Every finding on record at Regency at Northpointe

Based on interview and record review, the facility failed to consistently assess and adequately follow-up on a change in condition for 1 of 3 sample residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when there was delay in recognizing a change in condition (elevated heart rate) and notification to the medical provider for treatment decisions that resulted in hospitalization and a diagnosis of sepsis (life-threatening medical emergency). These failures placed residents at risk of infection, hospitalization , and a diminished quality of life. Findings included . Review of the Centers for Disease Control, About Sepsis, dated 03/08/2024 (https://www.cdc.gov/sepsis/about/index.html), showed sepsis is the body's extreme response to an infection, often starting in the gastrointestinal tract, lung, skin or urinary tract. Signs that healthcare providers used to identify sepsis included changes in heart rate and blood pressure. Review of the American Heart Association, Tachycardia: Fast Heart Rate, dated 09/24/2024 (https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia/tachycardia--fast-heart-rate), showed the normal heart rate is 60 to 100 beats per minute (bpm) and tachycardia is when the heart beats too fast, at a rate of more than 100 bpm at rest. Review of the quarterly assessment dated [DATE] showed Resident 1 was not able to communicate their needs, was dependent on staff assistance, and required invasive mechanical ventilator support (medical device that assists or replaces spontaneous breathing). Per the assessment, the resident did not have a diagnosis of tachycardia. The care plan dated 07/16/2024 showed Resident 1 had a history of lung and skin infections with multiple drug-resistant organisms (MDROs; germs that are resistant to multiple antibiotics, making infections potentially life-threatening) and a prior history of sepsis. Per the care plan, the resident's respiratory status was to be monitored every six hours and staff were to monitor the resident's vital signs for abnormalities. Review of Resident 1's electronic medical record vital signs for December 2024 showed from 12/01/2024 to 12/14/2024 the resident's heart rate was frequently documented between 60 and 100 bpm (57 of 61 entries) and infrequently above 100 bpm (four of 61 entries). Further review showed multiple entries per day documenting the resident's heart rate was above 100 bpm on 12/15/2024 (107 bpm at 9:39 AM, 115 bpm at 3:17 PM, 138 bpm at 6:20 PM, 123 bpm at 11:05 PM), 12/16/2024 (131 bpm at 5:01 AM, 127 bpm at 8:14 AM, 115 bpm at 1:50 PM, 110 bpm at 3:00 PM, 112 bpm at 6:21 PM, 116 at 11:13 PM), 12/17/2024 (119 bpm at 5:00 AM, 107 bmp at 9:29 AM, 105 bpm at 1:16 PM), and 12/18/2024 (120 bmp at 7:57 AM). The resident's blood pressure was not documented from 12/08/2025 to 12/17/2025. On 12/18/2025 Resident 1's blood pressure was elevated. Review of the December 2024 respiratory assessments for Resident 1 showed on 12/15/2024 at 6:20 PM a respiratory therapist notified a nurse that the resident was tachycardic at 138 bpm. The respiratory assessment showed the resident's respiration rate and oxygen level were normal, the resident's blood pressure was not documented. Additional respiratory assessments on 12/15/2024, 12/16/2024, and 12/17/2024 showed the resident's heart rate continued to be elevated; no further nurse notifications were documented. Review of Resident 1's December 2024 progress notes showed no nursing assessment of the reported elevated heart rate on 12/15/2024. Per the notes, on 12/16/2024 at 10:24 AM the medical provider was notified the resident's heart rate was 131 that day. There was no documentation showing the provider was notified of the additional five instances where the resident's heart rate was elevated in the prior 24 hours (see above). There was no documentation showing the provider's response. Additional review showed no nursing assessment or continued notification to the medical provider of the resident's elevated heart rate on 12/16/2024 or 12/17/2024. Per the progress notes on 12/18/2024 the resident had a sudden increase in their respiratory needs that required immediate transfer to the hospital. Review of the hospital admission notes dated 12/18/2024 showed the resident was admitted to the Intensive Care Unit with abdominal sepsis and acute on chronic respiratory failure. In an interview on 05/09/2025 at 2:33 PM Staff D, Respiratory Therapist (RT), stated residents were assessed by RT staff every six hours and the respiratory assessment included monitoring breath sounds, respirations and heart rate. Per Staff D respiratory staff notified nursing staff of resident changes including a change in heart rate, and if RTs continued to see abnormal vital signs they would go back and keep updating nursing staff. Staff D stated they worked with Resident 1 in the days prior to their hospitalization in December 2024 but were unable to provide information regarding the resident's increased heart rate, notifications to nursing staff, and/or notifications to the medical provider. On 05/09/2025 at 2:41 PM Staff C, Charge Nurse, stated Licensed Nurses (LNs) were responsible for resident care and if RTs reported a concern, then LNs were responsible to assess the resident's status. Staff C stated if a resident had a high heart rate LNs should review the resident for heart conditions and heart medications and check the resident's blood pressure then notify the provider. Per Staff C, the first day a resident was identified with new tachycardia they would be put on alert charting and would be addressed by a medical provider within 24 hours. Staff C stated they did not typically work with Resident 1 unless staff requested their assistance, and they did not work with Resident 1 in the days prior to their December 2024 hospitalization . At 2:55 PM the same day Staff B, Resident Care Manager, stated RTs were to report changes to nursing staff and LNs were to assess residents and notify providers of abnormal findings. Staff B reviewed Resident 1's vital signs and confirmed the resident's heart rate was elevated on and after 12/15/2024. Staff B stated they expected the provider would have been notified of the change and a note would have been written by the provider. At 4:09 PM the same day Staff A, Director of Nursing stated if a resident had an increased heart rate identified on a respiratory assessment, then nursing staff should recheck the heart rate, assess conditions potentially responsible for the elevated heart rate, and assess additional vital signs such as the resident's blood pressure. Staff A reviewed Resident 1's electronic medical record and stated they did not see a nursing assessment of the resident related to the increased heart rate initially identified 12/15/2024. Staff A stated the provider notification on 12/16/2024 was a printout of a vital sign alert from the electronic medical record and should have been followed up at that time. In an interview on 05/14/2024 at 2:32 PM Staff E, Nurse Practitioner stated Resident 1 was very active and would have instances of heart rate elevation over 100 but if it continued for 24 hours they should be notified. Staff E stated Resident 1 would become ill quickly and was stable when they last saw the resident on 12/13/2024. Reference WAC 388-97-1060 (1)

Based on observation and interview, the facility failed to ensure hand hygiene and use of hair coverings was implemented properly during the preparation and serving of food during 2 of 2 kitchen observations. This failure caused exposure of all residents to potential food contamination and food borne illness. Findings included: According to the CDC, Clinical Safety: Hand Hygiene for Healthcare Workers, hands should be cleaned using soap and water or an alcohol-based hand sanitizer immediately before touching a patient, before performing a task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces, and immediately after glove removal. When washing hands with soap and water the CDC recommends, wet hands with water, apply the soap to the hands, rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers, rinse hands with water and use disposable towels to dry. Use a towel to turn off the faucet. <Hair Restraints> During a observation in the kitchen on 08/21/2024 at 8:59 AM Staff Q, prep cook was observed working in the kitchen and wearing their hair up in a bun. The hairnet they were wearing was covering only the bun on the top of their head and loose hair was hanging down over the back of their neck. During an interview on 08/21/2024 at 9:31am when asked why the hairnet was only covering the bun on top of their head, Staff Q stated they had always done it that way. Staff Q stated it was important to have to the hairnet covering all their hair to keep hair out of the food. During an observation of the lunch meal service on 08/26/2024 at 11:23 AM, Staff R, cook was not wearing a hair restraint and was serving food for the residents onto plates. Staff Q, prep cook, was putting the plates of food onto the trays and was wearing a hairnet however strands of hair not covered by the hairnet were loose on the back of their neck. Both Staff P, dietary manager and Staff S, dietary aide were setting up separate meal trays with food and beverages. Staff P as well as Staff S had their bangs and hair on the side of their faces exposed, the hairnets they were wearing were only covered the top and back of their hair. In an interview on 08/26/2024 at 12:23 PM, Staff R stated they had forgotten to put on a hair restraint. During an interview on 08/26/2024 at 2:41 PM Staff P stated all hair was supposed to be covered by the hairnet and it was important to keep hair and germs out of the food. <Hand Hygiene> During an observation on 08/26/2024 at 11:46 AM Staff P, dietary manager performed hand hygiene and scrubbed their hands with soap for only two seconds, then proceeded to put on gloves and cook eggs and toast for a resident. During an observation on 08/26/2024 12:11 PM During lunch service, Staff R, cook was serving food and removed gloves, opened and removed an item from a refrigerator, then without performing hand hygiene proceeded to put on new gloves and continue serving food. In an interview on 08/26/2024 at 12:17 PM Staff R stated hand hygiene should be performed before starting food prep, after using the restroom or emptying the trash, and when moving from a dirty surface to a clean surface. They stated they supposed hand hygiene should be performed between glove changes. Staff R stated this was important to prevent disease transfer. Reference: WAC 483.60(i)(1)(2)-1100, 2980

Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies and Procedures to include, not reporting to the State Agency (SA) within the required timeframe and completing a thorough investigation for 1 (Resident 397) of 2 residents reviewed for abuse. This failure placed the resident and other residents at risk for potential abuse or neglect and a diminished quality of life. Findings included . Review of a revised October 2022 facility policy titled Abuse/Neglect/Misappropriation/Exploitation showed, the facility protected the residents from abuse and neglect by implementing procedures designed to prevent, identify, report, and investigate allegations of abuse and neglect. The policy instructed the staff to report immediately to the Abuse Hotline (a SA), but no later than 2 hours after an allegation involving abuse or neglect was made, if the events that caused the allegation resulted in serious bodily injury and no later than 24 hours if the events that caused the allegation did not involve abuse or result in serious bodily injury. The policy showed that all alleged incidents of abuse or neglect were thoroughly investigated to determine what occurred and make necessary changes to the provision of care and services to prevent recurrence. The policy showed a thorough investigation included but was not limited to, an interview with the alleged resident victim, the assigned caregiver and caregivers in the immediate area, and a physical examination of the resident. This policy defined neglect as the facility's failure to provide goods or services to a resident that were necessary to avoid physical harm, mental anguish, or emotional distress. Review of an 08/16/2024 admission assessment showed Resident 397 admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 397 as cognitively intact and required assistance from the staff for completing Activities of Daily Living, like dressing, toileting, transfers, and bed mobility. Review of a 08/13/2024 progress note in Resident 397's medical record showed, Pt. [Patient] noted to have become upset when staff was doing 0200 [2:00 AM] rounds. Pt. stated that [they] had been waiting for 3 hrs [hours] and no one came to help [them]. This LN [Licensed Nurse] witnessed to [sic] NAC [Nursing Assistant-Certified] performing care on [the resident] around 0015 [12:15 AM]. Staff encouraged pt. to use call light when [they] needs [sic] assistance. In an interview on 08/26/24 at 11:04 AM, Resident 397 re-told their account of the allegation identified by the facility on 08/13/2024. Resident 397 stated, I had to wait for them [the staff] to come and clean me up. I had a BM [bowel movement] in my bed and when I told the guy who came in, he just put two fingers up and I didn't see him until after 2 o'clock or after three [in the morning]. I called around midnight and he never did come back until 3 o'clock. I told him the first time what he needed to do, then he lifted his two fingers and left. Resident 397 stated that, I complained but nobody came to talk to me about it. I didn't talk to the nurse that night. I complained to the two aides but that's as far as it went. Review of the August 2024 Incident Log showed no documentation the facility reported the 08/13/2024 incident to the SA or that the facility thoroughly investigated Resident 397's complaint of having to wait three hours for staff to provide hygiene for fecal incontinence. On 08/26/24 at around 12:15 PM, Staff B, Director of Nursing, provided an incident report dated 08/14/2024, completed a day after the Resident 397's complaint was identified by the facility. The report showed, the Patient stated that no one came into his room for 3 hours to assist [them] on the night of August 13th 2024. The report showed the Immediate Action Taken by the facility was a chart review, call light response times reviewed, investigation initiated. The report showed no indication the facility completed a re-interview of Resident 397. The report stated, 6 patients were randomly selected for interview and included their initials but no documentation to show who the residents were, who interviewed the residents, or when they were interviewed. Similarly, the report showed the facility interviewed 2 NACs [Nursing Assistant Certified] and 2 LN [Licensed Nurse] that worked on the night shift, but showed no documentation who were the four staff interviewed, their own dated and signed witness statements, who interviewed the staff, and the content of the interviews. The document showed the facility reviewed the results of the investigation with the resident's daughter and the resident and that, all parties satisfied with resolution. The above information was shared with Staff A, Administrator, on 08/26/24 at 1:46 PM. Staff A stated that the 08/14/2024 incident report was interchangeable for an investigation. Staff A stated that when a resident tells the staff that they waited for three hours for someone to help them, My expectation is to report it to the Abuse Coordinator, make sure the resident is safe, and then report it to the nurse on shift. I tell the staff to call me directly and let me know right away so we can initiate protocols to rule out abuse or neglect. Staff A identified himself as the Abuse Coordinator. Staff A replied, I do not see it on here, when asked if the facility logged the incident in the Incident Reporting Log. Staff A stated that the complaint did and did not meet the definition of an allegation of neglect, It's double-sided. Since it was witnessed by the staff, we can rule it out right away. It's a case-by-case basis. Then alternately, Completely my mistake. It should have been logged. Even though the facility policy instructed the staff to report all alleged violations of abuse or neglect to the Abuse Hotline within a required timeframe, Staff A stated that they did not report it to the Abuse Hotline because, It was witnessed by the nurse, that's why it wasn't reported. It was witnessed by the staff that it didn't happen and I wouldn't consider it a reportable event so I wouldn't report it. Staff A acknowledged the 08/14/2024 investigation did not include supporting documentation the facility re-interviewed Resident 397, or the four staff and six residents mentioned in the incident report. Staff A stated on 08/26/24 at 1:50 PM, I personally interviewed the staff and residents. It was one nurse, the '2 LN' is a typo [sic], and two NACs, it was over the phone. So, I didn't get their statements. No additional information was provided by Staff A. Reference WAC 388-97-0640(2)

Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 2 of 2 sampled residents (67, 94) reviewed for hospitalization s. This failure placed the residents at risk for a disruptive and ineffective transition from the facility to the hospital setting. Findings included . <Resident 94> Review of the progress notes showed Resident 94 admitted to the facility on [DATE]. The 07/25/2024 progress notes showed Resident 94 experienced a change in condition, the staff notified the provider, the staff transferred the resident to the hospital, and notified the resident representative. In an interview on 08/27/24 at 9:03 AM, Staff U, Licensed Practical Nurse (LPN), stated that when a resident is transferred to the hospital, she notifies the Unit Manager, the Director of Nursing (DON), the family, and the doctor. Staff U stated that at the time of a resident's transfer to the hospital, they send with the resident and ambulance personnel printed copies of the current medications and their administration record, progress notes, and recent vital signs. Staff U stated that they also call in report to the emergency room personnel. Staff U stated that they documented the type of information or documents conveyed to the hospital by making an entry in the progress notes. Staff U showed a Transfer to Hospital checklist the staff use as a reference of what information is to be sent to the hospital. This list included a physician order, an eInteract Transfer Form, an ambulance medical necessity certification statement, a copy of the medical record, and nurses notes. In an interview on 08/27/24 at 9:12 AM, Staff N (LPN) stated that when a change in condition required a hospital transfer, they notified the provider and resident representative. Staff N stated that the documents they send to the hospital include the most recent laboratory results, progress notes, a demographics sheet, a POLST form [Physician Orders for Life Sustaining Treatment], a bed hold notification form, and a Transfer to Hospital Evaluation form. Staff N stated that the information conveyed to the hospital is sent with the resident and ambulance personnel at the time of the transfer and documented in the progress notes. Review of Resident 94's medical record showed no documentation the facility communicated to the hospital adequate and required communication at the time of the Resident 94's transfer on 07/25/2024, including: The basis for the transfer, the specific resident need(s) that could not be met, facility attempts to meet the resident needs, or the information provided to the receiving facility to include contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The above information was shared with Staff B, Director of Nursing, on 08/27/24 at 9:39 AM. Staff B confirmed via record review that documentation to show the staff conveyed all necessary clinical information to the hospital at the time of a facility to hospital transfer was not present in Resident 94's medical record. <Resident 67> A review of the record showed Resident 67 had history of a broken vertebra in their back and stroke. A review of progress notes documented on 07/13/2024, the licensed nurse was notified by the nursing assistant that Resident 67 had difficulty breathing and their oxygen levels were extremely low. After supplemental oxygen was applied, the physician and the resident's representative were notified. A decision was made to send the resident to the hospital. The licensed nurse documented they called the emergency room and gave them report. Further review of the record was unable to locate documentation of what information of Resident 67's was provided to the local hospital to allow for continuity of care when the resident was transferred as required. On 08/27/2024 at 8:28 AM, Resident 67's record was reviewed with Staff B, and Staff H, Medical Records Supervisor. When asked, Staff H stated nursing staff printed documents from resident records at the time of transfer. Staff B stated nurses had a reference list they referred to when a resident was being transferred. The documents on the list were printed, placed in an envelope, and these accompanied a resident to the hospital. Staff B stated the nurses then documented in progress notes that they called report or who they spoke to, then completed the hospital transfer document in the Assessments section of the electronic medical record. When Resident 67's Assessment section was further reviewed, there was no hospital transfer documentation completed. Staff B stated they would have to ask staff why the resident did not have the documentation completed. Reference WAC 388-97-0120. 46033

