cup with [MEDICATION NAME] (laxative) liquid. She crushed all meds together in the same envelope. Mixed them in hot water first from Hot Water Dispenser from beverage cart, then ice water from pitcher and followed the same procedure as observed with Resident #10. Asked about expiration dates on cards of medications already given to Resident #11, she looked for a time and located the expiration date by peeling back the pharmacy label to see it. <Oral and Inhaled Medications> 9) On 4/7/16 at 10:00 a.m., LN A was observed during medication administration to Resident #12 and left medications at the bedside. The LN was observed to withdraw medication cards from the locked drawer in the medication cart, pop out the medications from the bubble packs and return them to the drawer. He then opened the narcotic book and signed out the narcotic medication. No comparison observed between product on hand and narcotic sheet and no pain assessment performed before pouring the medication. When in the room, the LN was observed to wait while the resident swallowed pills, then take sips of [MEDICATION NAME]. Resident put cup with [MEDICATION NAME] on the bedside table and the LN said, You need to finish that, it's your [MEDICATION NAME], and walked out of room. 10) At 10:15 a.m., LN A was observed to administer medications to Resident #13. The LN took the poured medications to the Dining Room. The LN administered oral meds first, then an inhaler, then another [MEDICATION NAME] inhaler with 2 puffs in rapid succession, less than 5 seconds apart then asked the resident to return to his room for another nebulizer treatment. Medications were given in a public area. The LN asked the resident to return to his room to have breathing treatment at which time no respiratory assessment was performed. The LN located the nebulizer and tubing among clothing and other items on the seat of a chair next to resident's bed, the LN opened the nebulizer, administered a dose, then handed the resident a mask to put on before starting the nebulizer treatment. At 10:26 a.m., when the LN returned to cart, he was asked if there was a specific amount of time that is recommended to wait in between puffs of [MEDICATION NAME]. The nurse replied, a few seconds. The LN was asked if there were any written instructions about timing when giving [MEDICATION NAME]. The LN pulled out the box, took the medication information insert out, unfolded it, scanned it, and said: No, there's nothing like that. The surveyor looked at the pharmacy label on the resident's box of [MEDICATION NAME], asked the nurse to read instructions from the pharmacy printed on the label which was: Wait 1 minute between puffs. The LN read the instructions aloud and stated, I did not know that. 11) At 10:33 a.m., medication administration by LN A was observed for Resident #14. The LN said an aide told him the resident requested a pain med. The LN removed a dose of [MEDICATION NAME] (narcotic) from the locked drawer and then signed it out in the narcotic book. The LN did not perform a pain assessment and did not sign in the MAR that the medication was given. At 12:46 p.m., nearly two hours later, the printed MAR did not indicate the medication had been given or what the pain level was prior to administering the medication. 12) On 4/19/16 at 1:00 p.m., during interview with Resident #29, he complained of his medications constantly being late and not getting any better. The resident stated at times he receives his medications at 2:00 a.m. when he should have received them at bedtime. Review of the resident's MAR and facility records indicated LN N failed to provide correct doses at correct times for [MEDICATION NAME] and [MEDICATION NAME] (both for muscle spasm) medication and narcotic pain medications within the required times ordered on [DATE]; 4/9/16; 4/10/16. <Signing Off Meds At a Time Different Than When Acutally Given> 13) After returning to the med cart, LN A was observed to mark meds on the MAR as given while not removing them from the cart. The LN clicked through the medications and said: Already gave that, and that, and that. When the surveyor asked if he should mark them when taking them out of the draw, the LN said, Yes but I didn't have time earlier. When asked is it to do a double check to know when you're pulling the meds that you're giving the right medication to the right resident at the right time, the LN paused before answering and then stated: I think I'm pretty reliable. 14) At 10:50 a.m., LN G was observed to administer medications to Resident #15. The LN told the resident, I have your meds. The Resident asked: Which ones? The LN paused then started to recite some medication names from memory then stopped and asked the resident: Do you want the list? The resident answered, No, that's okay. The LN administered [MEDICATION NAME] (nasal spray) and assisted the resident without gloves by occluding each nostril. The LN gave 2 inhaled meds (Qvar and [MEDICATION NAME]), then asked the NA to bring a cup of water from the med cart. LN G then handed the cup of water to the resident and asked her to rinse her mouth and spit after the last dose. The LN stated to the resident, Sorry, she (surveyor) is going to make me do that. During these observations the following problems were identified related to lack of nurses providing care and services according to accepted professional practice standards: Combining crushed meds and giving all at one time via tube feedings without checking for placement; Giving narcotics and anti-anxiety medications without assessments. Timing medication administration for times noted on the MARs rather than the times actually administered such as those noted on the MAR to be given between 7:00 a.m. - 9:00 a.m. when observations after 10:00 a.m. were the actual times administered. Additional problems were transporting of uncovered needles down the hallway, Incorrect inhalation administration, Controlled (narcotic) medications not reconciled/signed out; Practice of giving medications and documenting later or not documenting at all; Leaving medications at the bedside; unclean trays being carried from room to room; lack of documentation to injection site locations; and the SDC modeling improper med administration responsibility to offer to perform medication administration for another LN. Refer to F 333 and F 353 for more detail regarding these residents.