Based on observation, interview and record review, the facility failure to ensure care plan revisions were made for 2 of 17 sampled residents (64, 397) whose care plans were reviewed. Failure to revised Resident 64's care plan to include additional interventions to prevent a further decrease in the ability to flex the fingers, and failure to revised Resident 397's care plan to include their preferences for bathing placed the residents at risk for diminished quality of life and unmet care needs. Findings included . <Resident 64> The 05/31/2024 quarterly assessment documented Resident 64 was severely cognitively impaired, non-verbal, had diagnoses which included stroke, and was dependent on nursing staff for activities of daily living (ADLS) such as dressing. In addition, the assessment documented the resident had impaired range of motion (ROM: the ability to move or flex a joint) to both upper and lower extremities and had received restorative services (a program in which staff work with residents to maintain and/or improve their functionality or independence). On 08/21/2024 at 10:21 AM, Resident 64 was observed being wheeled down the hall to the shower room by Staff L, Bath Aide. Resident 64 was sitting up right in the shower chair, with their forearms lying on their chest and both their hands clenched in a fist. The resident was not wearing hand splints, nor were any palm protector devices such as a rolled-up washcloth, placed in their hands to keep their fingers from staying in a fist position. On 08/22/2024 at 9:44 AM and 2:46 PM, Resident 64 was observed lying in bed with their eyes closed, their arms were lying at their sides and both hands were clenched in a fist. No hand splints or palm protector devices were being used. At 2:46 PM, the resident was again observed lying in bed with their eyes closed, both hands in a clenched fist position Similar observations of the resident's hands being clenched into fists with no hand splints or palm protector devices in place were made on 08/23/2024 at 10:22 AM, 11:17 AM, and 2:10 PM. A 07/13/2022 progress note documented Resident 64 received restorative services that included passive range of motion exercises to each extremity (exercises done with the assistance of nursing assistants to keep joint flexible). Review of the Contracture Screening Assessments, (an assessment to determine whether a resident was at risk of developing or had developed a contracture, a shortening of a muscle, which caused the muscle to be resistant to stretching) documented on 10/06/2022, the resident's joints were stiffer, and it was more difficult to do the passive range of motion exercises. The 11/29/2023 assessment documented Resident 64's fingers of both hands were difficult to extend fully. Review of the 04/08/2022 skin integrity care plan documented the resident had potential for an alteration in their skin integrity and interventions were implemented and revisions were made as changes in the resident's skin occurred, but no interventions were found or added to include measures to prevent skin breakdown related to the resident keeping their hands clenched in a fist position. Review of the 04/21/2022 ADL and Restorative care plans documented Resident 64 was identified for being at risk for contractures and interventions were implemented to include passive range of motion to both upper and lower extremities, but no interventions were found or added to include measures to prevent contractures related to the resident keeping their hands clenched in a fist position. In an interview on 08/23/2024 at 2:25 PM, Staff L stated the resident could not open their hands. When asked how the nursing assistants knew what the resident's care needs were, Staff L stated the care plan informed them. In an interview on 08/23/2024 at 2:32 PM, Staff M, Restorative Aide, stated Resident 64 received range of motion exercises to their hands and could extend their fingers, but always held their hands tightly in a fist position. Staff M further stated hand splints were not used, but rolled washcloths were always placed in the resident's hands. In an interview on 08/26/2024 at 10:09 AM, Staff N, Licensed Practical Nurse, stated Resident 64 was able to extend their fingers, but liked to keep them clenched in fists, so rolled wash cloths were placed in the hands as a preventative measure. In an interview on 08/27/2024 at 9:48 AM, when informed of the observations of Resident 64's hands being clenched into fists and no palm protection devices/rolled wash cloths in place, Staff O, Resident Care Manager (RCM), stated Resident 64's care plan should have been revised. 40297 <Resident 397> Review of an 08/16/2024 admission assessment showed Resident 397 admitted to the facility on [DATE]. This assessment showed Resident 397 answered that it was Very important to choose between a tub bath, shower, bed bath, or sponge bath. In an interview on 08/21/24 at 10:50 AM, Resident 397 stated that the staff, come and get me once a week or whatever it is and that they prefer to take a shower one every day if I could. Resident 397 said, No one has asked [how often I want to get showers]. All [staff] said is I'm scheduled for showers. Review of an 08/15/2024 Bathing/Showering care plan showed the resident required assistance of one person for bathing. The care plan showed Bathing/Shower per resident preference (SPECIFY) but did not show the resident's preference, to include mode and frequency. In an interview on 08/23/24 at 11:06 AM, Staff G (RCM) acknowledged the resident's bathing preferences did not show in the care plan and should have. Reference (WAC): 388-97-1020 (2)(c)(d).

Based on observation, interview and record review, the facility failed to ensure a resident received assistance setting up their meals for 1 of 4 sampled residents (67) reviewed for activities of daily living (ADLs). This failure placed the resident at risk of decreased dietary intake, potential weight loss and decreased quality of life. Findings included . <Resident 67> Review of the 07/26/2024 re-admission assessment documented Resident 67 had diagnoses including paralysis of the right side of the body following a stroke, difficulty speaking and swallowing, and severe calorie malnutrition. Resident 67 was severely cognitively impaired, coughed or choked during meals, held food in their mouth after meals, and required partial to moderate assistance for eating. The 07/06/2024 care plan documented Resident 67 had a deficit related to their ability to eat because of their stroke and a contracture (shortening of muscles and tendons that prevented normal movement) of their right hand. They required assistance of one staff to set up their meals. A 07/12/2024 weight change progress note documented Resident 67 had a major weight loss when compared to a previous stay at the facility. Resident 67 had poor oral intake since their current admission and their diet was changed to N.E.M. (nutritionally enhanced meals, adding gravies or butter to foods for example) for increased calories. On 07/31/2024, a provider order was given to provide Resident 67 a N.E.M., dysphagia (difficult swallowing) mechanical soft diet (foods that required little chewing such as ground, mashed or finely chopped items.) with thin consistency fluids. During a telephone interview on 08/21/2024 at 11:15 AM, Resident 67's representative stated they were unsure if the resident was eating well. They stated the resident had experienced a gradual weight loss over several months, but they were unsure of the cause. On 08/21/2024 at 12:12 PM, Resident 67 was observed seated in their wheelchair with their overbed table in front of them. The resident appeared thin and their trunk leaned slightly to the right. The resident's right arm and hand rested across their stomach and the hand was contracted. The resident's lunch was on the overbed table and included cooked carrots cut in cubes, a fruit cobbler in a separate dish, and a serving of lasagna that was covered in brown gravy. The lasagna was served in a square and was not cut up. Resident 67 was able to get small portions of cobbler on a spoon to eat. They were unable to use their right arm. When asked questions, Resident 67 answered each time saying, Good, good. An unidentified staff member entered the room and asked Resident 67if they wanted help. The resident answered no and the staff member exited the room. The lasagna was again observed and was not cut up for the resident. On 08/23/2024 at 8:01 AM, breakfast trays were distributed to the residents. At 8:19 AM, Resident 67 was observed sitting upright in bed. There was a Velcro-type brace on the resident's right hand, and their right arm and hand rested across their stomach. Resident 67 attempted to eat a substance that looked like pudding. On the resident's plate was half of an English muffin. A hollandaise sauce with small pieces of ham circled the English muffin. The resident has scraped any of the sauce and ham off the top of the muffin and eaten it but left the English muffin. The English muffin had been served without being cut up for the resident. On 08/23/2024 at 12:03 PM, Resident 67's lunch was delivered. Resident 67 was seated in their wheelchair and said Oh! Oh! in pain and moaned. The lunch was observed to include a whole burrito, chopped lettuce and diced tomato, rice, and a piece of cake. The burrito was left whole, and the nursing assistant (NAC) left the room to notify the nurse of the resident's pain. At 12:35 PM, Resident 67 was observed no longer groaning. They were taking bites of their cake. The resident had a different meal before them that included a ground meat with gravy, mashed potatoes and gravy, and Capri style vegetables. When interviewed at 12:41 PM, Staff C, NAC, stated the staff had recognized that Resident 67 had received the wrong foods. They had arranged for a new meal so the resident had the correct food textures. On 08/26/2024 at 8:16 AM, Resident 67 was eating their breakfast seated upright in bed. The resident was taking bites of scrambled eggs. There were also two half slices of toast on the plate. A bowl of cereal was set off to the side of the plate with the cover still on it, and a whole banana still in the peel was beside the plate. When interviewed on 08/27/2024 at 9:06 AM, Staff D, NAC, stated Resident 67 ate bananas but they needed to be peeled. Staff D stated the resident's son visited often, and the son often cut up or opened foods for the resident. When interviewed on 08/27/24 at 11:35 AM, Staff E, NAC, stated Resident 67's right hand was contracted and the resident was not able to use it to help cut up food, or open a banana. Staff E stated Resident 67 needed to have that done for them. Staff E further stated it was important to help a resident open their food and cut it up because if not, the resident might get tired or distracted or lose interest and then not eat. They wanted the residents to eat so they did not lose weight. When interviewed on 08/27/24 at 1:09 PM, Resident G, Resident Care Manager, stated Resident 67's ability to eat varied from independent to minimal assistance. The resident was at risk for weight loss, and needed assistance removing lids, opening containers or cutting up foods. Staff G stated it was important for residents to get assistance they needed when eating. If not, they risked not getting the nutrition they needed. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (91) reviewed for hearing, received the necessary treatment and services to maintain their hearing abilities. Failure to assess the etiology of and pursue services for Resident 91's identified hearing impairment, placed the resident at risk for a decline in communication, social isolation, changes in mood and behavior, and unmet needs. Findings included . Review of an 08/02/2024 admission assessment showed Resident 91 admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 91's hearing was highly impaired, used hearing aids, was able to make themself understood, and usually understood others. Staff assessed the resident to have moderate cognitive impairment. The staff assessed Resident 91 required assistance from the staff with most Activities of Daily Living (ADL), like oral hygiene, toileting, bathing, bed mobility, transfers, and dressing. An observation on 08/21/24 at 9:21 AM showed Resident 91 sitting up and in front of their over-the-bed table and wearing hearing aids bilaterally. Resident 91 could not hear the Surveyor and used a notebook to communicate. Resident 91 stated that they did not know how to turn on the hearing aids and that is when they used the notebook to communicate with the staff. On 08/23/24 at 8:22 AM, Resident 91 was observed eating their breakfast, did not hear the Surveyor, and hearing aids were not in use. Resident 91 stated that the hearing aids were inside the case on the bedside table being charged. An observation on 08/23/24 at 1:41 PM showed Resident 91 sitting on their walker's seat and, although the hearing aids were in both ears, could not hear the Surveyor. In an interview on 08/23/24 at 8:26 AM, Staff D, Nursing Assistant, stated that they found information on the level of assistance and types of devices the residents required to complete their ADL successfully, in the Kardex [a set of care instructions for the nursing assistants derived from the care plan]. Staff D stated that Resident 91 used and took care of their hearing aids and that staff's responsibility was, just give [the resident] the case to charge them. Staff D stated that they communicated with Resident 91 verbally or wrote in the resident's notebook if the hearing aids were not in use. Staff D was unaware of concerns with hearing aid malfunction. Review of Resident 91's care plan showed, The resident has a communication problem r/t HOH [hard of hearing], and it instructed the staff to, Ensure hearing aid(s) (left and right) are in place, Identify & treat underlying cause(s) of communication impairment as appropriate, and Refer to Audiology [hearing, balance, and related disorders] for hearing consult as ordered. The care plan showed no information that a notebook was used between the resident and the staff for communication purposes when the hearing aids were not in use. Additionally, the care plan showed no instructions for the care of the hearing aids, to include who was responsible for its care and maintenance, or the type of assistance the resident required to ensure the hearing aids were charged and turned on when in use. On 08/26/24 at 10:11 AM, Resident 91 was observed sitting on their bed. Resident 91 communicated without the use of the notebook. Hearing aids were observed in use bilaterally. Resident 91 stated that on Friday (8/23/2024), a Collateral Contact of theirs took the hearing aids for overnight service at Costco. When asked how it felt to be able to hear, Resident 91 stated, It makes a big difference. Resident 91 stated that they use the notebook to communicate with staff when the hearing aids do not work, or they cannot hear well. On 08/27/24 at 12:11 PM, Resident 91 was observed sitting up with lunch in front of them. The hearing aids were observed next to the lunch tray on the over-the bed table. Resident 91 stated that the hearing aids were out of their ears because the staff, just put drops in [their ears]. Review of physician orders showed an order with a start date of 08/26/2024 that instructed the staff to instill drops in both ears for ear wax build-up for four days, and then flush the ears with warm water on day five. An 8/27/2024 progress note showed, Continues on ear gtts [drops] for increase cerumen [ear wax] to bilateral ears. On 08/27/24 at 1:50 PM, Staff V, Licensed Practical Nurse, stated that they were familiar with Resident 91 and their care. Staff V stated that on Sunday afternoon, 08/25/2024, they overheard Resident 91's Collateral Contact tell Resident 91, The hearing aids worked. Maybe [the Resident's] ears are occluded [clogged up]. Staff V stated that when they overheard this conversation, they went to get the otoscope [a tool that uses a light and magnifying lens to examine the ear canal and eardrum] and checked [the resident's] ears. Staff V stated that they found the right ear had ear wax around the edges but I could see the ear drum, but left one was completely occluded. Staff V then started a provider's order for the ear drops to address the wax build-up. Review of an 08/05/2024 Social Services Note written by Staff W, Social Services Assistant, showed that, Resident scored moderately impaired on BIMS [a cognitive test]. Score seems to be reflective of resident being very hard of hearing even with hearing aides [sic] in and on. In an interview on 08/23/24 at 2:19 PM, Staff W shared that in a recent care conference, Resident 91's representative was present with the resident and the representative was reiterating things to Resident 91, repeating things louder into her ear. When asked if any care conference information was shared with the resident via written manner, Staff W stated, It seemed like [the resident] understood what we were talking about. Not from myself anyway. When asked if further enquiry or follow-up occurred as to why Resident 91 was, very hard of hearing even with hearing aids in and on, to include an audiology referral as mentioned in the care plan, Staff W stated, No. Not that I'm aware of. In an interview on 08/23/24 at 8:31 AM, Staff G, Resident Care Manager, stated that sometimes Resident 91 preferred verbal or written communication. Staff G stated that, while they were aware Resident 91 wrote in their notebook to communicate their needs to the staff even with hearing aids in use, Staff G did not enquire or determine why and stated, We allow [the resident] to use whatever [they] prefers. Staff G acknowledged the resident's care plan failed to but should have included Resident 91's preference for written communication even with the use of hearing aids, the type of assistance the resident required to ensure their hearing needs were met, and who was responsible for the care of the hearing aids. Staff G acknowledged on 08/27/24 at 1:35 PM that ear wax build-up can affect a resident's ability to hear adequately. No further information was provided. Reference WAC 388-97-1060(3)(a).

Based on observation, interview and record review, the facility failed to put measures in place to ensure the staff delivered heat therapy with adequate and complete provider orders, to include monitoring for injury associated with the use of a heating pad, for 1 (Resident 397) of 1 resident reviewed for accidents. This failure placed the resident at risk for trauma associated with the use of a heating pad. Findings included . Review of an 08/16/2024 admission assessment showed Resident 397 admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified Resident 397 as cognitively intact and required assistance from the staff for completing Activities of Daily Living, like dressing, toileting, transfers, and bed mobility. Observations on 8/21/2024 at 10:32 AM, 8/22/2024 at 9:18 AM and 04:13 PM, and 8/23/2024 at 9:52 AM and 11:21 AM, showed a green pad wrapped around Resident 397's thigh while seated in their wheelchair. Resident 397 was fully dressed, to include pants. The green pad was connected to a device on the floor called a T/pump [a heating and cooling therapy system that uses pads to provide localized temperature control for pain relief and comfort]. Resident 397 stated that the nurse applied the green pad to his leg. The green pad was connected to the T/ pump via connecting tubing. Resident 397 stated that he used the green pad, all day and all night. Observation of the T/pump showed it had four temperature settings, 50 - 95 - 100 - 107 degrees Fahrenheit. The T/pump also provided 3 modes of treatment delivery - continuous, 20 minutes or 30 minutes. Resident 397's T/pump was set to 107 degrees, the highest setting, in continuous mode. In an interview on 08/23/24 at 11:21 AM, Resident 397 stated, I didn't realize that the T/pump had different settings and temperature ranges to address their comfort level. An observation on 08/26/24 at 10:22 AM showed both the green pad and the T/pump on the floor. Review of a Service Manual for the T/Pump showed the T/pump carried a risk of explosion and electric shock. The manual showed the device pumps temperature-controlled water through a pad. The manual instructed the staff to set the pad temperature only as directed by and under the guidance of the prescriber and to monitor the resident's temperature and skin condition every 20 minutes or as directed by a physician. The manual showed that failure to adhere to the warnings could result in resident injury. Review of Resident 397's medical record showed a physician order and a care plan (both dated 08/15/2024) that instructed the staff to apply a Kpad [heating pad] as needed to the left hip and thigh. The order showed no defined temperature setting, if it was continuous application or a time-specific treatment duration, nor the required monitoring of the skin condition. Additionally, review of the August 2024 Medication Administration Record showed no documentation the staff applied the Kpad even though resident observation and review of the progress notes between 08/16/2024 to 08/23/2024 showed its use. In an interview on 08/23/24 at 10:46 AM, Staff G, Resident Care Manager, stated that the use of a heating pad carried the risk for temperature-associated injury to the skin. Staff G stated that measures to prevent potential injury from the use of a heating pad included monitoring its use and scheduled preventive maintenance checks. Staff G stated that the provider order should carry the settings for the T/pump and acknowledged that the current order did not carry those treatment details. In an interview on 08/23/24 at 11:18 AM Staff X, Registered Nurse, stated that Resident 397 used the Kpad as needed for thigh pain and lower left hip pain. Staff X stated that they knew what temperature and mode the heat therapy would be delivered by looking at the machine. Staff X stated that either nursing or therapy sets up the T/pump setting. Staff X stated the settings for the T/pump should be in the initial orders and acknowledged they were not upon order review. The above information was shared with Staff B, Director of Nursing, on 08/26/2024 at 8:57 AM. Staff B stated that her expectation with the use of a T-pump and heating pad is for the orders to show, a specific time frame when placed, how long it's on, what the setting is if multiple, and if monitored then who is responsible for that. Pretty specific not just a generic order so that we know what we are doing. No further information was provided. Reference WAC 388-97-1060 (3)(g).

Based on observation, interview and record review, the facility failed to ensure 2 of 2 residents (396 and 397) reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the residents at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . <Resident 396> A resident observation and interview on 08/21/24 at 09:49 AM with their Collateral Contact present showed, Resident 396 in bed and in a hospital gown. The resident stated it was hard to go to the bathroom and that she go Number 2 [bowel elimination] in their incontinence brief. No commode was nearby. Resident 396 stated that staff did not offer them a bed pan and that its use would be, more comfortable, less painful. Resident 396 described that when they experienced loss of control of their bowels it made them feel, shame myself. In another interview on 08/22/24 at 4:09 PM, Resident # 396 stated that they used just diaper for bowel elimination and the staff used no bed pan. Review of an 08/19/2024 admission assessment showed Resident 396 admitted to the facility on [DATE] with a fracture and other medically complex conditions. This assessment showed staff assessed the resident to be cognitively intact and was dependent on staff assistance to complete various Activities of Daily Living (dressing, bathing, personal hygiene, bed mobility, and toileting). This assessment showed the staff identified Resident 396 was frequently incontinent of their bowels and on no toileting program. Review of an 08/28/2024 Care Area Assessment (CAA - an analysis tool) associated with the 08/19/2024 admission assessment showed, the staff identified Resident 396, has remained frequently INC [incontinent] of bowel. Disposable incontinence products used to manage moisture This assessment showed the resident was able to make their needs known and use their call light appropriately. Review of bowel movement flow sheets from 8/15/2024 to 8/22/2024 showed Resident 396 experienced bowel incontinence 4 out of the 8 days reviewed, or half of the time. Review of the medical record showed no documentation the facility evaluated and subsequently developed effective and resident-centered interventions to address Resident 396's episodes of bowel incontinence. Review of an 08/15/2024 TOILET USE care plan showed a goal of, The resident will participate in toileting in the highest practicable level for their current condition. Interventions included, Prefers a bed pan and required maximum assistance of one person. Another 08/15/2024 care plan showed Resident 396 was at risk for bowel incontinence, and the goal was to ensure optimal bowel continence and instructed the staff to offer a bedpan or bedside commode. The Care Plan showed no interventions to anticipate Resident 396's episodes of bowel incontinence, like a toileting program based on the resident's preference or when the incontinence episodes occurred. In an interview 08/23/24 at 11:12 AM, Staff G, Resident Care Manager, acknowledged Resident 396's continued frequency of bowel incontinence episodes. Staff G stated, It's facility wide policy to check on [the residents] every 2 hours. Staff G acknowledged there was no toileting program to address Resident 396's continued bowel incontinence. Review of the medical record showed Staff G completed a Bowel Incontinence Evaluation on 08/25/2024. This evaluation showed the staff assessed Resident 396 developed new onset of bowel incontinence, was alert, oriented, and aware of the urge to evacuate their bowels. This evaluation concluded a Bowel Training program was indicated to help manage Resident 396's bowel incontinence. <Resident 397> On 08/21/24 at 10:32 AM, an empty urinal was observed on Resident 397's bedside table. Resident 397 sat in his wheelchair and stated, I use [the bedpan] at night [but] it's too late by the time [staff] get here in the daytime. In the daytime, I wet myself. Resident 397 stated that he must call the staff to let them know he needs to be toileted. No bedside commode was visible in Resident 397's room. In another interview on 08/23/24 at 9:52 AM, Resident 397 stated, [The staff are] not here when I need them. I messed on myself all day yesterday. So, I had to change my clothes. Resident 397 stated that he experienced bowel incontinence. Resident 397 stated, No, no, no. God, no, it never happened [bowel incontinence] at home. It makes me really upset when that happens. It's just upsetting to me. Resident 397 stated that staff do not come to offer to take them to the bathroom, that the resident must use the call light to let the staff know of their toileting needs. Review of an 8/16/2024 admission assessment showed the resident admitted to the facility on [DATE] with medically complex conditions. This assessment showed the staff identified the resident as cognitively intact, used a walker and wheelchair, and was dependent on the staff for transfers and toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). The assessment also showed Resident 397 was frequently incontinent of bowel and bladder but on no toileting program. Review of an 08/22/2024 CAA showed Resident 397, to be frequently incontinent of bowel and bladder, incontinent briefs and barrier cream in use for dignity and reducing risks of further skin breakdown. Resident needs staff assistance with toileting and hygiene needs post incontinence and can communicate [their] needs and use the call light system. The CAA also showed, Incontinence issues place [the resident] at increased risks for further skin breakdown, infections, falls, injury, pain and further health decline. Will proceed to care planning. Review of an 8/15/2024 Bladder Incontinence Determination and Evaluation showed the staff identified medical conditions that contributed to Resident 397's bladder incontinence and that the bladder incontinence would be managed with, Bladder Retraining: candidates are alert, aware of urge to void & require limited assist with toileting. A bladder retraining program is a behavior therapy that can help people with overactive or weak bladders regain control of their bladder by learning to hold more urine and decrease the frequency of urination]. Review of the resident's medical record showed no documentation the staff completed an evaluation to determine and address why Resident 397 experienced bowel incontinence. Review of the 08/15/2024 care plan showed a goal that Resident 397 would have optimal bowel continence. The care plan also showed the staff identified the resident had three types of bladder incontinence. The interventions instructed the staff to provide assistance of one person, Assess pattern of incontinence, and initiate toileting schedule if indicated, Provide bedpan/bedside commode, Evaluate incontinence per protocol to ensure optimal care is being provided and appropriate program is in place, and a BLADDER RETRAINING PROGRAM. The care plan showed no mention of the use or role of the urinal in managing Resident 397's bladder incontinence, no actual directions to the staff on how the bladder retraining program would be implemented, and no well-defined instructions on how the staff would help Resident 397 achieve optimal bowel continence. In an interview on 08/23/24 at 11:42 AM Staff D, Nursing Assistant, stated that they find information on a resident's toileting needs in the Kardex (care instructions derived from the care plan). Staff D described that residents may have a timed toileting schedule, a 2-hour check schedule, or the staff go to the resident when the resident turns on the call light. Staff D stated that they become aware of Resident 397's toileting needs as the resident, will call if they need help. Staff D stated that Resident 397 uses a urinal or staff assist them to the bathroom with a one-person assist. Review of bladder episodes flow sheets between 8/12/2024 to 8/22/2024 showed, Resident 397 experienced urinary incontinence two to three times daily, and bowel incontinence on an almost daily basis. In an interview on 08/23/24 at 10:51 AM, Staff G acknowledged this information as correct. Staff G could not say why Resident 397 experienced incontinence. Staff G stated that the staff had not evaluated Resident 397's bowel incontinence presently. In an interview on 08/26/24 at 8:34 AM, Staff T, Therapy Director, stated that when staff identified a resident experienced incontinence, he expected a referral request from the Nursing Department and get an order for Therapy to work with the resident. Staff T explained that for bladder retraining, the program starts with the therapy department, then handed off to the nursing department. Staff T was unaware of any residents in the facility currently on a bladder retraining program and stated, We get an order through nursing. [The resident] would need something more than just every 2-hour schedule. Therapy takes it up a notch. Staff T was unaware Resident 397 experienced dual incontinence. In an interview on 08/23/24 at 10:51 AM, Staff G stated that staff should complete bladder and bowel evaluations and implement a plan based on what we are seeing. Staff G acknowledged the staff failed to comprehensively evaluate Resident 397's bowel incontinence. Staff G acknowledged the staff identified Resident 397 was assessed to require a bladder retraining program, but that the care plan showed no instructions on how to implement the program. Staff G acknowledged the care plan lacked effective and resident-centered interventions to address the resident's dual incontinence. Staff G stated that at the minimum they would want to see interventions to show a toileting program, or a check and change schedule. No further information was provided by the facility. Reference WAC 388-97-1060 (3)(c).

Based on observation, interview, and record review, the facility failed to ensure the staff accurately monitored the fluid intake of 1 of 1 resident (91) reviewed for hydration. This failure placed Resident 91, who was on fluid restrictions, at risk for dehydration or fluid volume deficit. Findings included . Review of an 08/02/2024 admission assessment showed Resident 91 admitted to the facility on [DATE] with medically complex conditions, to include heart failure and an acute kidney infection. An observation on 08/21/24 at 9:18 AM showed signage above Resident 91's bed that stated the resident was on a fluid restriction. Two glasses of juice and water and a cup of coffee were observed on Resident 91's over-the-bed table. When asked why they were on a fluid restriction, Resident 91 stated, I don't know. They [staff] just told me I was on one. So, they limit the amount of fluids they have to give me. Review of an 08/05/2024 Nutrition Assessment showed Resident 91's fluid needs between 1,275 to 1,525 mL (milliliter - unit used to measure capacity). The assessment showed the resident, requires 1800 mL fluid restriction. Compliant w/ [with] fluid restriction and was on a diuretic [a drug that make the kidneys produce more urine] for heart failure. Review of the August 2024 Medication Administration Record (MAR) showed orders to restrict Resident 91's fluid intake to 1,800 mL every day. The orders showed the Kitchen Department provided 1,320 mL of the 1,800 mL at mealtimes, leaving the Nursing Department to provide 480 mL in a 24-hour period. Review of the August 2024 MAR showed that the nurses documented the total amount of fluids Resident 91 consumed daily. Record review showed the staff documented the amounts of fluids Resident 91 consumed at mealtimes in the Fluid Monitor Task Section. Interviews on 08/26/24 09:12 AM with Staff Y, Nursing Assistant, and on 08/23/24 at 08:47 AM with Staff G, Resident Care Manager, confirmed that Health Shakes 120 mL at mealtimes were included in the total tally of fluids documented in the Fluid Monitor Task Section. A comparison between what the Licensed Nurses (LNs) and Nursing Assistants (NAs) documented in the medical record showed, the amount of fluids Resident 91 consumed did not match the total daily tally of fluids the LNs documented in the August 2024 MAR from 08/06/2024 to 08/22/2024. The August 2024 MAR showed the nurses documented Resident 91 consumed a total daily average of 1,781 mL in the MAR, but the actual amount of fluids the resident consumed between what the LNs and NAs documented in the medical record fluctuated between a low of 540 mL and a high of 1,400 mL. Additionally, on six of the 17 days reviewed, the resident's fluid consumption stayed below one liter of fluid. On none of the days Resident 91's fluid consumption reached 1,500 mL of fluid. The above findings were shared with Staff G on 08/23/24 at 08:47 AM. Staff G stated that the fluid tally documentation, do not add up. Staff G acknowledged inaccurate fluid monitoring placed Resident 91 at risk for dehydration. Reference WAC 388-97-1060 (3)(i).

Based on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment was maintained in a clean manner and oxygen orders were followed for 1 of 2 sampled residents (19) reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . Per the 07/09/2024 quarterly assessment, Resident 19 had diagnoses which included morbid obesity, high blood pressure and had moderate cognitive impairments. Review of the 04/03/2024 physician order documented Resident 19 had been prescribed oxygen to maintain oxygen saturation greater than 91%, due to hypoxia (a condition in which the body is deprived of adequate oxygen). Per the August 2024 Medication Administration Record (MAR), the resident was not administered oxygen for levels of less than 92% on the following dates: -08/03/2024 oxygen level was 91% on day and night shift -08/09/2024 oxygen level was 90% on evening shift -08/10/2024 oxygen level was 90% on night shift -08/11/2024 oxygen level was 91% on day, evening and night shift -08/13/2024 oxygen level was 90% on evening shift -08/22/2024 oxygen level was 91% on day shift -08/24/2024 oxygen level was 90% on night shift -08/25/2024 oxygen level was 91% on night shift The 04/25/2022 physician order instructed nursing to change the oxygen tubing and filter weekly and as needed. According to the August 2024 MAR, the oxygen tubing had not been changed on 08/10/2024 and 08/17/2024 as ordered. On 08/22/2024 at 10:15 AM, Resident 19 was observed lying in bed and was not wearing oxygen. An inspection of the oxygen concentrator in the resident's room showed the concentrator was unclean with thick dust inside the vented area, and the filter had thick dust and debris. The oxygen tubing had no date as to when it had last been changed. Subsequent observations of the oxygen concentrator being unclean and the filter being dirty were made on 08/22/2024 at 3:57 PM and 08/23/2024 at 8:09 AM. During an observation on 08/23/2024 at 8:27 AM, Resident 19's undated nasal cannula and oxygen tubing was observed lying on the floor. On 08/23/2024 at 8:27 AM, Staff I, Respiratory Therapy Director, and the surveyor observed Resident 19's concentrator. The area inside the vent of the concentrator and the filter had thick dust. Staff I confirmed the filter was dusty and should have been changed. Staff I wound up Resident 19's oxygen tubing and nasal cannula that was on the floor and placed it in a bag on the concentrator and stated the tubing was stored in the bag until it needed to be used. Staff I added that the tubing was to be changed weekly. In an interview on 08/23/2024 at 9:30 AM, Staff J, Resource Nurse, stated nasal cannulas that touched the floor needed to be discarded because they were dirty and had germs. During an interview on 08/27/2024 at 11:04 AM, Staff B, Director of Nursing, stated oxygen filters needed to be kept clean and this was important to maintain functionality of the equipment. Staff B added that nasal cannulas found on the floor needed to be discarded immediately to ensure it was not used for the resident. During an interview on 08/27/2024 at 11:57 AM with Staff K, Resident Care Manager, stated Resident 19 according to the order should have worn oxygen when their saturation was less than 92% and it was important, so the resident had adequate oxygenation for their vital organs. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to ensure blood pressure medications were consistently monitored for 1 of 5 sample resident (90) reviewed for unnecessary medications. This failure placed the residents at risk for potential adverse side effects and medical conditions. Findings included . Per the 08/03/2024 admission assessment, Resident 90 had diagnoses which included high blood pressure. Review of the Physician Order Report documented the physician prescribed a blood pressure medication (Metoprolol) on 07/30/2024 to be given twice daily. The order instructed nursing staff to hold the medication if the heart rate was less than 60 beats per minute or the systolic blood pressure (the pressure in your arteries when your heart is beating and sending blood into your arteries) was under 100. In addition, the nursing staff were to notify the physician if Resident 90's blood pressure was out of the parameters listed. Review of the July and August 2024 Medication Administration Record (MAR) documented no blood pressures were taken prior to administration of the blood pressure medication as instructed in the physician's order. Review of the Vitals Parameters report from 07/30/2024 through 08/23/2024 documented Resident 90's blood pressure had not been taken twice daily most days and times did not always correlate when blood pressure medication was administered. In an interview on 08/26/2024 at 11:15 AM, Staff B, Director of Nursing, stated the blood pressure should have been monitored every time it was given, and the order was typically placed on the MAR and was missed. Staff B added it was important to monitor the blood pressure, so nursing knew when to hold the medication and notify the physician. Reference (WAC): 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to implement measures to promote proper positioning and maintain body alignment for 3 of 5 sampled residents (Residents 2, 3, and 4), reviewed for positioning. This failure placed residents at risk for a decline in mobility, increased risk of contracture (shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult), and a decreased quality of life. Findings included . <Resident 2> Review of the care plan revised 06/26/2023 showed Resident 2 had an intervention for bilateral resting hand splints to be applied in the morning, then removed after eight hours. Review of the September 2023 Treatment Administration Record (TAR) showed staff were to apply Resident 2's bilateral resting hand splints at 8:00 AM and remove them at 4:00 PM. The splints were marked as applied on 09/11/2023. Observation on 09/11/2023 at 11:46 AM showed Resident 2 was lying in bed without the ordered hand splints applied. The resident's hands opened, and their fingers extended when their hand was moved. At 1:20 PM the same day, Staff C, Registered Nurse, observed Resident 2 with the surveyor and confirmed the ordered hand splints were not applied. Staff C searched the room and found the splints in the resident's closet. Immediately after the observation Staff C reviewed Resident 2's TAR, then asked Staff D, Nursing Assistant, to enter the resident's room with them. Staff C exited the room and stated Staff D was responsible for the resident's care that day and misunderstood the use of the hand splints. Staff C stated they educated Staff D that the splints were to be on for eight hours each day and had assisted Staff D to apply the ordered splints. <Resident 3> Review of the 06/13/2023 Occupational Therapy Discharge Summary, dated 06/13/2023, showed Resident 3 was to wear resting hand splints to both hands for eight hours during the day and to be removed at night. Review of the August 2023 Medication Administration Record showed Resident 3 was to have bilateral resting hand splints applied at 8:00 AM and removed at 4:00 PM. In an interview on 08/21/2023 at 2:03 PM a representative for Resident 3 stated they felt the resident's range of motion had worsened in the past few months and stated the resident's fingers were stiff. Observation on 08/21/2023 at 3:35 PM showed Resident 3 was lying in bed with no splints applied to their hands. The ordered splints were observed lying on a chair near the bed. The resident was able to move their fingers but did not reach full extension. In an interview on 08/21/2023 at 3:17 PM, Staff B, Rehab Manager, stated Resident 3 was assessed by therapy staff and confirmed the resident was to be wearing splints to their hands during the day. Staff B added that therapy staff had received a request that day to further evaluate the resident's splints. Observation on 11/03/2023 at 2:01 PM showed Resident 3 was once again lying in bed with no splints applied to their hands. <Resident 4> Review of the Occupational Therapy notes dated 3/31/2022 to 04/15/2022 showed Resident 4 was at risk of contractures and had bilateral resting hand splints which staff were to continue applying after the resident was discharged from therapy services. The notes did not show an assessment of the resident's lower body and/or discharge plan related to positioning of their legs. Review of the Physical Therapy (PT) notes dated 03/30/2023 to 04/15/2023 showed Resident 4 admitted to the facility unable to completely extend their knees, which impacted their ability to sit in a wheelchair. Per the PT notes staff were to assist the resident to sit up in their wheelchair three or more hours per day for upright tolerance and positioning of the lower extremities after the resident was discharged from therapy services. There were no instructions included related to the positioning of the resident's lower extremities while they were in bed. Review of Resident 4's care plan, revised 08/21/2023, showed they were to use body positioning pillows to decrease pressure. Review of the August 2023 TAR showed the resident was to use a wheelchair to help maintain proper positioning while out of bed, however there were no instructions regarding frequency or duration of wheelchair use (see above). In an interview on 09/11/2023 at 9:30 AM Resident 4's representative stated when they visited the resident their splints on their hands were not on, and the representative would have to request nursing staff apply them. Additionally, the resident was constantly laying with their legs in a butterfly position (feet together with knees bent and extended outward from the body). Observation on 09/11/2023 at 11:40 AM and 1:13 PM showed Resident 4 was lying in bed with splints to both hands, but no pillows for positioning. The resident's legs were in the butterfly position with their knees extended outward from the body and hovering over the bed with no support underneath. Observation at 2:36 PM and 4:20 PM the same day showed the resident now had a pillow underneath the side of their body, but their legs remained in the same position, without support under their legs/knees. In an interview on 09/11/2023 at 4:23 PM, Staff E, Nursing Assistant, stated Resident 4's legs should be supported with pillows while they were in bed, and stated the resident's legs were always like that (butterfly position). Staff E was not aware of any other interventions to assist the resident with neutral positioning of their legs. In an interview at 4:45 PM the same day Staff B stated Resident 4 was supposed to spend time up in their wheelchair each day to keep their hips from splaying out and that side lying would help as well. Staff B performed passive range of motion to the resident's legs and stated they were still able to achieve motion to neutral and had no increased contracture from their admission status. In an interview on 09/11/2023 at 3:45 PM Staff A, Director of Nursing, stated the facility did not have policies specific to use of splints, range of motion, and/or positioning and staff were to follow guidance of therapy staff. Reference: WAC 388-97-1060(3)(d)(m)(4)