Based on observation, interview and record review, it was determined the facility neglected to perform personal care, timely assessments, evaluate, treat and/or implement ordered interventions for 2 of 4 sampled Residents (#17, #6), 1 former Resident (#21) and 2 discharged Residents (#22 and #23) reviewed for neglect. This failure resulted in harm to these residents when staff neglected to promptly recognize/intervene for residents who requested and/or demonstrated the need for immediate/emergent care and resulted in Immediate Jeopardy for Resident #6, #21, #22 and #23. In addition, dependent Resident #17 was harmed when staff neglected to position her hand to prevent injury; dependent Residents #2 and #3 were harmed when staff neglected to provide incontinence care and services that affected their health, comfort and/or safety. Findings include: 1) Staff neglected to intervene on 4/9/16 at 5:00 a.m. when Former Resident #21 lost approximately 4 cups of blood from his mouth and continued to bleed for two days before his passing. 2) Staff neglected to intervene when discharged Resident #22 demonstrated a significant change in condition/decline in mentation and function and required oxygen on 3/20/16 at 11:00 p.m. 3) Staff neglected to intervene when discharged Resident #23 received blood pressure (BP) medication without assessment and was found 5 hours later with a critically low BP of 74/49. 4) Staff neglected to intervene when Resident #6 complained of excruciating pain on his entire right side. Refer to F 309 for detail regarding these residents. 5) Staff neglected to ensure dependent Resident #2 and #3, were provided incontinence care in a timely manner. Refer to F 241 and F 312 for detail regarding these residents. 6) Staff neglected to ensure dependent Resident #17 was properly positioned and re-positioned in her wheelchair over a 6-hour period and resulted in harm to her right hand. Refer to F 323 for detail regarding this resident.

Based on observation, interview and record review, it was determined the facility failed to ensure the safety and supervision of 1 of 1 sampled Residents (#17) when she was placed in the wheelchair with her hand underneath her which was unobserved for approximately 6 hours. Failure to ensure the resident was properly positioned in the wheelchair (w/c) and monitored for repositioning resulted in harm to the resident and placed all residents at risk of a similar event when being improperly positioned and without monitoring. Findings include: Resident #17 was admitted to the facility on [DATE] with multiple health conditions including a stroke with right-sided weakness/paralysis, gastrostomy (feeding tube in stomach) and dementia. She was totally dependent on staff for all care. The resident required a Hoyer (mechanical lift) for all transfers. On 4/14/16 at 11:30 a.m., Nursing Assistant (NA) 9 and NA 10 used the Hoyer to transfer the resident from the bed to the w/c. The resident indicated her right hand hurt when it was touched. Her hand was discolored/light purple from the wrist to her darker purple fingertips. The fingers were concave-appearing and bent at the last joint on the fingers. There was a small white dressing on the top of the hand and a black dime-sized area to her index finger. The NA asked the resident if her hand hurt and she said ow and winced when lightly touched by the NA. The NA said when the resident was mechanically lifted to the w/c a couple of weeks ago her hand was caught in the Hoyer transfer sling. At noon, the on duty Licensed Nurse (LN) K was asked about the resident's hand and if it looked different than before the injury. The LN was unable to describe the resident's hand prior to the event and although worked regularly with the resident, had not seen her hand since the accident on March 17, 2016. Review of the investigation log dated 3/17/16 indicated blister. Review of the report indicated the resident was placed in her w/c around 11:30 a.m. with a lap blanket covering her. She was observed by staff at various times throughout the day in her w/c in the Dining Room and TV room and was found sitting on her hand after dinner around 6:00 p.m. It took two people to lift the resident up to remove her hand from under her and the resident did not appear to be able to move her arm. The hand was very red with the imprint of the mesh sling to the back of her hand with what appeared to be the beginning of bruising and blister to her finger. The statement continued: .NA's (evening shift) said neither of them had helped the resident to get up and the resident had been sitting in her w/c since the beginning of their shift at 2:00 p.m. The investigation concluded: It is reasonable that the resident had moved her hand under her leg independently. This conclusion was not congruent with her previously assessed abilities. .