Based on observation, interview, and record review, the facility failed to ensure the care plan was reviewed and revised for 1 of 36 sampled residents (Resident 67), whose care plans were reviewed. This failure placed the resident at risk for unmet care needs. Findings included . According to a 03/22/2023 comprehensive assessment Resident 67 was admitted to the facility with a diagnosis of Spastic Quadriplegic Cerebral Palsy (a disorder of the brain, that affects the person's ability to control their muscles). The assessment also showed Resident 67 was unable to walk or speak, and had severe intellectual disabilities. According to a 02/28/2023 alert progress note by Staff M, Registered Nurse (RN), the resident's condition deteriorated, and they were admitted to the hospital. A 03/03/2023 progress note by Staff N, RN, showed that the resident returned to the facility with a urinary catheter (a tube inserted into the bladder to drain urine into a bag) and IV therapy (medications given through a needle or tube that went directly into a vein). A review of the resident's current care plan showed that they had a urinary catheter, initiated on 03/03/2023. The care plan further showed a goal to remain free of catheter-related trauma, revised on 03/21/2023. The care plan also showed the resident received IV therapy. This focus was initiated on 03/03/2023 and revised on 03/21/2023. According to the March 2023 Medication Administration Record (MAR), Resident 67's urinary catheter was removed on 03/07/2023, and their IV was removed on 03/08/2023. A further review of the resident's care plan did not show that the resident had a seatbelt on their wheelchair, which had been present since admission. An Interdisciplinary Care Conference note from a meeting on 03/16/2023 showed that the care plan was reviewed and updated quarterly and as needed. On 04/20/2023 at 12:01 PM, Resident 67 was observed sitting in their wheelchair. No urinary catheter or any IV access was seen. On 04/21/2023 at 2:27 PM, the resident was observed in their wheelchair with a seatbelt fastened across their lap. On 04/26/2023 at 11:32 AM, the resident was wheeling themselves down the hallway. The resident had their seatbelt fastened across their lap. During an interview on 04/26/2023 at 12:13 PM, Staff D, Nursing Assistant (NA), stated that Resident 67 used a seatbelt in their wheelchair. During an interview on 04/27/2023 at 9:15 AM, Staff C, NA, stated that Resident 67 was able to undo their seatbelt, but did not try because they were not supposed to. In a follow-up interview at 11:43 AM that day, Staff C said that the resident had the seatbelt ever since they had been admitted to the facility, even on their old wheelchair. Staff C further stated that the seatbelt should be on the Kardex (the care plan for nursing assistants), but it was not. During an interview on 04/27/2023 at 9:45 AM, Staff F, Licensed Practical Nurse (LPN), stated that the resident had a seatbelt on their wheelchair. They confirmed that the seatbelt should be on the care plan and the Kardex. During an interview on 04/27/2023 at 11:21 AM, Staff E, LPN, stated that either the floor nurse or the Patient Care Coordinator (also referred to as Resident Care Manager or RCM), could update the care plan. They further stated during day shift, the care plan was updated by the RCM, since they often took the order, and that should have been done within a couple of days of the new order. During an interview on 04/27/2023 at 11:31 AM, Staff H, RN, stated that sometimes the floor nurse updated the care plan when they carried out the order. They further stated that since the RCM's received orders from the physician and put them into the computer, they usually updated the care plan at the time. During an interview on 04/27/2023 at 11:41 AM, Staff F, LPN, stated that usually the RCM's updated the care plan on day shift, but that the floor nurses did it also. During an interview on 04/27/2023 at 12:02 PM, Staff G, RN, RCM, stated that the floor nurse or the RCM updated the care plan. They further stated that the RCM often helped with that task, but they were supplemental. Staff G brought up Resident 67's care plan on the computer, which showed a urinary catheter and IV therapy as current issues, although the urinary catheter and IV were both discontinued 7 weeks ago. Staff G further stated that the seatbelt was not addressed in the care plan, until the omission was brought to their attention by the surveyor the previous day. Staff G acknowledged that the care plan issues should have been caught earlier, and that they missed it. Reference: WAC 388-97-1020(2)(c)(d)

Based on observation, interview, and record review, the facility failed to provide cueing during mealtimes for 1 of 3 sampled residents (Resident 31), reviewed for activities of daily living. This failure placed the resident at risk for decreased food and fluid intake, and possible unintended weight loss. Findings included . Resident 31 had diagnoses including Alzheimer's dementia (a decline in mental ability severe enough to interfere with daily life). An annual assessment completed 02/16/2023 showed the resident was severely cognitively impaired, had physical and verbal behaviors directed at others, and rejected care. The assessment also showed the resident required supervision (oversight, encouragement or cueing) and set-up help for eating. The 02/15/2022 comprehensive care plan showed the resident was at risk for nutritional problems related to Alzheimer's dementia. Per the care plan, staff were to explain the importance of maintaining the diet ordered, monitor weights per protocol, and provide and serve the diet as ordered. The care plan also showed the resident preferred to eat in their room, and required cueing at mealtimes as needed to facilitate intake. The 02/21/2023 Annual Nutrition Risk Assessment by Staff I, Registered Dietician, showed the resident was at high nutritional risk, and staff were to anticipate the resident's needs. Per the assessment, the resident's weight had been stable over the last year, and the resident had maintained a good appetite, though occasionally they refused meals due to their days and nights being mixed up and eating several snacks throughout the night. A review of the resident's weights showed the following: 03/08/2023-210 pounds (lbs.), 04/19/2023-184.0 lbs., and 04/26/2023-194.5 lbs., a 7.4% weight loss from 03/08/2023. A 30-day look back at the nursing assistant meal intake from 03/28/2023 through 04/26/2023 showed the resident refused 28 meals and ate 50% or less for 18 meals. There was no documentation for 20 meals during that period. On 04/24/2023 at 2:37 PM, Resident 31 was observed in their room. Their lunch tray was still on the overbed table in front of them. There were bites taken from the mashed potatoes; the rest of the food was uneaten. The resident made a face and stated they would eat it later. There were no intakes documented for breakfast, lunch or dinner on 04/24/2023. On 04/25/2023 at 12:15 PM, the resident was provided their lunch tray. The resident took bites at times, then stared off at times. No staff entered the resident's room or cued the resident to eat during their meal. At 12:42 PM, the resident's tray was removed. The resident had consumed approximately 75% of their meal. On 04/26/2023 at 12:16 PM, Resident 31's lunch was provided. At 12:17 PM, the resident was provided a glass of ice water. The resident took bites, or sat without eating, staring off at times. At 1:07 PM, the resident's tray was removed. The resident ate less than 50% of their meal. During continuous observation, no staff entered the resident's room, assisted or cued the resident to eat during their meal. During an interview on 04/27/2023 at 9:03 AM, Staff J, Nursing Assistant, (NA), stated Resident 31 did not require assistance to eat. Per Staff J, the resident had behaviors and swore at them so they left the resident alone. Staff J did not think the resident had lost weight. During an interview on 04/27/2023 at 12:04 PM, Staff K, NA, stated Resident 31 slept a lot, got agitated often and needed help eating. Upon questioning, Staff K stated cueing a resident to eat meant staff offered a resident their juice, or food, or reminded the resident their food was there. During an interview on 04/27/2023 at 3:00 PM, Staff L, Registered Nurse Resident Care Manager, stated they spoke with a couple of the staff regarding Resident 31, and was told the resident needed cueing. Staff L stated cueing included giving a resident a verbal cue, offering a drink, letting the resident know their food was there, or those types of things. They stated Resident 31's behavior varied a lot, so the care plan showed cueing as needed, but staff were expected to be checking in with the resident. Staff L also stated the resident's weight loss was unexpected, they had notified the Registered Dietician. During an interview on 04/28/2023 at 11:17 AM, Staff I, Registered Dietician, stated Resident 31's weight had been stable, but they had just triggered for weight loss. Staff I noted the resident slept during the day then got snacks at night, and was unsure but thought the weight loss was because of decreased intake. Resident I stated the resident was to receive cueing as needed, and said not getting cued might add to the resident's decreased intake. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for spread of communicable diseases, including COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death), were consistently implemented for 4 of 7 sample residents (1,2,3,4), reviewed for transmission-based precautions. Failure to follow guidance related to the use of personal protective equipment (PPE) by 2 staff (D, E), for residents on quarantine (separation of a person believed to have been exposed to a communicable disease to prevent possible spread of the disease), placed other residents at risk for exposure to an infectious disease. Findings included . Per review of Washington State Department of Health (DOH) guidance Personal Protective Equipment (PPE) for Long-Term Care Settings During COVID-19 Pandemic, dated 11/22/2021, in quarantine rooms staff were to use fitted N95 respirators (a mask/device worn on the face to reduce the risk of inhaling hazardous airborne particles including infectious agents), eye protection, gowns and gloves during each resident encounter. The PPE items were then to be discarded after each use if disposable, or disinfected if re-usable. An encounter was defined as any in-person interaction between staff and residents closer than six feet for any period of time. Upon entering the facility on 01/28/2022 at 9:35 AM, Staff A, Administrator, stated the facility had a number of residents test positive for COVID-19 recently, but none in the last 12 days. Per Staff A, no residents remained in isolation on the COVID-19 unit, but most residents in the facility were in quarantine, related to exposure to either a staff member or another resident who tested positive. At 11:00 AM the same day, Staff D, Nursing Assistant, was observed exiting Resident 3 and Resident 4's room. According to a sign posted outside the room, the residents were on contact/droplet precautions (a type of isolation to reduce the risk of droplet-borne infections). Staff D had on an N95 mask, eye protection, a gown, and gloves. The staff member removed the gown and gloves, but did not change their N95 mask, or change/sanitize the eye protection, and proceeded down the hallway to dispose of a trash bag. Staff D then put on a new gown and gloves, and entered Resident 1 and Resident 2's room, which also had a contact/droplet precaution sign outside the door. At 11:05 AM, Staff E, Licensed Practical Nurse, was observed exiting Resident 3 and Resident 4's room. Staff E removed their gown and gloves, but did not change their N95 mask, or change/sanitize their eye protection. In an interview 01/28/2022 at 11:06 AM, Staff E stated all the residents on the unit were in quarantine. Per Staff E, staff were to put on gowns and gloves in addition to the N95 mask and eye protection they were already wearing, prior to entering any of the rooms. Staff E stated the gown and gloves were to be removed upon exiting the room, but the N95 mask did not need to be changed and the eye protection cleaned, unless doing resident care. In an interview on 01/28/2022 at 11:15 AM, Staff D stated all the residents on the unit were on quarantine, and N95 masks were to be changed and eye protection sanitized after every resident encounter. When the previous observations were shared with the staff member, Staff D stated they had just spaced, and forgotten to do it. In an interview on 01/28/2022 at 11:35 AM, Staff A, Administrator, was asked about the expectations regarding PPE use in quarantine rooms. Staff A stated in addition to the N95masks and eye protection already being worn, staff were to put on gowns and gloves prior to entry to the room. Per Staff A upon exiting the room, gowns and gloves were to be removed, N95 masks were to be changed, and eye protection sanitized each time, regardless of what staff was doing in the room. Reference: WAC 388-97-1320 (1)(2)

Based on interview and record review, the facility failed to provide a written transfer notice at the time of transfer to the hospital, for three of three sample residents (#1, 2, 3), reviewed for hospitalization . This failure placed the residents and their representatives at risk for a lack of knowledge regarding their appeal rights. Findings included . Review of the facility's policy titled, Bed Hold/Notice of Transfer/Discharge, dated October 2018, showed residents would be made aware of their rights to appeal the facility's decision to transfer the resident, and also in the event the facility denied readmission to the facility after a hospital stay. In the case of an emergency transfer, resident representatives would be mailed a copy of the notice within 24 hours of the resident's transfer. 1. Per a 01/05/21 facility investigation, Resident #1 was transferred to the hospital on [DATE] for further evaluation at the recommendation of local law enforcement, during an investigation of alleged abuse. No documentation was found in the resident's record to show the resident and her representative were given a written notice of transfer, which included the right to appeal the transfer, including information on how to do so. In an interview on 03/24/21 at 10:15 AM, the resident's representative stated they received verbal notice from the facility that the resident went to the hospital, but did not receive the notice in writing specifying whether the resident was transferring or discharging, or any information on how to appeal a transfer, or who to contact and how to contact the State Long-Term Care Ombudsman office for information on transfer appeals. The resident's representative stated the facility denied the resident readmission to the facility; see F-626 for more information. 2. Per a progress note dated 03/05/21, Resident #2 was transferred to the hospital that day, for an acute medical need. No documentation was found in the resident's record to show the resident and her representative were given a written notice of transfer, as required. In an interview on 03/25/21 at 1:50 PM, Resident #2's representative stated they received verbal notification from the facility when the resident was transferred to the hospital, but did not receive written notice, or information on transfer and/or discharge appeal rights. 3. Per a progress note dated 03/05/21, Resident #3 was transferred to the hospital on the same date, for an acute medical need. No documentation was found in the resident's record, to show the resident and his representative were given a written notice of transfer, as required. In an interview on 03/25/21 at 12:30 PM, the resident's representative stated they were in communication with the resident when the hospital transfer occurred, but did not receive notice from the facility of the resident's transfer, or their appeal rights. In interviews from 3:00 PM to 4:00 PM on 03/24/21, Staff C, Resident Care Manager, Staff D, Resident Care Manager, Staff E, Charge Nurse, Staff F, Registered Nurse, and Staff G, Licensed Practical Nurse, all stated clinical records were sent with the resident when they transferred to the hospital, and phone calls to resident representatives were done by the nursing staff. All stated nursing staff were not responsible for providing written notice, or appeal information to the resident and resident representative. On 03/25/21 at 11:45 AM, Staff G, Admissions, stated the facility had a standard packet of documents, including transfer notices, which nursing staff were to send with the resident to the hospital. Staff H was unable to provide any information when asked as to how resident representatives were provided written notice. In an interview on 03/26/21 at 4:20 PM, Staff A, Administrator, was asked about written transfer notices for Residents #1, 2, 3, and their representatives. Per Staff A, notices for residents should have been included in the paperwork sent to the hospital with the resident, and the representative was notified by phone call only. Reference: (WAC) 388-97-0120 (2)(a-e), -0140 (1)(a)(b)(c)(i-iii)

Based on observation, interview, and record review, the facility failed to permit a resident to return to the facility after a hospitalization , for one of three sample residents (#1), reviewed for hospitalization . This failure resulted in a prolonged hospital stay (more than 74 days) during a global pandemic, instead of returning to the facility for care and services. Findings included . Review of the facility's policy titled, Bed Hold/Notice of Transfer/Discharge, dated October 2018, showed residents would be placed on a waiting list with top priority for the next available bed, if no appropriate bed was available when a resident decided to return to the facility from the hospital. Review of the 09/11/19 admission assessment showed Resident #1 admitted to the facility on [DATE], had a [DIAGNOSES REDACTED]. Per a 01/05/21 facility investigation, the resident was transferred to the hospital on [DATE], for further evaluation at the recommendation of local law enforcement, during an investigation of alleged abuse. The facility's investigation documented the resident was confused due to an acute infection, and the care plan was updated to include female care only, prior to the resident's transfer. Review of the progress notes from January 2021 to March 2021 showed no entries of discussions with the resident and/or their representative about plans for re-admission to, or discharge from the facility, after the resident's hospital stay. A physician's discharge summary, stating the resident transferred to another facility from the hospital, was dated 03/02/21. In an interview on 03/24/21 at 9:45 AM, a representative of the hospital stated the resident was confused and fearful for her safety at the nursing facility initially upon admission to the hospital, and her family member verbalized concerns about returning to the facility during that time. Per the hospital representative, the resident continued to be confused until approximately 01/20/21, after which time the resident spoke to the family member and expressed a desire to return to the facility. The representative stated she reached out to the facility originally when the resident first admitted to the hospital, and was told the resident would be accepted back when she was ready to discharge. The hospital reached out to the facility again in February 2021, and was told by facility staff the resident could not be readmitted , due to the resident's past allegations. She further stated the resident continued to remain in the hospital since the 01/09/21 admission, as the facility was the only skilled nursing facility in eastern Washington with respiratory therapy services, which the resident required. In an interview on 03/24/21 at 10:15 AM, the resident's family member stated she was at the facility on the weekend after the resident's hospital admission to pick up items the resident needed while at the hospital (phone, wheelchair), and spoke with facility administration about the resident's need for re-admission to the nursing facility. Per the family member, she did not tell the facility the resident wished to discharge, and she was not informed the resident was considered discharged during that conversation. The family member provided electronic communications with the facility, dated 02/08/21, which showed the family member made a request to clarify when the resident was considered discharged , as neither the resident nor the representative spoke to facility staff about wanting to discharge. The included facility response showed the facility considered the resident discharged from the facility based upon hospital records documenting the resident and family did not wish to return (rather than the facility contacting the resident and/or representative about their wishes). Per the resident's representative, the resident had high medical needs that required skilled nursing care, and there were no other options for the resident that were near the family, provided a similar level of care and safety for the resident, and remained within the same state borders. Observation on 03/24/21 from 2:00 PM to 4:45 PM showed the facility had available beds on the unit the resident previously resided on, and continued to provide respiratory therapy and nursing services to residents with similar needs as Resident #1. On 03/25/21 at 1:01 PM, Staff G, Admissions, stated the nursing facility determined on 01/12/21 they would not accept the resident back in the facility, based off of hospital notes showing the resident's representative was unhappy with the care in the facility. Per Staff G, if a resident was not allowed to re-admit due to lack of an available bed they would be placed on a waiting list for the next available bed, however, Resident #1 was not placed on a waiting list because it did not apply to the situation. In an interview on 03/26/21 at 3:45 PM, Staff A, Administrator, stated the facility was not required to accept the resident back in the facility because the hospital transfer and subsequent hospital stay was considered a resident-initiated discharge, as the hospital notes were clear the resident's representative was unhappy with the facility care. When asked about any facility follow up with the resident or representative regarding re-admission, Staff A also stated there was a conversation with the family member on 01/17/21 (the weekend following the resident's hospital admission), where the family member stated the resident did not want to return to the facility. When asked for supporting documentation of this conversation, the facility provided an untitled, undated electronic document, separate from the medical record, which documented the family was planning to have the resident discharge from the hospital to a personal home with a family member. During the same interview, Staff A stated he was notified sometime between 01/20/21 and 01/25/21 that the resident wished to return to the facility, but there were no available beds at that time. Additionally, Staff A stated the facility was not able to provide female care only during the night shift, or to provide a second staff member as a witness when no female staff were available. Records showing how the facility assessed their staffing levels and capability to provide care as needed per the resident's care plan were requested; none were provided. Review of a facility-provided list of resident admissions from 01/01/21 to 03/24/21 showed residents were admitted and readmitted to the same unit the resident had discharged from. The new admissions included two residents with similar demographics to Resident #1; Resident #4 admitted on [DATE], and Resident #5 admitted on [DATE]. Reference: (WAC) 388-97-0120 (4)(b)