Based on observation, interview and record review, it was determined the facility failed to provide personal care to 4 of 12 dependent sampled Residents (#2, #3, #4 and #5) reviewed for Activities of Daily Living (ADLs) and who were unable to provide personal grooming and hygiene care for themselves and resulted in harm to Resident #2 and #3 who were left for a prolonged period of time in soiled beds and clothes. Findings include: 1) On 4/2/16 during morning tour at 9:15 a.m., Resident #2 and #3, who shared a room and were totally dependent on staff for all care and services, were observed in bed. From the hallway, an overpowering odor of urine/ammonia was noted and worse when entering the room. Resident #2 was fully visible from the hallway. Her briefs were saturated with urine and dried stool. She was attempting to get out of bed. Resident #3 was in bed. The linens under her upper body/shoulders were visibly stained brown. The residents remained in this condition until 10:30 a.m., when LN A was asked to provide help to the residents. He was busy and requested help from others. At 4:00 p.m., during interview with the DNS, she said she is in the facility often during off-hours and had never found residents in the condition she found Resident #2 and #3 and it did not make her feel good. 2) On 4/7/16 during tour at 6:45 a.m., Residents #2 and #3 were observed in bed. An odor of urine was present. Resident #3 said neither she nor her roommate had any care all night. Both residents were found incontinent by NA 6 who said she had been in the room alone providing care since she came on duty after 6:00 a.m. When asked why the residents did not receive care during the night, the NA thought it could be the way the units were divided for care as this room was not identified. She said: When I work, I start in this room first because of it. Resident #3 said: I have been here all night waiting for help. I'm wet and no one helped me. 3) On 4/7/16 at 9:00 a.m., Resident #4, who was totally dependent on staff for all care and services was observed in a hospital gown in his wheelchair in the hallway. The resident was using a ventilator and unable to speak. He kept hitting the left arm of his wheelchair. Staff members walked by telling him to wait just a minute and he would be helped soon. At 9:15 a.m., NA 2 approached the resident and asked if he needed to go to the bathroom and the resident indicated yes. The NA took the resident to his room and used the mechanical lift to put the resident in bed and offered the bedpan. Review of the Resident's records indicated he had fallen from his bed on 3/25/16 due to trying to get out of his soiled bed after having loose stools. 4) On 4/2/15 at 9:15 a.m. Resident #5 was interviewed. He was in bed and assisted to breathe with a mechanical ventilator. He had limited movement of his head and could not move from the neck down. The resident was alert and oriented and could make his needs known. His speech was clear and understandable. He said he felt staff members tried to provoke him to anger with the tone of their voices, the looks and behaviors and there's not enough qualified staff to take care of me and others here. At 11:00 a.m., during observations of personal care, the resident's catheter bag was full. When asked, NA 7 told the resident he refused to let her empty it earlier. The resident denied he refused and asked the NA: Why would I refuse to let you empty my catheter bag? I did not tell you that. The NA told the resident he had been asked three times to let her empty the catheter bag. When the NA tried to empty the bag, she did not know how to do so and the resident tried to provide instructions to her. The interaction continued and when the NA left, the resident said: See that's what I mean. She didn't even know how to empty the catheter bag, so she said I refused. Did you hear me try to tell her how to do it? They try to provoke me to get mad. Look at me. I can't do anything. I am at their mercy. They can do and say whatever they want and I can't do a thing about it. When asked if he told anyone about his treatment/feelings, he said: I used to but it doesn't do any good. Yes, I have spoken the Social Services Director (SSD) and then I was asked if I wanted to move out of the facility by the administrator. This is my home, I like being in this town but I feel if I complain about things, they will move me. The administrator asked me twice if I wanted to move because I was so unhappy. 4a) On 4/7/16 at 8:30 a.m., Resident #5 was in his electric wheelchair in a hospital gown going to the dining room. At the end of the hallway intersection approaching the 300 unit, he became stuck between another resident and the food distribution cart. The wheels of his chair became entangled with another resident's wheelchair and he could not move. Staff members were in the area where the resident was in clear view. LN G approached the area and moved the food cart but did not help the resident or say anything to him. He still was unable to get untangled from the other resident's wheelchair. He continued to move his chair back and forth and eventually able to get through the hallway. When asked about needing help at this time, the resident said: I'm used to it .they don't care. When asked about going to the dining room in his hospital gown, the resident said: It's okay. There is not enough people to help get me up and dressed and if I don't get to breakfast, I miss it.

Based on observation, interview and record review, it was determined the facility failed to provide care in a respectful manner to promote, maintain and/or enhance dignity for 4 of 12 sampled residents (#2, #3, #4 and #5) reviewed for dignity and resulted in harm to Resident #2 and #3. Failure to provide care in a manner that treated residents with dignity and respect created an environment in which a reasonable person would have felt embarrassment, diminished self-esteem and helplessness. Findings include: 1) On 4/2/16 at approximately 9:15 a.m., dependent Resident #2 and #3, were observed in bed. Resident #2 was fully visible from the hallway. Her shirt was up around her stomach and briefs and bed were saturated with urine and dried stool. Resident #3 was in bed. The linens under her upper body/shoulders were visibly stained brown. Her linens were saturated with urine. The Director of Nursing Services (DNS) who was called in to the facility due to the surveyor's visit, assisted other staff members to help residents into clean, dry clothes and beds. Resident #3's bed linens were saturated through to the mattress and dripped urine. The resident had dried bowel contents around her perineal area and liquid stool. At 4:00 p.m., during interview with the DNS, she said she is in the facility often during off-hours and had never found residents in this condition before and and it did not make her feel good. On Friday 4/7/16 during tour at 6:45 a.m., Residents #2 and #3 were observed in bed. An odor of urine was present. Resident #3 said neither she nor her roommate had any care all night. Both residents were found incontinent by NA 6 who said she had been in the room alone providing care since she came on duty after 6:00 a.m. When asked why the residents did not receive care during the night, the NA thought it could be the way the units were divided for care as this room was not identified. She said: When I work, I start in this room first because of it. Resident #3 said: I have been here all night waiting for help. I'm wet and no one helped me. At 4:15 p.m., during interview with the DNS, she was not aware the residents had not received care during the night and would follow up but thought the assignments were clearly divided to include this room and felt the residents had received care. 2) On 4/7/16 at 9:00 a.m., Resident #4, who was totally dependent on staff for all care and services was observed in a hospital gown in his wheelchair in the hallway. The resident was using a ventilator and unable to speak. He kept hitting the left arm of his wheelchair. Staff members walked by telling him to wait just a minute and he would be helped soon. The resident continued to hit his hand on the wheelchair. When asked if he needed help, he nodded and pointed to his abdomen. He indicated he needed the bathroom. At 9:15 a.m., NA 2 approached the resident and asked if he needed to go to the bathroom and the resident indicated yes. The NA took the resident to his room and used the mechanical lift to put the resident in bed and offered the bedpan. Review of the Resident's records indicated he had fallen from his bed on 3/25/16 due to trying to get out of his soiled bed after having loose stools. 3) On 4/2/15 at 9:15 a.m. Resident #5 was interviewed. He was in bed and assisted to breathe with a mechanical ventilator. The resident was alert and oriented and could make his needs known. He said he felt staff members tried to provoke him to anger with the tone of their voices, the looks and behaviors and there's not enough qualified staff to take care of me and others here. At 11:00 a.m., during observations of personal care, the resident's catheter bag was full and needed to be emptied and NA 7 told the resident, in front of others in the room, that he refused to let her empty it earlier. An uncomfortable interaction followed between the Resident and the NA. The resident said: See that's what I mean. She didn't even know how to empty the catheter bag, so she said I refused. Did you hear me try to tell her how to do it? They try to provoke me to get mad. Look at me. I can't do anything. I am at their mercy. They can do and say whatever they want and I can't do a thing about it. This is my home, I like being in this town but I feel if I complain about things, they will move me. 3a) On 4/7/16 at 8:30 a.m., Resident #5 was in his electric wheelchair in a hospital gown going to the dining room. At the end of the hallway intersection approaching the 300 unit, he became stuck between another resident and the food distribution cart. The wheels of his chair became entangled with another resident's wheelchair and he could not move. Staff members were in the area where the resident was in clear view. Licensed Nurse (LN) G approached the area and moved the food cart but did not help the resident or say anything to him. He still was unable to get untangled from the other resident's wheelchair. He continued to move his chair back and forth and was eventually able to get through the hallway. When asked about needing help at this time, the resident said: I'm used to it .they don't care. When asked about going to the dining room in his hospital gown, the resident said: It's okay. There is not enough people to help get me up and dressed and if I don't get to breakfast, I miss it. At 3:45 p.m., during interview with the Social Services Director (SSD), it was learned the resident had fewer complaints this year compared to last year. She was not aware of some of the resident's concerns that it did no good to complain because no one cared and he was afraid of being moved. When told of the interactions with staff and how the resident felt, she said she understood and would follow up with the resident and staff immediately. Refer to F 353 for more detail regarding these residents.