Based on observation, interview and record review, the facility failed to conduct COVID-19 testing of all residents since the start of 2/15/21 COVID outbreak, as required. Facility tested all residents for COVID-19 last on 1/18/21 but their outbreak was ongoing as of 2/23/21. This failure increased the likelihood for delayed identification/[DIAGNOSES REDACTED]. On 2/23/21 at 5:55 PM the facility's Administrator and Director of Nursing (DON) was notified of an Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (h) (F886) for failure to conduct COVID-19 testing of all residents since the start of 2/15/21 COVID outbreak, as required. Facility tested all residents for COVID-19 last on 1/18/21 but their outbreak was ongoing as of 2/23/21. This failure increased the likelihood for delayed identification/[DIAGNOSES REDACTED]. On 2/24/21 at 12:08 PM the Administrator was notified the immediacy was removed based on onsite verification that IJ removal plan was implemented. Following the removal of the immediacy, noncompliance remained at a scope of pattern, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During concurrent observation and entrance interview on 2/23/21 at 10:30 AM DON stated there she was also the facility's Infection Preventionist (IP) since last week when IP left. DON stated that there were no known positive COVID residents however a staff member tested positive on 2/15/21 and therefore several residents were on contact/droplet transmission based precautions (TBP) because of COVID exposure. Staff have been tested twice weekly but will be tested on ly once this week due to drop in county positivity rate. A period of 14 days with no new positive COVID tests from resident or staff had not lapsed since staff tested positive for COVID on 2/15/21. Entrance interview was held in conference room in Administrative office area. DON stated that staff COVID testing was completed yesterday and DON moved several boxes containing COVID testing materials to clear conference room table. COVID testing materials included boxes of Abbot BinaxNOW COVID-19 Ag Cards and BD Veritor Plus (point of care rapid tests that detects protein [MEDICATION NAME] to [DIAGNOSES REDACTED]-CoV-2 (Severe acute respiratory syndrome coronavirus 2, [DIAGNOSES REDACTED]-CoV-2, which is [MEDICAL CONDITION] that causes COVID-19) from nares in about 15 minutes, each box contained about 40 test kits which could test about 40 individuals). More than 10-15 boxes were observed on conference room shelves. Review of Centers of Disease Control and Prevention (CDC) cases and deaths by county, https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/county-map.html, report dated 2/4/21 to 2/17/21, accessed 2/22/21, showed Spokane County (the county where the facility was located) had 5.9 percent positivity rate indicating yellow zone positivity classification. Review of Centers for Medicare and Medicaid Services (CMS) Quality Safety Oversight memo (QSO) 20-38-NH, dated 8/26/20, https://www.cms.gov/files/document/qso-20-38-nh.pdf, showed the LTC (Long term care) facility must test residents and facility staff for COVID-19. At a minimum, for all residents and facility staff, the LTC facility must: (1) Conduct testing based on parameters set forth by the Secretary, including but not limited to: (i) Testing frequency. In addition, under Testing of Staff and Residents in Response to an Outbreak, an outbreak was defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. The guidance above represented the minimum testing expected. Review of Washington State Department of Social and Health Services Aging and Long-Term Support Administration (WA DSHS ALTSA) NH #2020-064, QSO-20-37-CLIA, NH AND QSO-20-38-NH, regarding rule changes to require COVID-19 testing and guidance, dated 9/10/20, https://www.dshs.wa.gov/sites/default/files/ALTSA/rcs/documents/nh/020-064.pdf, showed When prioritizing individuals to be tested , prioritize individuals with symptoms of COVID-19 first, then testing triggered by an outbreak, then routine testing Testing of staff and residents in response to an outbreak. Upon identification of a single new case of COVID-19 (an outbreak), all staff and residents should be tested , and all individuals who tested negative should be retested every three to seven days until testing reveals no new cases among residents and staff for a period of at least 14 days since the most recent positive result. Review of American Health Care Association (AHCA) CMS Testing Mandate: How to Get Started, dated 12/21/20, https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-Preparedness/Documents/COVID19/Guidance-CMS-Testing-Mandate.pdf, showed When and Who to Test: There are three triggers for testing. It included Outbreak Testing: Test all staff and residents in response to an outbreak (any single new infection). Continue to test all staff and residents that tested negative every 3-7 days until 14 days since the most recent positive result has passed. On 2/23/21 at about 2:00 PM when facility's COVID policies were requested for review, Administrator provided large binder which included copies of QSO 20-38-NH memo, WA DSHS ALTSA NH #2020-064 and AHCA CMS Testing Mandate. During concurrent record review and interview on 2/23/21 at 3:00 PM, DON stated that there was no issue with obtaining testing supplies, access to quick testing results, or resident or staff refusing testing. Review of Employees previously COVID-19 positive re-testing after 3 months, undated, showed Rehabilitation Staff (RS)1 tested positive for COVID-19 on 1/15/21. DON clarified the 1/15/21 date was an error and should have showed 2/15/21. Reviewed staff testing logs with DON which showed RS1 received negative COVID tests on 2/4/21, 2/8/21, and 2/11/21 and positive COVID test on 2/15/21. RS1 was not working on 2/15/21 but felt sick, sinus infection, and was tested . RS1 worked full-time at the facility, worked regularly at the facility prior to positive COVID test, and did not work in other long term care facilities. Contact tracing was completed with local public health/local health jurisdiction (LHJ) with five residents identified as being exposed to COVID based on interactions with RS1 on 2/11/21 and 2/12/21. These five residents were placed in transmission based precautions and tested on [DATE] and 2/22/21 for COVID. When asked how these five residents were identified, DON stated LHJ stated that RS1 had contact within 6 feet for more than 15 minutes within last two days of symptom onset with these five residents. When asked about testing for residents other than five identified, DON stated that LHJ said RS1 was not suspected to get COVID from the facility and therefore the last testing for all residents, other than five identified by LHJ, was on 1/18/21. During an interview on 2/23/21 at 3:34 PM DON and Administrator stated that LHJ provided guidance that only subgroup of 5 residents who had exposure to RS1 needed to be tested . DON stated that facility staff was tired, overwhelmed and it took a lot of time to test all residents. DON stated that all residents were being monitored for COVID symptoms but not all residents were tested for COVID. During an interview on 2/23/21 at 3:58 PM LHJ stated that she recommended targeted testing method after conducting an extensive interview with RS1 and concluded that transmission of COVID did not occur in the facility and RS1 got COVID from the community. LHJ stated that if another or second resident or staff received a positive test, then the facility would be in an outbreak. When informed that CMS QSO memo 20-38-NH defined an outbreak as any single positive resident and staff that then required all residents and staff to be tested , LHJ stated that she was aware of memo but if that was followed, the facility would always be in an outbreak. LHJ stated that testing all residents was overly burdensome, it's a huge undertaking to be in outbreak status and it is silly to me to test residents who are on a different hall. When asked if all residents were not tested , how could the facility know if there was a asymptomatic resident or asymptomatic staff prior to scheduled weekly staff testing given that CDC's studies have shown when a resident or staff tests positive, there is likely to be more positive resident(s) and/or staff, LHJ's response was that could happened any day at any time and it was not appropriate to ask staff to test all residents. LHJ stated that there is fatigue of staff to test residents. When informed of infection control concerns observed by facility staff as possible modes of transmission by staff to residents, LHJ did not provide verbal response. During an interview on 2/23/21 at 5:55 PM DON and Administrator stated that State has always told them to consult with LHJ and assume that everything LHJ tells them is consistent with federal and state regulations. Reviewed CMS QSO memo 20-38-NH with DON and Administrator with emphasis that an outbreak was defined as any single positive resident and staff that then required all residents and staff to be tested as minimum expectations. Also showed section of memo where collaboration with LHJ was referenced for asymptomatic staff who refuse routine testing or if facility was having difficulties securing testing supplies or resources. There was no reference in memo to collaborate with LHJ with respect to testing requirements. When informed that facility is accountable for compliance with LTC requirements even if LHJ or other consultant provides guidance, Administrator did not provide verbal response. Review of facility updated Census Room List, dated 2/23/21 at 6:00 PM, showed 85 residents, of which 3 residents were last tested on [DATE], 18 residents tested positive within the last 3 months and therefore did not require re-testing, resulting in 62 residents who were last tested on [DATE] and 2 residents who were admitted on [DATE] and were not yet tested . The census showed 20 residents in the ventilator/trach unit, who were high risk for respiratory infections and 15 residents in the Medicare/short term unit. Of the 15 residents in the Medicare unit, one resident previously tested positive for COVID-19 within the past 3 months and therefore did not require COVID testing/re-testing; however, 13 of the residents were admitted after 1/18/21 which was the last time facility tested all residents. Review of list of residents on TBP, dated 2/23/21, showed 12 residents on contact precautions due to Admit COVID precautions and 5 additional residents (R2, R3, R14, R16, R17) on contact precautions due to COVID exposure. Review of Census Room List, given during entry into facility, dated 2/23/21, showed R3 (exposed to covid, on TBP and tested for COVID) shared a room with R1 (not tested for COVID) and R14 (exposed to covid, on TBP and tested for COVID) shared a room with R15 (not tested for COVID). During interview on 2/24/21 at 10:53 AM Rehabilitation Manager stated that the eight full-time rehabilitation staff worked only at this facility. Assignments were made by resident and not by sections/units of the facility and currently most services are provided in resident's rooms and not in the therapy/gym location. Over the course of a day, individual rehabilitation staff could see resident in their rooms on the vent/trach unit, and then Medicare/short term unit and then long care unit. On 2/24/21 at 12:08 PM the Administrator was notified the immediacy was removed based on onsite verification that IJ removal plan was implemented. The IJ removal plan included testing on 2/23/21 of all residents in the facility who required re-testing and testing of all staff on 2/24/21 to ensure twice weekly testing of staff. On 2/24/21 at 1:00 PM at Exit conference Administrator confirmed facility did not have a specific policy for COVID testing but adopted QSO 20-38-NH memo, WA DSHS ALTSA NH #2020-064 and AHCA CMS Testing Mandate as facility policy. Please also refer to F880.

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases, including COVID-19 and infections. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Specifically: 1. Failed to clean and disinfect shared blood pressure cuff and pulse oximeter after and between use on 6 of 6 residents (R) (R1, R3, R10, R11, R12, R13) observed for vital sign measurement. 2. Failed to doff (remove) isolation gown after use with 2 of 12 residents (R) (R7 and R14) observed who were on droplet/contact transmission-based precautions (TBP) due to COVID-19 exposure or admission to the facility within the past 14 days. 3. Failed to ensure personal protective equipment (PPE) face shield was fully covering and protecting sides of eyes from potential splashes and sprays while within six feet of residents (R7, R8, R9) who were on contact/droplet TBP for 1 of 4 certified nursing assistants (CNAs) observed. 4. Failed to clean/disinfect all high-touch surfaces and allow sufficient contact time for disinfecting high-touch surfaces in 2 of 2 resident room (room [ROOM NUMBER] and #144) during daily room cleaning observation. 5. Failed to change gloves and perform hand hygiene after picking up trash and before touching multiple clean surfaces during 1 of 2 resident room (room [ROOM NUMBER]) daily room cleaning observation. These failures increased the risk for the spread of infection and its associated discomfort and decline in physical condition. Findings include: During interview on 2/23/21 at 10:30 AM Director of Nursing (DON) stated that she was also the facility's Infection Preventionist (IP) since last week when IP left. DON stated that there were sufficient PPE inventory with no known positive COVID residents however a staff member tested positive on 2/15/21 and therefore several residents were on contact/droplet transmission based precautions (TBP) because of COVID exposure and several residents were on contact/droplet TBP as they were new admissions. Review of facility's policy, Interim Policy for Precautions SNF, revision date 12/2/20, showed the facility will follow CDC guidelines for the use of PPE to contain and prevent the spread of infection. Yellow indicated new or re-admissions, person under investigation . (contact/droplet precautions). Healthcare personnel should wear full PPE (gloves, gown, mask, eye protection/face shield). Review of list of residents on TBP, dated 2/23/21, showed 12 residents (including R7, R8, and R9) on contact/droplet TBP due to Admit COVID precautions and 5 residents (including R14) on contact precautions due to COVID exposure. *Cleaning and disinfection of reusable medical equipment Review of Mycolio disinfectant wipe container showed EPA registration number -1 and the treated surface must remain visibly wet for the appropriate time indicated for the purpose intended to clean and disinfect. Use additional wipes if needed to ensure the correct wet contact time. Wipe the surface dry. Review of EPA N list website, https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19, accessed 2/23/21, showed EPA registration number -1 product was effect against COVID-19 with contact time of 3 minutes. The contact time is the amount of time the treated surface should remain wet to be effective against [DIAGNOSES REDACTED]-CoV-2 (COVID-19). The surface should be visibly wet for the full duration of the contact time. Observation on 2/23/21 at 2:12 PM showed CNA2 wearing PPE placing pulse oximeter (portable device used to measure oxygen levels in the blood) on R3's finger. CNA2 placed blood pressure (BP) cuff around R3's arm and took R3's temperature. After pulse oxygen and BP measures were obtained, CNA2 wiped pulse oximeter and blood pressure cuff with Mycolio wipe and walked over to R1's bed and within 30 seconds placed same pulse oximeter on R1's finger. R3 and R1 shared a room. CNA2 exited room which showed a yellow contact TBP sign outside room. CNA2 took single wipe out of Mycolio container and wiped BP cuff and pulse oximeter and within 30 seconds placed same BP cuff on R13's arm and pulse oximeter on R13's finger. CNA2 wiped BP cuff and pulse oximeter with Mycolio wipe and after 49 seconds, placed pulse oximeter and BP cuff on R12's wrist and finger. After obtaining measurements, CNA2 wiped pulse oximeter and BP cuff with Mycolio wipe and after 28 seconds, placed pulse oximeter on R11's finger. CNA2 again wiped pulse oximeter and BP cuff with Mycolio wipe and within 30 seconds placed pulse oximeter on R10's finger. During an interview on 2/23/21 at about 2:25 PM CNA2 stated that she used wipes on BP cuff and pulse oximeter equipment between residents to make sure it's clean for each resident. CNA2 stated that equipment is wiped off and she lets it set for one minute. CNA2 further stated that this means she doesn't use the equipment for one minute to let it dry. When asked does it mean the equipment stays wet for a period of time, CNA2 shook her head and said, No. During concurrent record review and interview on 2/23/21 at 3:00 PM, DON stated that Rehabilitation Staff (RS)1 had positive COVID test on 2/15/21. Contact tracing was completed with local public health/local health jurisdiction (LHJ) with five residents (R2, R3, R14, R16, R17) identified as being exposed to COVID based on interactions with RS1. Review of Census Room List, given during entry into facility, dated 2/23/21, showed R3 (exposed to covid) shared a room with R1. During an interview on 2/23/21 at 5:55 PM DON stated that resuable medical equipment shared between residents such as blood pressure cuff and pulse oximeter should be cleaned and disinfected between residents using disinfecting wipes in accordance with disinfecting wipes manufacturer's instructions. Administrator stated that the facility had many different disinfecting wipes because it was still difficult to obtain supplies. When asked how staff know the contact time for individual products, Administrator stated that staff needs to read the product label. When asked how the facility makes it easier for staff to identify the contact times for each product, Administrator nodded his head and stated, I see where you are going. Review of facility's policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revision date 7/15/20, showed dedicated medical equipment is used for patient care whenever possible .routine cleaning and disinfection procedures applying an EPA-registered .disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label. Upon request for facility's policy on reusable medical equipment, Administrator referred to this policy. *Doffing isolation gowns outside COVID exposed or new hospital resident rooms Review of facility's policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revision date 7/15/20, showed residents with suspected COVID-19 will be placed on droplet precautions. Personnel entering the room will use PPE including gloves, gowns, mask and eye protection. PPE will be removed in the patient's room and discarded. Review of facility's competency checklist for donning and doffing (putting on and taking off gear), undated, showed gown should be removed before exiting patient room. Resident 7 Record review showed R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R7's Minimum Data Set (MDS-assessment tool), dated 2/14/20, showed resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene and toileting. Observation on 2/23/21 at about 12:00 PM showed R7's room with yellow contact/droplet TBP sign. TBP sign showed full PPE required which included gloves, gown, mask, and eye protection. CNA3 entered R7's room with lunch tray, CNA1 followed CNA3. Both CNAs donned (put on) gloves and gown. CNAs already had face shields and N95 masks on. CNA1 stated that resident needed to be pushed up in bed and stood within six feet of resident on resident's right side and repositioned resident higher up in bed. CNA3 doffed gown and gloves before leaving room and performed hand hygiene. CNA1 doffed gloves and then exited room. CNA1 did not doff gown and walked about 30-40 feet down the hallway, stood near meal cart and then doffed gown. Staff did not reuse or extend use of gowns. During an interview on 2/23/21 at about 12:07 PM when asked about not doffing isolation gown after providing cares for resident on contact precautions, CNA1 stated that she forgot but should have removed gown in room. During an interview on 2/23/21 at 12:07 PM DON stated that she saw CNA1 wearing isolation gown in the hallway, outside resident room and said, I told her about that, right before you came. DON confirmed gown should not have been worn outside of resident room. Resident 14 Record review showed R14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 2/23/21 at about 1:00 PM showed R14's room with yellow contact/droplet TBP sign. TBP sign showed full PPE required which included gloves, gown, mask, and eye protection. Housekeeper (HK)1 entered R14's room after donning gloves and gown. HK1 already had face shield and N95 mask on. HK1 wiped door handle and other items in the room, entered bathroom and stayed for a few minutes and then bagged trash and placed new plastic bag in trash can. HK1 then exited room with trash, cloths, and cleaning products. HK1 did not doff gown before exiting room. HK1 walked across the hallway and several feet down the hall to housekeeping cart. While standing near housekeeping cart, HK1 doffed gown. During an interview on 2/23/21 at 1:30 PM Housekeeping Manager (HM) stated that HKs should remove gown when exiting room. During an interview on 2/23/21 at 5:55 PM DON stated that staff should remove isolation gowns before exiting rooms of residents on contact TBP. Review of CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#adhere, updated 2/23/21, showed health care personnel who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should remove and discard the gown in a dedicated container for waste before leaving the patient room or care area. *Face shield Observation on 2/23/21 at 11:50 AM on Medicare/short stay unit showed several resident rooms with yellow contact/drop TBP signs. CNA1's face shield was observed not covering the sides of her face or eyes as the face shield was tilted upwards at a 45 degree angle from the vertical. The top of CNA1's face shield was high on her forehead, about 2-3 inches above her hairline and tilted at an angle, the bottom of the face shield was not flush with CNA1's chin, thereby the face shield was not covering the sides of her eyes. CNA1 stood within 6 feet of R9 while delivering and setting up her meal tray. CNA1 was observed entering R8's room and stood within 6 feet of R8 while providing cares. CNA1 then entered R7's room after CNA3. CNA1 stated that resident needed to be pushed up in bed and stood within six feet of resident on resident's right side and repositioned resident towards head of the bed. During an interview on 2/23/21 at 12:07 PM surveyor asked DON to observe placement of CNA1's face shield. CNA1's face shield was tilted upwards at a 45 degree angle from the vertical but was then moved lower while CNA1 was donning new gown. DON stated, Our policy is not to wear face shield high on head. CNA1 joined interviewed and when asked if the sides of her eyes were protected from splashes and sprays, CNA1 said, Probably not, spray would get eyes CNA1 then stated that with mask and face shield, it was hard to breathe. Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated 11/20/20, accessed 3/2/21, showed eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face). Review of CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html, updated 2/23/21, accessed 2/23/21, showed Put on eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use strategies to optimize PPE supply .gaps between glasses and the face likely do not protect eyes from all splashes and sprays. *High-touch surfaces and hand hygiene Observation on 2/23/21 at about 1:00 PM showed room [ROOM NUMBER] (where R14 and R15 resided) with yellow contact/droplet TBP sign outside room. Housekeeper (HK)1 grabbed couple of cloths from bin filled with liquid on housekeeping cart and picked up spray bottle with blue label and then entered room after donning gloves and gown. HK1 already had face shield and N95 mask on. HK1 wiped room and bathroom door handles with cloth, wiped table surface and then wiped the bottom rail of both residents overbed table, sprayed liquid from spray bottle and wiped window sill and then entered the bathroom. After bagging trash, HK1 wiped the top of sharps container and room light switch and then exited the room. HK1 returned to room and mopped floor and placed wet floor sign. HK1 then proceeded to clean room [ROOM NUMBER]. HK1 got two cloths from bin filled with liquid on housekeeping cart and picked up spray bottle with blue label and then entered room [ROOM NUMBER]. HK1 wiped overbed table with cloth. A sheen was observed on the top of overbed table immediately after cloth was applied. Within a few seconds, the sheen was no longer present on the entire surface of the table, sheen was not observed on sections of the table and within 30 seconds the table was not wet to touch. HK1 continued cleaning room and was later observed bending down near trashcan at room [ROOM NUMBER]'s door entrance. HK1 moved trash can and several pieces of crumbled tissues and other trash was observed between trashcan and wall. HK1 picked up trash with gloved hands and placed in trash bag, then tied trash bag and exited the room. HK1 did not change gloves and with the same pair of gloves used to pick up trash on floor near trash can in resident's room, HK1 touched housekeeping cart lid and return sprayer and then touched cart again to close lid and grabbed mop handle and placed in resident's room. HK1 then removed gloves. During an interview on 2/23/21 at about 1:25 PM HK1, through an interpreter CNA4, stated that she used the cloths only and nothing from blue spray container to clean overbed table and used the sprayer to clean door handles and light switches. When asked about the solution on the cloths when pointing to the container of cloths in liquid solution on housekeeping cart, HK1 stated that only water was on cloths. When asked about the cleaning and disinfection of the call light and bed control, HK1 stated that she would wipe these items with the cloths only and if it was really dirty, she would use the blue sprayer. When it was stated that HK1 was not observed to clean or wipe call light or remote bed control, HK1 did not say anything. When asked to elaborate of how HK1 could tell items were really dirty, HK1 stated that items are really dirty if food is on it. When asked how items are wiped with cloths or blue sprayer and if the items needed to remain wet for a certain period of time, HK1 stated that she wipes and go and if she needs to wipe again, she uses the blue spray if there's food or item is really dirty. During an interview on 2/23/21 at 1:30 PM Housekeeping Manager (HM) stated that during daily room cleaning HKs should clean high-touch surfaces such as handrails, door knobs, night stands, call cords, bedside table, and tv remote control. When asked what solution or liquid was in bucket with cloths on housekeeping cart, HM took surveyor to housekeeping closet and pointed to dispenser attached to Multi-purpose neutral ph germicidal detergent that showed EPA registration number -131. The label showed let solution remain on surface for a minimum of 10 minutes. When asked about contact time for cleaning/disinfecting high-touch items, HM stated HK take 3 cloths with them, wipes high-touch items and it stays damp. They stay in the room for about 10-15 minutes. When informed that 10 minutes is a long time and items wiped, such as overbed table, did not remain wet for 10 minutes, HM said he will check. When asked how HK ensure items remain wet for 10 minutes, HM did not respond. When informed of observation of HK picking up trash and not changing gloves before touching clean items, HM stated that gloves should be changed when dirty and trash is dirty, gloves should be changed after touching something dirty and before touching clean things. During an interview on 2/23/21 at 1:52 PM Licensed Nurse (LN)1 stated that resident in room [ROOM NUMBER] uses both her call light and bed control. Resident in #142 refused interview and room [ROOM NUMBER] had TBP signage; therefore, not interviewed. Review of spray container with blue label on housekeeping cart showed Quat Plus TB with EPA registration number 1839-83. Review of Multi-purpose neutral ph germicidal detergent that showed EPA registration number -131. Review of EPA N list website, https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19, accessed 2/23/21, showed for EPA registration number 1839-83, the product was effect against COVID-19 with contact time of 1 minute and EPA registration number -131, the product was effect against COVID-19 with contact time of 10 minutes. The contact time is the amount of time the treated surface should remain wet to be effective against [DIAGNOSES REDACTED]-CoV-2 (COVID-19). The surface should be visibly wet for the full duration of the contact time. Review of facility's resident room and facility's high-touch surfaces showed this list can include surfaces not listed, if you feel a surface is high touch particular to a resident-clean it. The list included remote control and bed control which was not observed to be cleaned. The list did not show resident call light as a high-touch surface. Review of Centers for Disease Control and Prevention Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, updated 11/20/20, accessed 2/23/21, showed under Environmental Cleaning and Disinfection to clean and disinfect frequently touched surfaces in resident rooms .Use an EPA-registered disinfectant from List N on the EPA website to disinfect surfaces that might be contaminated with [DIAGNOSES REDACTED]-CoV-2. Ensure HCP are appropriately trained on its use. Review of facility's policy, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), revision date 7/15/20, showed COVID-19 is transmitted via indirect contact transmission via hand transfer of COVID-19 virus [MEDICAL CONDITION]-contaminated surfaces or objects to mucosal surfaces of the face (e.g. nose, mouth) may also occur .routine cleaning and disinfection procedures applying an EPA-registered .disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label. During email received on 3/2/21 at 3:46 PM Administrator stated that the facility's policy for Hand Hygiene followed acceptable practices and CDC guidelines. Review of CDC's Hand Hygiene guideline, https://www.cdc.gov/handhygiene/providers/guideline.html, dated 1/30/20, showed hand washing should occur after touching patient's immediate environment and after contact with contaminated surfaces. Review of facility's Hand Hygiene Monitoring Tool, dated 10/2017, showed hand hygiene should be done after contact with inanimate objects. During an interview on 2/24/21 at 11:25 AM Administrator stated that disinfectant products should be used in accordance with manufacturer's instructions and EPA's contact time. During Exit on 2/24/21 at 1:00 PM when observations about HK not cleaning/disinfecting high-touch items in resident rooms (including call light and bed control) and not allowing sufficient contact time per disinfectant and EPA use of product to ensure items are effectively disinfected and HK not changing gloves after touching trash and before touching clean items, Regional Vice President, Administrator, and DON confirmed these observations were not within facility's expectations.

Based on interview and record review, the facility failed to ensure resident care was provided safely for one of four sample residents (#61), reviewed for accidents. This failure resulted in actual harm, when the resident suffered a fracture, after rolling off a bed during care. Findings included . According to an 08/28/18 quarterly assessment, Resident #61 was severely cognitively impaired, and had paralysis on one side of her body. Per the assessment, the resident required the assistance of two people for repositioning and/or turning in bed, and one person assistance for bathing/showering. According to a 09/18/18 progress note, at 1:00 PM that day, the resident was laying on her right side in bed while Staff E, Nursing Assistant, was giving her a bed bath. Per the note, the resident shifted more to the right, and rolled off the bed onto the floor. On initial assessment, the resident was found to have skin tears on her left elbow and wrist, as well as a scratch on her right lower back. Another progress note, written at 8:32 PM that same day, showed the resident was sent to the hospital, due to increased confusion and difficulty speaking. A facility investigation of the incident showed the shower aide was providing a one person assist bed bath to the resident, when the resident shifted her weight, and rolled off the bed. Per the investigation, the resident was assessed to have only superficial skin tears, but was found to have a lower leg fracture after examination at the hospital, later that evening. According to the care plan in place at the time of the incident, Resident #61 required the assistance of one to two staff to turn and reposition in bed. Per the care plan, the resident preferred one shower and one bed bath per week, which required the assistance of one staff (despite a bed bath involved turning/repositioning the resident in bed - which per the assessment, required two staff). Review of nursing assistant documentation for (MONTH) (YEAR) showed the resident required assistance of two staff for bed mobility 31 times (more than half of the time), and one staff 25 times, during the two weeks prior to the incident (from 09/03/18 - 09/17/18). Nursing progress notes on 08/23/18, 08/24/18, and 08/28/18 documented the resident required the assistance of two staff with bed mobility. The resident was not interviewable, and refused to allow the surveyor to observe care or repositioning. In an interview on 01/10/19 at 9:20 AM, Staff G, Nursing Assistant, stated that the resident did better with two person assistance, when turning in bed. On 01/10/19 at 9:40 AM, Staff C, Resident Care Manager, was asked if Resident #61 was able to assist with turning in bed. Staff C stated that the resident's right side was unusable, and that the resident could potentially help with her left hand, but generally did not. In an interview on 01/10/19 at 11:26 AM, Staff D, Registered Nurse, stated prior to the incident, the resident required two staff to assist with bed mobility (in part due to the fact that she could be combative at times), but also because she needed that much assistance. In an interview on 01/10/19 at 2:28 PM, Staff H, Nursing Assistant, stated the resident required two staff to assist with turning in bed, ever since Staff H had started working at the facility (a year ago). Staff H added that it was not safe for one staff member to turn the resident. In a follow-up interview on 01/10/19 at 2:37 PM, Staff C confirmed an air mattress, that was slightly raised on the sides to alert the resident that she was close to the edge, had been in use at the time of the incident. Staff C stated that the resident's abilities varied, and some days the resident was more able to participate and assist with turning than others. Staff C added the resident did have a history of rolling off the bed, but that had last occurred over a year before the 09/18/18 incident, and had not occurred while staff was in the room giving care. In an interview on 01/10/19 at 3:00 PM, Staff B, Director of Nursing, stated that Resident #61 was paralyzed on the right side of her body, but could still move and shift her weight around. Staff B added the resident required one to two staff to assist with bed mobility, due to a history of resisting care and combativeness, but had been a one person assist for baths for some time. Staff B stated that he felt the resident's fall was unavoidable, but confirmed that if a second staff member would have been present, they may have been able to stop the resident from rolling off the bed. In an interview on 01/11/19 at 10:13 AM, Staff E, Nursing Assistant, stated that the resident was usually able to roll to her right with a little boost from staff. Per Staff E, on 09/18/18, she had just finished washing the resident's back, and the resident was lying on her right side. Staff E stated that she was tucking a brief underneath the resident, when the resident rolled a little too far, and ended up rolling off the bed, fracturing her leg. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure one of four sample residents (#1), was free from probable sexual abuse. The facility failed to provide adequate supervision, or implement procedures to prevent Resident #1 from leaving the facility with an individual unknown to some staff, without approval from the resident representative. This failure resulted in actual harm to the resident, with known cognitive/decision-making impairments, who had sexual intercourse, was sent to the emergency room for a sexual examination, and subsequently placed on medication to prevent disease. Findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. According to the most recent assessment, dated 06/09/18, Resident #1 had moderately impaired cognition, disorganized thinking, and required extensive assistance with most activities of daily living. Per review of the last care conference note, dated 04/05/18, the social service summary showed Resident #1 was moderately impaired in decision-making, needing cues and supervision . Disorganized thinking switching from subject to subject Resident often tells childhood stories and will repeat often. According to a 05/17/18 physician visit note, Resident #1 had no significant change in her condition. The note showed the resident was verbal but very confused, had progressive dementia and physical debility, and was wheelchair bound. The end of the note showed Systems reviewed - profound dementia. Per review of the admission documents, listed under contacts was Resident #1's brother, who was identified as her Responsible Party and emergency contact. In addition, three other siblings were listed as emergency contacts for Resident #1. A Durable Power of Attorney document, dated 09/07/05, identified a sibling as the decision- maker for the resident. Per record review of nursing progress notes from (MONTH) (YEAR) through (MONTH) (YEAR), Resident #1's brother was notified by facility staff of any changes in condition, falls, or medication changes. Per record review, he also signed the (YEAR) and (YEAR) consents for the resident to have the influenza vaccine. Review of the facility Social Leave Policy, dated (YEAR), .Residents may consent to an out of facility social outing unless a Guardian is in place facility must get prior approval from Guardian. According to the facility investigation, on 08/11/18 at around 10:30 a.m., a former employee of the facility entered the facility, and was visiting with staff and residents. The former employee told Staff C, Registered Nurse (RN), he was a family friend of Resident #1, and wanted to take her to lunch. The investigation showed Staff C was not aware he was a former employee of the facility; Resident #1 appeared in agreement about leaving for lunch. Staff C, and the former employee, signed the resident out in the sign-out book. Review of the sign out book revealed the former employee signed out as friend, with destination as only lunch, and no estimated return time documented. Per an 08/11/18 written investigation document, Staff D, Nursing Assistant ( NA), stated she saw the former employee talking to Resident #1, stopped and asked what he was doing, and he stated he was taking Resident #1 to lunch. Staff E, NA, also wrote she spoke with the former employee on 08/11/18, who told her he was taking Resident #1 out for Mexican food. Staff F, Nursing Assistant, wrote he was out in his car on 08/11/18, and witnessed the former employee transfer Resident #1 out of her wheelchair and place her in his car. Per the written statement, Staff F felt the transfer was very poor, and asked about the circumstances - Staff C, RN, stated she was unaware who the person was, and thought he was a family friend. After Staff F informed Staff C that the person who took Resident #1 was a former employee, she called Staff A, Administrator, and Staff B, Director of Nursing. The investigation showed at 12:32 p.m. the same day, Resident #1 returned to the facility with the former employee. Staff members separated them, taking Resident #1 to her room. Staff F, NA, asked Resident #1 where she had gone and she responded to my friend's apartment; she stated she had not gone to lunch, and had not eaten. A skin assessment was performed, and Resident #1 had on no brief (per the resident's current care plan, she wore a brief at all times), and there was blood observed in her genital area. No bruising or other skin impairments were found. During a follow-up interview with Resident #1, she was asked if she had had sex with the former employee and she responded, yes, a little bit. She stated she wanted to have sex, was not fearful of the former employee, and felt safe. The facility contacted the police, who interviewed the former employee, who denied any sexual contact with Resident #1. According to the hospital records, dated 08/11/18, Resident #1 was admitted for a sexual assault evaluation, requested by her Durable Power of Attorney. Per the record, Resident #1 was in no acute distress, and alert but disoriented. She stated she had had sexual intercourse with a man, and stated she wanted to have sex with him. The physical exam showed a small mucosal tear on the left vaginal wall, with minimal bleeding. The note documented the resident was oriented only to person and date of birth, and showed, Patient's decision- making capacity at time of visit: Non-decisional. The note later showed, Given the patient's history and physical exam findings the most likely cause of symptoms is possible sexual assault and urinary infection. The resident was placed on medication to prevent serious diseases after sexual intercourse. In an interview on 08/14/18 at 12:15 p.m., Resident # 1's family member (responsible party), stated he was the person the facility contacted when there was any change in Resident #1's condition, and if she had a fall, they always called him. He stated he did not give consent for Resident #1 to leave the facility with anyone. He stated neither he nor any of the other family members take Resident #1 out of the facility, because of the extensive care she required. He stated he did not feel she was capable of making decisions on her own, and all siblings assist in making decisions they feel are best for Resident #1. On 08/14/18 at 1:19 p.m. Resident #1 was in her room in a wheelchair; she was smiling and recognized her sibling, who requested to be present at the interview. When asked if she had recently left the facility she stated yes, she thought she was going to lunch but he (former employee) said they were going to his apartment, and she did not get lunch. Resident #1 stated the former employee lifted her in and out of his car, and put her wheelchair in the trunk. She stated she remembered he brought her back to her room, gave her a kiss, and said see you later. She stated she had not seen or talked to him since. Throughout the conversation, Resident #1's verbalizations became disorganized, and she repeated, I am small but mighty. She changed subjects rapidly, and repeated sentences. She denied going to the hospital. The facility investigation concluded a possible sexual encounter took place. Per the record, Resident #1 had no changes in behavior or daily routine. There was no evidence of physical or psychological harm. The facility failed to protect Resident #1, who had surrogate decision makers, and known confusion related to dementia, from being removed from the facility by an unauthorized party, who then had sexual intercourse with the resident. Reference WAC 388-97-0640(1)

Based on observation, interview, and record review, it was determined the facility failed to ensure that 1 of 3 sample residents, reviewed for medications (#1), was free from a significant medication error. Resident #1 received a narcotic medication that was ordered for Resident #2, resulting in harm to Resident #1, who required hospitalization to treat symptoms of accidental overdose, including decreased respirations and decreased oxygen levels. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review of an assessment dated [DATE], the resident was cognitively intact, and able to make her needs known. The resident required assistance with taking her medications. Per record review, on 08/03/16 at approximately 4:00 p.m., Staff A was providing medications to residents on the South hall. According to Staff A, Resident #1 approached the medication cart, and stated her name. Staff A looked at the Medication Administration Record [REDACTED]. Staff A continued on with her medication pass, realized her mistake, and contacted the facility physician, who directed staff to monitor Resident #1 closely for sedation. According to nurse progress notes dated 08/03/16, Resident #1 appeared to be very sleepy, so she was taken to her room. At approximately 7:50 p.m., a nursing assistant could not wake the resident up. A nurse assessed Resident #1, who was unresponsive to verbal or tactile (touch) stimuli; and her oxygen saturation level was 60 % (normal adult oxygen saturation is 95-100%). 9-1-1 was called, and the resident was transported to the hospital. Per review of the hospital records dated 08/03/16, Resident #1 suffered an accidental overdose, causing significant lethargy, and a noted respiration rate of 6 breaths per minute (normal adult respirations range from 12-16 per minute), prior to arriving at the emergency room . Resident #1 was admitted to the hospital for an acute overdose, and required a [MEDICATION NAME] drip (an intravenous medication given to reverse an overdose). The resident spent 3 days in the hospital. In an interview on 08/17/16 at 10:50 a.m., Resident #1 was alert and oriented. She said she remembered the medication error, and could recall not being able to breath, and being sent to the hospital.