Based on observation, interview and record review it was determined that the facility failed to ensure assistive devices were used in the manner they were intended for 1 of 4 (#1) Sampled Residents reviewed for accidents. This failure caused Resident #1 for fall from the lift causing injuries that required emergency surgery. The facility used two different slings, a shower sling and a disposable sling, in a manner in which they were not intended. This failure caused harm to Resident #1. Findings Include: Observations on 9/18/13 at 12:45 p.m. revealed Staff J was opening plastic packaging with new mechanical lift slings inside. Staff J reported slings have a 6 months life span after initial use and slings throughout the facility were being replaced. SHOWER SLING: During an interview on 9/18/13 at 3:00 p.m. Staff B reported that on 9/16/13 Resident #1 was being transferred into her bed by using a mechanical lift. Staff B further reported that while Resident #1 was in the sling, lifted into the air, between beds, the sling broke, causing Resident #1 to fall to the ground and partially landing on the legs of the lift. During an interview on 9/18/13 at 3:05 p.m. Staff B reported she had not yet finished her investigation. Staff B further reported the sling used at the time of the incident had been thrown away. Staff B confirmed there was not any of the same type that was being used when the incident occurred to be visualized by the surveyor. Staff B reported she did not have an invoice to evidence when the sling had been purchased by the facility. Review of the manufacturers recommendations for use of sling revealed slings are available in sizes ranging from small through double extra-large, and the sizes varied "significantly depending on the resident's size and girth. The instructions indicated each size of sling is designed to support a specific weight range. Further review of the instructions, revealed directives, "sling must be dated prior to being put in use." Review of the investigation confirmed while Resident #1 was raised into the air, the sling that was securing her tore and gave way causing the resident to fall. The investigation indicated there was not a tag to indicate the size of the sling. Additionally, the sling did not have a visible date. During an interview on 9/18/13 at 3:05 p.m. Staff B confirmed there was not a tag on the sling used in the incident. Staff reported she did not know if the sling was the appropriate size for the resident. Staff B further reported the sling was not dated and she did not know how long the sling had been in use. Review of the shower sling manufacturer's instructions indicated bleaching agents should never be used when laundering slings. The manufacturer's washing instructions directed staff to wash sling separately from other items. During an interview on 9/25/13 at 9:05 a.m. Staff G reported she does laundry in the facility. Staff G reported she washes the slings in the washing machines with sheets. Staff G confirmed when she washes sheets a bleaching agent is used. Three minutes later, at 9:08 a.m., Staff B was observed talking to Staff G in the hallway outside of the laundry room. At that time Staff G approaches the surveyor and reported she had given incorrect information earlier, and that actually she does not wash slings with the sheets in the bleach solution. During an interview on 9/25/13 at 9:12 a.m. Staff B reported she had asked Staff G how she laundered the slings and Staff G reported she occasionally washed them with the sheets. Staff B reported that is not what we do, we wash them with personal items. When the surveyor attempted to clarify with Staff B that Staff G reported to her she does occasionally wash the slings with the sheets, Staff B again insisted Staff G had reported in error and what she said was wrong. Staff B again reported the slings are always washed with personal items. The manufacturer's instructions address both not using bleach solutions as described by the laundry staff and not washing sling with any other items such as the personals that Staff B reported. Both staff reported a different way laundering the slings, and both were not according to the manufacturer's directions. During an interview on 9/25/13 at 9:00 a.m. Staff D reported he/she had not requested the facility administration to purchase new slings, but had heard staff did report sling wear and tear and the need for new slings. During an interview on 9/25/13 at 9:08 a.m. Staff E confirmed there had been staff requests made for the facility to purchase new slings, however, up