Based on interview, and record review, the facility failed to take action and evaluate a pressure ulcer for 1 of 3 residents (#3) in a sample of 6, which resulted in harm for Resident #3. Findings include: Resident #3, per record review, admitted to the facility for rehabilitation following a [MEDICAL CONDITION] with no pressure ulcers on 7/4/13. He was nutritionally at risk due to [MEDICAL CONDITION] and had a history of [REDACTED]. He had memory problems and required extensive assistance with dressing/bathing. On 7/4/13, the facility put general interventions in place for the resident upon admission, which included weekly skin checks, pressure reduction for bed/wheel chair, and for staff to report any red areas to the licensed nurse. The resident discharged home on[DATE] with orders for home health. Per the home health assessment dated [DATE], the resident had a pressure ulcer on the dorsal foot that measured 1.0 centimeters (cm) x 1.0 cm and the right heel had a necrotic area that measured 5 cm x 5 cm and had a foul odor. The wound edges were red, warm, and inflamed. The home health nurse notified the doctor and he recommended that he be seen at the emergency room . He had an infection and required surgical debridement of the pressure ulcer. Per review of the discharge instructions completed by the facility dated 7/25/13, there was direction to monitor the resident's feet, but there was no mention of a pressure ulcer on the resident's right heel or top of the right foot. Per review of therapy notes on 7/9/13, a "black or dark blue blister" wad discovered on the resident's right heel. Staff #B implemented a special boot to alleviate pressure, put the resident on the 24 hour report, and notified his nurse. Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The nurses signed off that they checked his right foot twice daily. Per review of therapy notes on 7/17/13, the blister on his right heel was open and weeping fluid. During an interview with Staff #B on 7/31/13 at 3:30 p.m., she reported the resident had blisters on top of his right foot and had a quarter sized "mushy" area on his right heel. She notified the nurse and implemented a special boot for his right foot. She reported on 7/17/13 during therapy, he did not have a sock on she noticed his right heel ulcer was open and draining fluid. She again notified the nurse that the pressure ulcer was now open and draining. On 7/31/13 at 5:10 p.m., Staff #C did not know that he had a pressure ulcer on his heel. She thought the twice daily check was just to make sure his boot was on and in place. On 8/1/13 at 10:10 a.m., Staff #G reported the facility practice was for the treatment nurse to monitor skin/pressure ulcers. She stated she never looked at his heel. On 8/1/13 at 10:30 a.m., Staff #F (wound nurse) reported she was never told about the pressure ulcer on the resident's right heel. Per record review, there was no measurement of the right heel pressure ulcer when the pressure ulcer was red or when it opened and was draining. On 8/6/13 at 3:25 p.m., Staff #A reported she investigated the resident's skin breakdown after notification of the status from the home health agency, and was told the resident's right heel was "mushy," but staff never reported the skin breakdown. She discussed that through her investigation she was able to determine the resident had some type of skin impairment at the time of discharge, but he was not seen by the home health agency until 4 days after he went home. The facility failed to take action or re-evaluate the pressure ulcer on his right heel after the specialty boot was placed or when the pressure ulcer got worse. This failure resulted in harm for Resident #3.

Based on interview and record review, the facility failed to notify the physician when the resident had a significant change in condition that required physician intervention for 1 of 9 residents (#1). This resulted in hospitalization for Resident #1. Findings incude: (Please refer to F 327) Resident #1, per record review, had history of [MEDICAL CONDITION] and had recently suffered from pneumonia. Normally the resident was alert and oriented and was independent with eating and drinking. The care plan directed the staff to monitor for signs and symptoms of dehydration. The resident's advance directives noted that she wanted nutrition and hydration if clinically indicated. Per review of the nursing notes dated 1/10/13, the resident was found to be lethargic and the doctor ordered a urine specimen to be sent to determine if she had a urinary tract infection [MEDICAL CONDITION]. On 1/11/13 during day shift, the resident had rambling speech and difficulty with eating and drinking and required full assistance. On 1/12/13, the day staff had difficulty getting the resident to swallow food or water and she was not responding verbally. That evening she only took sips of water. On 1/13/13, day staff documented that the resident continued to be non-responsive, would not swallow water, and took in a total of 50 ml of water. The day nurse described her lips as dry and that the resident did not void during his shift. That evening the nurse documented she still had difficulty swallowing and had no verbal response. The doctor was not notified until 1/14/13 at 12:30 p.m. when the resident was found unresponsive and unable to take any fluids. The facility sent the resident to the hospital via ambulance where she was diagnosed with [REDACTED]. On 1/23/13 at 9:30 a.m., Staff #G reported she thought the doctor was already aware of her change in condition. The facility failed to notify the doctor promptly so that he could take action, which resulted in hospitalization for Resident #1.

Based on interview and record review, the facility failed to ensure the resident received sufficient fluid intake to maintain proper hydration and health for 1 of 9 residents (#1). This resulted in harm for Resident #1. Findings incude: Resident #1, per record review, had history of [MEDICAL CONDITION] and had recently suffered from pneumonia. Normally the resident was alert and oriented and was independent with eating and drinking. Per the dietary assessment dated [DATE], the resident's fluid needs were 1607 milliliters (ml) to 1950 ml per day. The care plan directed the staff to monitor for signs and symptoms of dehydration. The resident's advance directives noted that she wanted nutrition and hydration if clinically indicated. Per review of the nursing notes dated 12/30/12, the resident started on antibiotics for pneumonia. She continued on antibiotics through 1/5/13. On 1/10/13 the resident was found to be lethargic and a urine specimen was sent. On 1/11/13 during day shift, the resident had difficulty with eating and drinking and required full assistance. On 1/12/13, the day staff had difficulty getting the resident to swallow food or water. That evening she only took sips of water. On 1/13/13, day staff documented that the resident continued to be non-responsive, would not swallow water, and took in a total of 50 ml of water. The day nurse described her lips as dry and that the resident did not void during his shift. That evening the nurse documented she still had difficulty swallowing and had no verbal response. Per review of the meal monitors for January 2013, the resident had multiple refusals of food/fluids during the first week of the month. On 1/11/13 - 1/14/13, the resident had no documented fluids. On 1/22/13 at 4:50 p.m., Staff #B reported the resident's intake had declined over the last week before she was hospitalized . She said her lips were dry, but she applied lip balm frequently to keep them moist. She reported she tried to give her fluids, but she had trouble swallowing and told the nurse. On 1/22/13 at 5:15 p.m., Staff #C reported the resident wouldn't take fluids but he said staff got her to take a small amount. He said he was not aware of the blank meal monitors and her poor meal intake. On 1/23/12 at 9:05 a.m., Staff #E reported that the resident slept a lot the last few days before she was hospitalized . She said her lips were dry and she offered her food/fluids, but she wouldn't take anything. She said she reported the refusals to the nurse. On 1/23/12 at 9:30 a.m., Staff #G reported the resident was not her normal self, but she thought the doctor already was aware of her condition change. On 1/23/12 at 11:15 a.m., Staff #I reported she was not aware that the resident wasn't taking fluids until Monday. She said the nurses should have contacted the doctor. Interviews with the staff and review of the records showed the resident only took in approximately 300 ml of fluid per day. Per review of the hospital records dated 1/14/13, the resident admitted to the hospital with [REDACTED].

Based on interview and record review, the facility failed to ensure 2 residents (#2, 3) were free from significant medication errors in a sample of 3 residents. This resulted in harm for Resident #2. Findings include. 1. Resident #2 had chronic pain issues and was on a narcotic pain patch that was changed every three days. Per assessment, she had no memory problems or difficulty with making daily decisions. On 8/21/12 at 4:00 a.m., the resident's record documented the resident was found to be dusky, had low oxygen saturations, and irregular breathing. She was sent to the hospital and found to have 2 narcotic pain patches on and was over medicated. She spent 6 days at the hospital. Per record review, there was no system in place prior to 8/21/12 to ensure that patches were removed before another patch was placed. On 8/27/12 at 4:50 p.m., Staff #A reported the resident generally removed her patches and would hand the nurses her old patches. Staff #A said the nurse who administered the patches the last 3 times resigned her position. On 8/27/12 at 5:10 p.m., Staff #A reported the facility had put additional measures in place and inserviced the licensed nurses. The facility's failure to have a system in place to ensure that previous pain patches were removed caused an over dose of narcotic pain medication and harm for Resident #2. 2. Resident #3 admitted to the facility on [DATE] following hospitalization and was on anti-coagulation (blood thinning) injections that were to be discontinued on 8/1/12. Per record review, the resident received this medication through 8/16/12. She received 16 additional doses of an anti-coagulation therapy. There were no further labs drawn to ensure the resident was not at risk for excessive bleeding due to the error of administering additional doses of the anticoagulant. On 8/27/12 at 5:10 p.m., Staff #A confirmed the medication was not discontinued on 8/1/12.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services for 3 residents (#10, 47, 53) in a sample of 48 related to pain with wound care, mood, and skin conditions. This resulted in harm to Resident #10, who experienced repeated episodes of unrelieved pain during dressing changes. Findings include: PAIN: 1. Resident #10, per record review, had [DIAGNOSES REDACTED]. The resident had no memory problems and was able to make daily decisions. The resident required extensive assist with all activities of daily living. The resident's plan of care directed staff to administer pain meds as needed, monitor effectiveness and reposition for comfort. Per record review, the resident had a physician order [REDACTED]. Per record review, the resident's pain assessment on 3/22/12 noted the resident was in pain almost constantly and usually rated it at an 8 (severe) on a scale of 1-10. On 4/30/12, the resident rated his pain a 10. On 5/7/12 at 12:45 p.m., the resident was observed in his wheelchair at his bedside. The resident was leaning over to his left side. When asked if he had pain he stated, "yes". When asked about his pain during his dressing changes he stated the pain was so bad "I could shoot myself". The resident stated he didn't think he got medication prior to the dressing change. He said when he told staff it hurt during the dressing change they respond "I am sorry". Per review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the May 2012 MAR indicated [REDACTED] The peak effectiveness of the narcotic pain medication the resident was taking was about 40-60 minutes after swallowing. On 5/9/12 at 9:00 a.m., Staff #F stated the resident had his dressing change done at 6:30 a.m. Per record review, the resident received his pain medication on 5/9/12 at 3:00 a.m., 3 1/2 hours prior to the dressing change. On 5/10/12 at 11:35 a.m., Staff #I stated she was covering for the treatment nurse. She did a dressing change on Resident #10 at 10:00 a.m. She had been instructed by the treatment nurse that Resident #10's dressing change was difficult because it was really painful for him. When asked if the resident was pre-medicated, the nurse stated he had already received his pain medication from the day nurse and it was too early to medicate him again. Per record review, the resident had received his pain medication at 5:00 a.m., 5 hours prior to his dressing change. On 5/10/12 at 1:25 p.m., Staff #J stated she wasn't aware the resident had severe pain during his dressing changes. She stated his legs and wounds always hurt and he took pain medication as needed. She confirmed that having his medication 5 hours prior to his dressing change would not have helped the pain during his dressing change. The facility failed to evaluate the resident's pain during wound care which resulted in harm for the resident. 2. Resident #53, per record review, had [DIAGNOSES REDACTED]. The resident did not have any memory problems and required extensive assistance for most activities of daily living. Per the pain assessment completed in March 2012, the resident had pain in her back and in her lower extremities. The resident was noted to be on routine pain medication and her pain was considered to be well-controlled. Per record review, the resident had a pressure ulcer on her right heel that developed prior to the pain assessment completed in March 2012. The resident was noted to have pain from the ulcer, however this was not reflected on the pain assessment. Care planned interventions included quarterly and as needed pain assessments, pain medications as ordered, report to licensed nurse when the resident had an increase in pain, and reposition for comfort. The resident also had an order for [REDACTED]. Per nursing notes dated 4/29/12, the resident called out in pain when staff turned the resident. The resident stated her pain was "okay" if she did not move but when she did move it was painful. There was no assessment done to evaluate the characteristics of the resident's pain. On this date an order for [REDACTED]. There was no additional information to indicate staff attempted to determine the severity of pain at that time. On 5/3/12 at 9:45 a.m., the resident reported her heels were hurting and it helped to keep them off the floor. The resident said she had pain everyday and did not know how to describe it. The resident said she also had pain "on my backside." The resident said she had boots she was supposed to wear but did not think they helped so she did not wear them. Per nursing notes dated 5/3/12, the resident refused to turn or be changed and stated as long as she did not move, she had no pain. There was no further information noted. On 5/4/12 at 9:30 a.m., 11:00 a.m. and 12:00 p.m., the resident was in her wheelchair in front of her television with her feet (not wearing protective boots, only socks) on the ground. The resident said she always had pain in her heels and said putting her heels up would help because they rubbed on the floor. The resident did not have any leg rests on her wheelchair. Per nursing notes dated 5/4/12, the licensed nurse noted the resident did not complain of pain or report any pain. However, again the resident was noted to refuse turning and changing. On 5/7/12 at 10:00 a.m., the resident was in her wheelchair in front of her television with her feet on the floor. The resident had a flat affect and when asked if she had any pain, she said yes, in her heels. The resident said she always had it. The resident was asked to rate her pain for the surveyor on a scale of 1-10. The resident said "I guess a 5 or a 6" (moderate pain). Per nursing notes dated 5/7/12, the licensed nurse noted the resident was resting comfortably, no other documentation regarding assessment of pain. On 5/7/12 at 10:05 a.m., Staff #R reported the resident had pain all the time when staff transferred her or put her on her commode. Staff #R said the resident was upset and combative at times with staff because she had so much pain and he said her pain was in her heels. Staff #R said the resident sat in her wheelchair during the day quite often, but he did not think there were any interventions in place for her heels while in the wheelchair for pain relief. Staff #R said he had never seen the resident wear protective boots. On 5/7/12 at 10:30 a.m., Staff #S reported the resident was not happy and was always in pain. Staff #S said the resident complained of pain in her heels all the time and just wanted to be left alone. On 5/8/12 at 9:45 a.m., Staff #T reported the resident's pain was in her heels and confirmed the resident got routine narcotic pain medication twice a day (a.m. and p.m.). Staff #T said he assessed her by observing for pained facial expressions and said the resident did not verbalize her pain well when asked. He said he was not aware the resident was recently calling out in pain during cares on 4/29/12. He said when he assisted with turning and changing the resident he felt she was not in pain but was just upset and embarrassed because it took so many staff to assist her. Per record review, the resident consistently refused to wear the ordered boots for wound healing/pain relief. However, there were no other interventions put in place to keep her comfortable while sitting in her wheelchair and putting pressure on her heels. Staff were aware of the resident's pain in her heels and reported she just wanted to be left alone and not moved. Licensed staff confirmed the resident had pain in her heels and that the resident did not communicate her pain level well. Though the resident was placed on alert charting for pain, there was no evidence in the record that the facility did a comprehensive accurate assessment of the resident's pain daily or monitored the effectiveness of the current pain medications. The facility failed to comprehensively assess the resident's increase in pain and revise the resident's plan of care with appropriate, effective interventions for comfort. NON-PRESSURE SKIN CONDITIONS 3. Resident #47 had [DIAGNOSES REDACTED]. The resident preferred to spend most of each day in bed except for showers. The resident's care plan noted the resident was frequently incontinent, declined to wear a brief in bed, and sometimes refused incontinence care. The care plan for potential skin impairment noted the resident had a history of [REDACTED]. Staff was directed to monitor her skin condition weekly, report red or open areas to the licensed nurse, keep the resident's nails without jagged edges, and apply barrier cream after each incontinent episode. In addition, staff was directed to apply lotion to the lower legs every evening. Per record review, the resident was treated with antibiotics for left leg [MEDICAL CONDITION] in March 2012. Review of the weekly skin assessments for May 2012 revealed the resident had no open skin areas. On 5/2/12 at 11:20 a.m., the resident's nails were long and jagged with dried brown debris visible under each nail. During observation of care with Staff #K and #L on 5/7/12 at 1:50 p.m., there was a strong urine odor in the room. Six small open wounds were present on the left outer thigh. Each open wound had red wound margins with no drainage. Staff applied barrier cream to the open wounds and stated the nurses said to keep the areas "greased up." The resident's skin on the left lower leg was dry and scaly. Per record review, there was no evaluation of the resident's open wounds on 5/7/12. In an interview on 5/8/12 at 12:00 p.m., Staff #F stated the resident had the skin condition on and off which was most likely related to incontinence. The surveyor informed her of the open areas and she stated she would look at the resident. Per record review, there was no evaluation of the open wounds on 5/8/12 or 5/9/12. In an interview on 5/10/12 at 10:05 a.m., Staff #C stated the resident had the open wounds on her left thigh for awhile. In an interview on 5/10/12 at 11:50 a.m., Staff #E stated she had not been notified of the resident's open wounds. She confirmed staff should report the presence of open wounds to the licensed nurses. The facility's failure to timely re-evaluate open wounds placed the resident at risk for delayed treatment and repeated skin infection.