until Resident #1's fall, only a few had been replaced. During an interview on 9/25/13 at 8:38 a.m. Staff F also reported there had been requests made by staff for the purchase of new slings, but they had not yet received them until the fall. Washing slings in a bleach solutions, extended laundering and exposure to soap and water in the shower daily all contributed to faster material breakdown. Failure to date the sling when it was put into use in the facility allowed staff to use the sling beyond the timeframe in which it was intended and placed residents at risk for injury. Failure to identify the tag was missing indicated staff used a sling without first ensuring it was the proper size to hold the resident's girth and weight. All of these factors combined potentially contributed to the breakdown in material that caused Resident #1 to fall. Review the hospital records indicated Resident #1 arrived at the hospital following the fall from the sling with injuries to include a rapidly bleeding laceration on her spleen, and five fractures to her left side ribs. Resident #1 underwent emergency surgery to remove her spleen. Upon the last day of investigation in the facility 9/25/13, Resident #1 remained in the hospital. DISPOSABLE SLING Observations on 9/18/13 at 1:45 p.m. revealed a white fabric sling with rainbow colored handles in Resident #1's room sitting on her chair. The sling had Resident #1's name written on it, but no date. Further inspection of the sling revealed directions on the sling that indicated the sling is disposable and is intended for a single use. The sling also had a tag that read "do not use this has been washed." The sling appeared stretched, thinned, and worn. During an interview on 9/18/13 at 3:00 p.m. Staff B reported following the incident in which Resident #1 fell , she went through the facility removing all slings that were worn, did not have tags, or were not dated. On 9/18/13 at 3:18 p.m. Staff B observed the white fabric sling in Resident #1's room and confirmed it was a disposable and should not be used more than one time. Staff B reported Resident #1 did not use the sling, it would not even fit on the facility's mechanical lifts. Staff B reported she did not know where the sling came from, but possibly from the hospital or paramedics the last time the resident was transported. Review of Resident #1's records with Staff K revealed the last time Resident #1 had been hospitalized had been over one year ago, in January of 2012. During an interview at the hospital on [DATE] at 8:15 a.m. Resident #1 reported she likes the white sling in her room and prefers to use it. Resident #1 reported she had never made a request for a shower sling, the one that broke was just by chance that it was used during her shower. Resident #1 reported nobody at the facility had ever told her the white sling should not be used more than once, or told her there were risks involved with using a sling in a way that it was not intended for. Resident #1 further reported she had used the sling for months, and months, maybe close to a year. Resident #1 reported the sling had gone through the laundry at the facility. During an interview on 9/25/13 at 8:45 a.m. Staff C confirmed Resident #1 had been using the white sling when up in her chair, and it had been attached to the facility's mechanical lift. During an interview on 9/25/13 at 9:18 a.m. Staff E confirmed Resident #1 had been using the white disposable sling when getting up into her chair. During an interview on 9/25/13 at 9:15 a.m. Staff D reported she wasn't sure how long Resident #1 had been using the white sling, but it had been several months. During an interview on 9/25/13 at 9:12 a.m. Staff F reported Resident #1 had been using the same white sling for approximately 1 year and it was attached to the facility's mechanical lift system. Review of manufacturer's instructions for disposable slings includes although they may be used more than one time they break down if wet from being soiled or being laundered. The instructions included directives that the sling had a "wash indicator." The wash indicator changes when washed to read I have been washed to alert staff not to use the disposable sling. Review of Resident #1's medical record on 9/25/13 at 9:45 a.m. with Staff H revealed there was no documentation that risks of using a disposable sling had been explained to the resident. Repeated use and laundering of a sling that was intended for brief use placed the garment at risk for breakdown in material, potentially placing the resident at risk for falls, and/or injuries.