Based on interview and record review, the facility failed to consult with the physician related to significant changes for 1 of 6 sampled residents (#1) as required by 483.10(b)(11)(i)(B). The failure to consult with Resident #1's physician about continued complaints of not feeling well resulted in harm to Resident #1. Findings include: Resident #1, per record review, had [DIAGNOSES REDACTED]. He was admitted on [DATE] for rehab following vascular surgery. The resident had no memory problems or difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's). Per record review, the resident had to request to be sent to the hospital on [DATE]. The notes documented, "res states he doesn't feel good, he states he has an ache in his leg & that ever since he was admitted 'he hasn't felt good,' res requests to go to hosp. to find out what is wrong with him. Res did not want on-call MD called or any testing here-he is sick of just generally not feeling good & wants to go to hosp..." The resident was admitted to the intensive care unit (ICU) of the hospital with acute kidney problems and critical high potassium levels. Per review of the hospital records the resident's mouth was dry and his eyes sunken in and he had [DIAGNOSES REDACTED]." Per record review, labs were drawn on 12/22/11 and showed his kidney function lab was abnormal. The doctor ordered fluid to be pushed and labs redrawn on 12/26/11. The lab sheet for 12/26/11 showed the kidney function was still abnormal on 12/22/11. There was no order for future labs to be drawn or changes made to the resident's plan of care. Per record review, the resident lost 4.2 pounds from 12/20/11 - 1/5/12 and there was no [MEDICAL CONDITION] documented. The meal monitors showed numerous missing entries and poor food/fluid intake, despite the need for encouragement of fluids. The hydration status was not assessed the last 3 days while at the facility. Multiple staff were interviewed on 1/9/12 and reported the resident had continued complaints of not feeling well. Five of 9 staff stated they had reported the resident's complaints of not feeling well to licensed staff in early January. (Refer to F 309). Despite reports by nursing assistants and therapists that the resident was not feeling well, there was no documentation, a physical assessment, or vital signs obtained. There was no documentation the doctor was consulted with from 12/26/11 to 1/5/12. The facility failed to consult with the doctor when the resident continued to complain of not feeling well. This resulted in harm to Resident #1.

Based on interview and record review, the facility failed to provide the necessary assessment and evaluation by licensed staff for 1 of 6 sampled residents (#1) who repeatedly verbalized not feeling well. The failure to assess and evaluate the resident's condition resulted in harm to Resident #1. Findings include: Resident #1, per record review, had recent vascular surgery and history of stroke and was at the facility for rehabilitation. The resident was admitted on [DATE] with no memory problems or difficulty with making daily decisions. The resident required extensive assistance with activities of daily living (ADL's). Per record review, the resident had to request to be sent to the hospital on [DATE]. The notes documented, "res states he doesn't feel good, he states he has an ache in his leg & that ever since he was admitted 'he hasn't felt good,' res requests to go to hosp. to find out what is wrong with him. Res did not want on-call MD called or any testing here-he is sick of just generally not feeling good & wants to go to hosp..." The resident was admitted to the intensive care unit (ICU) of the hospital with acute kidney problems and critical high potassium levels. Per review of the hospital records the resident's mouth was dry and his eyes sunken in and he had [DIAGNOSES REDACTED]." The care plan directed staff to report to the licensed nurse for complaints of pain and give medications as ordered. The nurses were also instructed to monitor hydration status daily and encourage fluids. The resident received a routine narcotic pain medication daily and a non narcotic pain medication at bedtime. He could have narcotic pain medications every 3 hours as needed. Per record review, the physician ordered labs on 12/22/11 and the resident's kidney function was abnormal (high). The physician ordered a repeat lab to be drawn on 12/26/11 and wanted fluids to be pushed. The results of the lab showed the resident's kidney function continued to be abnormal for the 12/22/11 lab. There was no order for future labs to be drawn or changes made to the resident's plan of care. Per record review, the resident lost 4.2 pounds from 12/20/11 - 1/5/12. The meal monitors showed numerous missing entries and poor food/fluid intake, despite the need for encouragement of fluids. The hydration status was not assessed the last 3 days while at the facility. Per record review therapies documented multiple complaints at the end of December and beginning of January. The resident did not participate 7 times from 12/20/11-1/5/12 and his participation was limited due to pain or not feeling well. Staff interviewed on 1/9/12 during the abbreviated survey gave the following input related to the resident: *Staff #C reported she gave the resident a shower on 1/4/12. She said he complained his stomach wasn't feeling well. She reported the resident was not a complainer and she told the nurses he wasn't feeling well. *Staff #D reported the resident put his call light on frequently and complained of back pain or not feeling well. She reported she told the nurses so he could get pain medications. *Staff #E reported the resident usually said he didn't feel well. She reported she took care of him several days before he went to the hospital and he told her this wasn't his usual "I don't feel well!" She reported she told Staff #F. *Staff #G reported the resident told her he didn't feel well and she reported to the nurses each time. *Staff #J reported the resident hadn't felt good a lot of the time, but the last couple of days of his stay he really complained of not feeling well. He said he gave him a shower on 1/4/12 and some light exercise and stated, "It didn't go well." He reported he let the nurse know. *Staff #K reported the resident refused to get up on 1/4/12. She said they tried to get a urine specimen, but his brief was dry and he did not urinate during evening shift, which was not usual for him. She reported she usually emptied his urinal 2-3 times per shift. She told the nurse the resident would not get out of bed and that he did not urinate all shift. *Staff #L reported the resident did not urinate during the evening shift on 1/4/12. *Staff # F reported the resident complained of pain once in a while. She said he was quiet and didn't want to do much. She reported the nurse supervisor wanted them to obtain a urine specimen, but the resident did not urinate and she was unable to get the specimen. She said she did not notify the doctor. *Staff #M reported the resident was not feeling well, but initially didn't want to go to the hospital. She said he was a lot different this time than from his previous stay at the facility. She said this time he complained more and was confused. He refused meals since his admission. She said he didn't feel well the day he went to the hospital, but he just generally didn't feel well. *Staff #N reported he generally didn't look good. She reported his kidney function was high, but they pushed fluids and the labs got better. She said the nurses should have monitored the fluid intake at meals and then added in what was taken in each shift, along with the hydration monitors. Despite reports by nursing assistants and therapists that the resident was not feeling well, there was no documentation a physical assessment or vital signs were obtained. There was no documentation the doctor was consulted with from 12/26/11 - 1/5/12. The facility failed to assess/evaluate continued reports of "not feeling well" or implement planned interventions. This caused harm to Resident #1, who ended up asking to go to the hospital to be evaluated.

Based on interview and record review the facility failed to ensure that the resident ' s airway was open without obstruction for 1 of 4 residents (# 1) with a [MEDICAL CONDITION] cuff. A speaking valve was placed over the resident ' s [MEDICAL CONDITION] site without ensuring that the resident ' s [MEDICAL CONDITION] cuff was properly deflated to allow unobstructed breathing. The resident was discovered approximately 30 minutes later not breathing. Failure of staff to be aware of the inflated or deflated status of [MEDICAL CONDITION] cuffs placed residents with [MEDICAL CONDITION] cuffs at risk of significant harm and was determined to be immediate jeopardy. Resident # 1 had [DIAGNOSES REDACTED]. Per the resident's record he was alert and oriented. Per the Minimum Data Set assessment dated [DATE] the resident required extensive to total assistance of ,[DATE] persons for all activities of daily living. Per the resident's record he required the assistance of a ventilator at night for respiratory support. During the day, the resident was able to come off the ventilator and use a Passy-Muir speaking valve for communication. Per the resident's plan of care it was noted he used a Passy -Muir valve for speaking, however there were no guidelines related to monitoring the pilot line for correct inflation/deflation of the [MEDICAL CONDITION] cuff when using this speaking device. There were no signs/symptoms noted for staff to be aware of in case of improper placement and respiratory difficulty when using the speaking device. Nor were there any guidelines for staff for monitoring residents using tracheostomies with cuffs to determine when it was appropriate for [MEDICAL CONDITION] to be deflated or inflated. On [DATE], two nursing assistants were providing care for the resident and he was coughing. Staff A asked the resident if he wanted respiratory therapy and he "mouthed" yes. Staff A went and got a respiratory therapist (RT) (Staff B). Per Staff B statement, she suctioned the resident and placed his Passy - Muir valve. She said he said "thank you" and she left the room to attend other residents. Per a telephone interview on [DATE], Staff B confirmed she did not check the resident's [MEDICAL CONDITION] cuff prior to placing the Passy-Muir valve and she left the room. Staff B said since the resident said thank you, she assumed the cuff was deflated and the resident had an airway. Staff B said he was not her resident and she did not follow up with any other RT's or licensed nurses to inform them she had placed a Passy-Muir valve in resident # 1's [MEDICAL CONDITION]. At 10:10 per Staff C (RT manager) respiratory note, she responded to the resident's room at a licensed nurse's request and the resident was blue and was not breathing. The RT removed the Passy-Muir valve and attempted to ventilate the resident. The ventilation was unsuccessful and the resident did not regain respirations and he expired. Per an interview on [DATE] Per interviews with RT and Licensed Nurses, there was no system in place to insure that respiratory staff and licensed nurses communicated pre and post placement of the Passy -Muir valve to monitor the respiratory competency of the resident before leaving the resident's room to ensure the resident's airway was patent and the cuff was deflated. In addition, interviews with licensed nurses, respiratory staff, and administration revealed that there were no guidelines on resident care plans that indicated which residents with trachs should have [MEDICAL CONDITION] inflated or deflated based on care needs. Nor were staff aware as to how to check if a resident ' [MEDICAL CONDITION] was inflated. Failure to ensure a functional communication system was in place between RT's and Licensed nurses to insure a resident with a Passy-Muir valve received adequate monitoring pre and post placement and failure of the facility to ensure that staff were aware of which residents could have [MEDICAL CONDITION] deflated put all residents [MEDICAL CONDITION] at risk for respiratory compromise. This was determined to be an immediate jeopardy. Refer to F 281 Standards of practice for more detailed information regarding the Passy- Muir speaking valve..

Based on interview and record review the facility failed to follow the standard of care for resident's with cuffed [MEDICAL CONDITION] for 1 of 4 residents (# 1). The [MEDICAL CONDITION] cuff was not completely deflated prior to insertion and the resident was found without respirations approximately 30 minutes later. Failure of Staff to recognize and respond to the inflated [MEDICAL CONDITION] cuff put all residents with [MEDICAL CONDITION] cuffs at risk for airway obstruction and potential respiratory arrest which constituted an Immediate Jeopardy. Findings include: Resident # 1 had [DIAGNOSES REDACTED]. Per the resident's record he was alert and oriented. Per the Minimum Data Set assessment dated [DATE] the resident required extensive to total assistance of 1-2 persons for all activities of daily living. Per the resident's record he required the assistance of a ventilator at night for respiratory support. During the day, the resident was able to come off the ventilator and use a Passy-Muir speaking valve for communication. Per the resident's plan of care it was noted he used a Passy -Muir valve for speaking, however there were no guidelines related to monitoring the [MEDICAL CONDITION] for correct inflation/deflation when using. There were no signs/symptoms noted for staff to be aware of in case of improper placement and respiratory difficulty. Passy- Muir speaking valve Per the company information booklet the following was noted; The patient must be awake, responsive, and attempting to speak prior to placing a Passy -Muir valve. If a patient has a [MEDICAL CONDITION] with a cuff on it, the cuff must be COMPLETELY DEFLATED once the speaking valve is inserted or the persons airway will be occluded (the person will not be able to breath). REMOVE THE VALVE IMMEDIATELY if the person has difficulty breathing suction and/or change the tube. Attach warning labels to the pilot line of the patient's cuffed [MEDICAL CONDITION] and post at the patients bedside and in the patients chart to facilitate staff awareness of proper use. OBSERVE patient to ensure that the diaphragm of the Passy - Muir valve opens during inspiration and remains closed during exhalation. Ensure adequate airflow around the [MEDICAL CONDITION], if exhibits signs of respiratory distress remove the valve immediately and reassess for airway patency. Per the resident's record on 6/7/11, two nursing assistants were providing care for the resident and he was coughing. Staff A asked the resident if he wanted respiratory therapy and he "mouthed" yes. Staff A went and got a respiratory therapist (RT) (Staff B). Per Staff B statement, she suctioned the resident and placed his Passy - Muir valve. She said he said "thank you" and she left the room to attend other residents. Per a telephone interview on 6/10/11, Staff B confirmed she did not check the resident's [MEDICAL CONDITION] cuff prior to placing the Passy-Muir valve and she left the room without ensuring the cuff was deflated and the resident had a patent airway. Staff B said since the resident said thank you, she assumed the cuff was deflated and the resident had a patent airway. Staff B said the resident "was not her resident and she did not follow up with any other RT's or licensed nurses to inform them she had placed a Passy-Muir valve in resident # 1's [MEDICAL CONDITION]". On 6/10/11 per a telephone interview with the funeral home staff, the following was noted: Per the Director, he had checked the pilot line and balloon. He confirmed the balloon had "more air in it than not". Per the secretary at the funeral home, she also confirmed there was more air in the balloon than not. Per observation approximately 30 minutes later, the pilot line had been cut and the balloon was no longer attached to the [MEDICAL CONDITION]. Per an interview with the RT manager, she could not confirm if the cuff on the resident's [MEDICAL CONDITION] cuff was deflated after the resident had stopped breathing. Not one staff member involved in the respiratory arrest of the resident could identify if the [MEDICAL CONDITION] cuff was inflated or deflated. Per the licensed nurse who found the resident, she did not know how to identify if the [MEDICAL CONDITION] cuff was inflated or deflated and what signs/symptoms the resident would exhibit with inflation and/or deflation of the cuff. Per interviews with RT, and Licensed nurses, there was no system in place to insure that respiratory staff and licensed nurses communicated pre and post placement of the Passy -Muir valve to monitor the respiratory competency of the resident before leaving the resident's room to ensure the resident's airway was patent and the cuff was deflated. Per staff interviews, Licensed nurses and nursing assistants had no special training to provide care to residents with cuffed [MEDICAL CONDITION]'s in the ventilator unit of the facility. One of two nurses interviewed was aware of what the pilot line and balloon on the [MEDICAL CONDITION] indicated if inflated and/or deflated. Per the licensed nurses, RT would be responsible to manage the resident's respiratory status for residents with [MEDICAL CONDITION]'s. Per interviews with staff there was no coordination between the licensed nurses and respiratory therapists to check on residents after the Passy -Muir valve had been placed to ensure the cuff was deflated. Failure to ensure a system was in place to insure licensed nurses and nursing assistants were trained within their scope of practice to care for resident's and respond to respiratory emergencies, and RT to communicate to licensed nurses which resident's required closer monitoring put all resident's at risk for [MEDICAL CONDITION] which resulted in an immediate jeopardy.

Based on interview and record review, the facility failed to provide informed consent for 1 of 8 sample residents (#7). The failed practice resulted in actual harm to the resident who experienced complications from the discontinuation of a medication. Findings include: Resident #7 had [DIAGNOSES REDACTED]. The resident was identified as being capable of making his own health care decisions. Per record review, the resident had a history of [REDACTED]. The medication was to be used long term to prevent further clot formation. According to the record, on 4/26/11 the physician gave orders to discontinue the resident's regular blood thinning medication. There was no documentation to indicate the resident was informed of this change in medical treatment. On 5/22/11 the resident developed respiratory distress and was noted to have a lump on the calf of his right leg. The resident was transported to the hospital where he was diagnosed with [REDACTED]. The resident was admitted to the hospital's Intensive Care Unit. During an interview on 5/24/11 at 10:00 a.m., Staff A (a licensed nurse) stated she told the resident, "Your medications are being adjusted because you're doing better." , but did not give him any specifics regarding the blood thinning medication being discontinued. The resident was interviewed on at the hospital on [DATE] at 10:30 a.m. The resident stated he knew he had to be on blood thinning medication for the rest of his life, was not informed he was being taken off his blood thinning medication, and "Would never have let them if I had been told."

Based on interview and record review, the facility failed to ensure 1 of 8 sample residents (#7), was provided necessary care to maintain the highest practicable level of physical well-being. The failed practice resulted in harm to the resident who developed complications after being taken off a medication. Findings include: Resident #7 had [DIAGNOSES REDACTED]. Per the record, the resident was admitted to the facility from the hospital on [DATE] with physician orders [REDACTED]. In progress notes dated 3/14/11, the attending physician acknowledged the resident's history of blood clots and the need for long term blood thinning medication. On 4/26/11 the same physician wrote orders to discontinue the resident's blood thinning medication. Despite the resident's known history of recurrent blood clots and need for chronic anticoagulation, nursing staff did not question the physician's orders [REDACTED]. Over the next 27 days, multiple nursing staff caring for the resident failed to identify the error which they could and should have caught. On 5/22/11 the resident was hospitalized for [REDACTED]. During a telephone interview on 6/13/11, the resident's family member stated the resident had been on the blood thinning medication for at least 8 years and was told he would need to be on it for the rest of his life.