Based on interview and record review the facility failed to ensure emergency equipment was accessible, implement appropriate interventions and provide adequate supervision to 1 of 9 Sampled Residents (#1) identified at risk for aspirating. This failure resulted in harm due to the resident not receiving the necessary and appropriate emergency response to a choking episode. Findings include: Resident #'s 1 [DIAGNOSES REDACTED]. The resident was determined to be at risk for aspiration by the speech therapist. Interview with Staff K on [DATE] at 11:30. a. m. revealed on [DATE] while administering medication at approximately 8:00 a.m. Staff K saw Staff N motion that she needed assistance; Staff N was feeding Resident #1 in the dining room and the resident appeared to be choking. Staff K retrieved a suction machine from the nurse's station because no suction machine was available in the dining room. The suction machine in the nurse's station had to be put together and there was no suction catheter or yankauer (oral suctioning tool) available. Staff N brought the resident to Staff K because there was no extension cord available for the suction machine to reach the resident. Staff K attempted to suction the resident using the connecting tube for the suction machine. Staff K told Staff N to get Staff J. Staff K said she thought she heard Resident #1 take a breath just before Staff J entered the dining room. Staff K indicated only one to two minutes elapsed from the time she began suctioning to when Staff J arrived. When Staff J entered she instructed Staff K to stop suctioning because "she's gone". Interview with Staff J on [DATE] at 9:10 a.m. revealed on [DATE] Staff N informed her that she was needed in the dining room. Upon entering the dining room Staff J saw Resident #1 with her head hanging, her face and lips were purple. Staff J instructed Staff K to stop suctioning "she looked expired". Staff J said she felt for a carotid (neck) pulse which was not perceptible and looked for the chest to rise which was not visible. Staff J said she attempted one abdominal thrust while the resident was in the wheel chair; the resident began to shake so she stopped. Staff J then instructed staff to take the resident to her room. The staff used a Hoyer lift (an assistive device for transferring residents with limited mobility) to transfer the resident to her bed. Staff J checked the resident's code status and decided not to call 911; Staff J then retrieved a stethoscope and Staff M used the stethoscope to listen to the resident's chest and back and determined the resident was without pulse and respirations. Interview with Staff M on [DATE] at 9:15 a.m. revealed Resident #1 was already in bed when she arrived in the resident's room around 8:20 or 8:25 a.m. Staff M used a stethoscope and found the resident was without respirations or pulse. Staff M then handed the stethoscope to Staff J for Staff J to assess. Staff M then asked Staff O to assess the resident because the facility policy required two RNs (registered nurse) to assess a resident to pronounce a death (Staff J was also an RN). Statement by Staff N indicated while feeding Resident #1 the resident began coughing and turned purple. Staff N called for Staff K. Staff K observed the resident then immediately left to get a suction machine. Staff N moved Resident #1 close to the suction machine; the resident coughed, tried to spit then exhaled. Staff K told Staff N to get Staff J from her office. Staff J arrived checked the resident's neck and wrist then said, "Guys she's not breathing." Staff J instructed Staff N to take the resident to her room; Staff J cleaned the food from the resident's mouth with a wash cloth. Staff J rubbed the resident's chest and said, "Guys she's getting cold, very cold." The resident was still in the wheel chair at this point. Staff N indicated she tried to push the resident forward so the staff could attempt the Heimlich maneuver (abdominal thrusts) but Staff J informed her, "She is big we cannot do that." Observation of suction equipment and emergency carts in facility revealed flow-sheet used to check emergency equipment was initiated on [DATE]. Staff B indicated on [DATE] at 10:00 a.m. the emergency equipment was already available the flow-sheets to check the equipment was added on [DATE]. Emergency equipment was not readily accessible and available for use when Resident #1 choked during breakfast on [DATE]. The staff never obtained the equipment needed to adequately suction the resident. The staff never attempted abdominal thrusts (Heimlich maneuver) while the resident was conscious; when the resident lost consciousness and the staff never followed the facility procedure for clearing the airway of an unconscious resident.

Based on interview and record review the facility failed to ensure licensed nurses followed the current standard of practice and facility policy during an emergent situation. This failure resulted in harm due to untoward effects resulting from not following standards of practice. Findings include: Record review of facility policy for Response to choking situation instructed staff to assess for consciousness. If the resident is conscious and distress is noted implement the [MEDICATION NAME] maneuver (abdominal thrusts). If the resident is not conscious, position the resident on their back, call paramedics and initiate CPR. Interview with Staff B on [DATE] at 2:00 p.m. revealed the facility used a Code Blue response system for medical emergencies. The response system summons staff to the location of the emergency. Staff B said all staff were trained on how to call a Code Blue. Interview with Staff K on [DATE] at 11:30. a. m. revealed on [DATE] at approximately 8:00 a.m. Resident #1 was observed choking in the dining room. After assembling the suction machine located at the nurse's station Staff K found that a suction catheter or [MEDICATION NAME] (oral suctioning tube) was not available. Staff K suctioned the resident using the connecting tubing. (The facility has a ventilator unit with suction devices available.) Staff K did not get the appropriate suction devices or send someone to get the suction devices needed to adequately suction the resident. Staff K indicated in a written statement the resident became ashen and unresponsive during the suctioning process. Staff K did not call 911 or Code Blue as per facility policy. However; Staff K sent a staff to get Staff J who arrived within minutes. During the interview on [DATE] at 11:30 a.m. Staff K reported she asked Staff J if 911 should be called, Staff J said she needed to find the resident's code status. Staff J left to find the code status but asked Staff N to take the resident to her room. Interview with Staff J on [DATE] at 9:10 a.m. revealed being summoned to the dining room; upon arriving Staff J observed Staff K suctioning Resident #1. Staff J said she saw the resident was purple in color then felt for a pulse in the resident's carotid (neck) and radial (wrist) but was not able to feel one. Staff J also said she observed the resident's chest to see if it was moving and determined the resident was not breathing. Staff J then instructed Staff K to stop suctioning and declared the resident expired. During same interview Staff J said she did not call 911 or a code blue because she determined the resident already expired; she checked the code status and saw the resident elected to be a DNR (do not resuscitate). Staff J instructed Staff N to put the resident to bed. Staff J admitted that staff had to use a mechanical lift to put the resident to bed and after the resident was in bed then a stethoscope was used to assess the pulse and respirations of the resident. Statement by Staff N dated [DATE] indicated Staff J instructed her to take Resident #1 to her room. Upon arriving in her room Staff J asked Staff N to get washcloths then Staff J cleaned the resident's mouth with the washcloths commenting on how cold the resident was becoming. Staff J instructed Staff N to not perform the [MEDICATION NAME] while the resident was in the wheel chair because the resident was too big. After the resident's mouth was cleaned then staff used a mechanical lift to transfer the resident to her bed. Interview with Staff M on [DATE] at 9:15 a.m. indicated she was asked to assess Resident #1 using a stethoscope at approximately 8:20 or 8:25 a.m. Staff J and Staff K did not follow the facility policy for responding to a choking resident by calling a code blue or 911 or instructing another staff to do so. The resident was not assessed using medical equipment for 20 - 25 minutes after the resident was observed choking. Staff J did not thoroughly assess the resident in a timely manner using a stethoscope or other medical equipment to assess the resident in accordance with standard of practice. Interviews confirmed none of the staff called 911 when the resident began to choke. Interviews with administrative staff and nursing staff and review of facility documentation on [DATE] revealed immediately following the incident on [DATE] the facility conducted a facility-wide inservice education and training with licensed and non-licensed staff. The inservice education consisted of implementation of Code Blue (staff return demonstration and mock codes) and provided training on how to handle or interpret DNR (No Code) orders during an event or incident of obstructed airway. .

Based on record review and interview, the facility failed to provide adequate supervision to prevent accidents/injuries and failed to revise the plan of care to prevent accidents/injuries for 1 of 4 residents (former Resident #7) reviewed for injuries. These failures resulted in harm to Resident #7 when the resident received a substantial leg injury from hitting the wheel chair foot rest during a transfer. The plan of care was not changed to prevent recurrence. Resident #7 was harmed a second time during a transfer involving a foot rest. Findings include: Closed record review revealed former Resident #7 admitted during 3/2011 and discharged from the facility during 7/2011. The resident's medical [DIAGNOSES REDACTED]. Review of a facility investigation dated 5/14/11 revealed Staff I transferred Resident #7 to the wheel chair without removing the foot rests. Resident #7 sustained a deep, wide skin tear to the left calf measuring 6 centimeters (cm) by .8 cm by .2 cm deep. The resident went to the emergency room and received sutures before returning to the facility. Review of the facility's conclusion written by Staff A (director of nursing) for the above investigation revealed it was a "preventable injury" because the foot rests should have been removed prior to Staff I transferring the resident. Review of the resident's care plan "Accidents and Injuries" dated 5/30/11 did not include revision to the plan of care to remove wheel chair foot rests during transfers. Review of a facility investigation dated 6/23/11, approximately ten days later, revealed Resident #7 was found with a 4 by 4 cm skin tear on her left leg. Facility investigation determined the injury lined up with the wheel chair foot rest. Closed record review revealed no evidence the resident's care plan was revised to prevent injury related to the foot rest following the second similar injury. Staff B (administrator) was informed of the above during interview at 1:15 p.m. on 8/3/11. There was no further evidence of care plan revision provided prior to exit on 8/4/11.