Every finding on record at Richland Post Acute

Based on interview and record review, the facility failed to identify a change in condition for 1 of 3 residents (Resident 1) reviewed for assessments. The failure to perform an assessment disallowed an opportunity to adequately evaluate the resident's medical condition, which potentially caused a delay in treatment. Findings included . <Resident 1> Review of Resident 1's medical record showed they were admitted on [DATE] with diagnoses including an upper arm fracture, pancreatic cancer, and diabetes (a disease that results in too much sugar in the blood). Review of the admission summary note dated 06/21/2025 showed the resident was alert and oriented to self, was able to conversate about their health and was able to follow directions without difficulty. The admission summary notes also showed Resident 1 had a foley catheter (a flexible tube used to drain urine from the bladder into a collection bag). Review of Resident 1's vitals sign records showed on 06/25/2025 at 7:05 AM, there was one set of vital signs recorded as followed; blood pressure 113/94 ([BP]-systolic the force of blood pushing against the walls of the blood vessels and the diastolic resting pressure between heartbeats; Normal BP 120/80), heart rate 67 (HR-normal rate 60-100), oxygen saturation 92% (normal range 95-100%). There were no additional recorded vital signs for the day. During an interview on 06/27/2025 at 10:54 AM, Resident 1's Representative, (RR), stated they had arrived at the nursing home facility to accompany Resident 1 to an appointment on 06/25/2025. The RR stated they had to wait at the nurse's station for 45 minutes for their transportation to arrive. The RR stated during this time, Resident 1 was slumped over and leaning far to the right in a wheelchair and was hard to arouse. The RR stated when they voiced their concern to staff at the nurse's station, nobody checked on Resident 1. The RR stated the transport ride was 20 minutes and upon arrival at the medical appointment, clinic staff were very concerned about Resident 1's condition. The RR stated the clinic staff performed a quick assessment and called emergency services and transported Resident 1 to the emergency room. The RR further stated Resident 1 was admitted to the hospital and was placed on comfort care until they pass away. During an interview on 06/27/2025 at 11:22 AM, Staff A, Nursing Assistant, stated they noticed a change in Resident 1 during lunchtime on 06/25/2025. Staff A stated Resident 1 was not responding to them very well. Staff A stated they assisted a nurse with Resident 1's dressing change after lunch and noticed when Resident 1 was holding onto a grab bar during the dressing change in the restroom, they became weak and seemed like they wanted to drop. Staff A stated after the dressing change, they assisted Resident 1 to dress and then wheeled them to the nurse's station to wait for their transport to the medical appointment. Staff A noticed Resident 1 was heavily leaning to the right and not responding to voice or visual commands. Staff A stated other staff members came to adjust Resident 1 in the wheelchair by placing blankets on their right side to prop them up. Staff A stated they were not asked by a nurse to take any vital signs. During an interview on 06/27/2025 at 12:16 PM, Staff B, Registered Nurse, stated Resident 1 was sleepy as the resident had not taken a nap on 06/25/2025. Staff B stated Resident 1 was leaning to their right side and they propped them up to straighten them out in the wheelchair. Staff B stated they thought it was odd for Resident 1 to be sleepy. They did not chart any assessments for Resident 1 as they were only to document by exception (documentation for deviations from a resident's established norm or expected outcome). Staff B stated Resident 1's vital signs were normal earlier in the day and they did not have an indication to perform an assessment for their sleepiness. Additionally, Staff B did not obtain a current set of vital signs. Review of the 06/25/2025 ambulance report showed emergency medical services (EMS) was notified on 06/25/2025 at 2:39 PM to respond for Resident 1 with an altered level of consciousness (LOC) at a medical providers office appointment. The report showed Resident 1 had been weaker and had an altered LOC prior to the appointment. The EMS findings showed Resident 1 slumped over in a wheelchair, responsive to sternal rub (a vigorous rub to the breastbone), pupils were constricted, low BP and urine in the foley catheter bag was dark with visible debris. The report showed the following BPs obtained by EMS: 2:51 PM, BP 69/47; 2:55 PM, BP 50/30; 2:58 PM, BP 60/36; 3:03 PM, BP 61/43; 3:06 PM, BP 79/45. Review of the hospital emergency notes dated 06/25/2025, showed Resident 1 presented with shock (a serious life-threatening medical emergency that can cause extremely low blood pressure, confusion, unconsciousness and sleepiness) and treatment included high flow oxygen support and medication to increase blood pressure. During an interview on 06/27/2025 at 10:19 AM, a medical clinic Collateral Contact I, (CCI), stated Resident 1 had a 3:00 PM medical appointment on 06/25/2025 and had arrived by a transport service and was not appropriate for the appointment in the condition they presented in. CCI stated Resident 1 was slumped over in a wheelchair and was unable to be aroused without a sternal rub when they arrived for a medical appointment. CCI stated the staff obtained vital signs which showed Resident 1's blood pressure measured 51/33. During an interview on 06/27/2025 at 12:55 PM, Staff C, Director of Nursing, stated when a resident seemed different the staff should perform an immediate assessment and obtain vital signs and then notify the provider and await further instructions. Staff B stated Resident 1 should have had an assessment and vital signs obtained and based on the findings laid down in bed and decided if the resident needed to be transported to the emergency room. During an interview on 06/27/2025 at 4:01 PM, Collateral Contact II, (CCII), stated upon arrival at the nursing facility on 06/25/2025 at 2:12 PM, Resident 1 was slumped over in a wheelchair and their face was almost to their knees. CCII asked a staff member which resident they would be transporting and a staff member pointed at Resident 1 and stated, Ya that's what we are dealing with today. CCII stated they placed Resident 1 into the transport vehicle and had to lift Resident 1's upper body to place the seatbelt on. CCII stated during the transport Resident 1 was unarousable and they were extremely concerned about their well-being. Reference WAC: 388-97-1060(1)

Based on observation interview and record review the facility failed to maintain a dignified dining experience for 2 of 7 residents (Residents 25 and 215) reviewed for dignity during dining. The facility did not provide timely meals to Residents 25 and 215 who waited for their meals after the other residents had been served. This failure placed residents at risk for decreased dignity and overall, wellbeing. Findings included . <Resident 25> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including osteoporosis (a disease that weakens bones and worsens over time), muscle weakness and history of a recent fall with left knee and hip pain. Review of the residents care plan dated 06/10/2025 showed the resident was cognitively intact, ambulated with a walker and required minimal assistance from staff for basic self care tasks. <Dinner Meal> During an observation on 06/21/2025 at 5:11 PM dinner trays arrived in the main dining room and facility staff passed them out to the residents seated at their tables. During an observation on 06/21/2025 at 5:29 PM, Resident 25 sat at a table across from another resident who had been served their dinner tray and was eating. Continued observation showed Resident 25 had not received their dinner tray. The other residents in the dining room had also been served their dinner trays. Resident 25 stated, I am pretty hungry, apparently my food went out on the hall cart and didn't make it to the dining room. Resident 25 further stated This is not unusual for this place. During an observation on 06/21/2025 at 5:47 PM, showed Resident 25's dinner tray was brought into the dining room and placed in front of them. Numerous other residents had completed their meal and had left or were leaving the dining room when Resident 25 received their dinner tray. The resident had waited 36 minutes for their dinner tray to arrive after the other residents had been served and begun eating their dinner. During an interview on 06/21/2025 at 5:55 PM Staff H, Nursing Assistant (NA), stated Sometimes residents change their minds where they want to eat and their meal tray goes to a hall cart instead of the dining room. <Resident 215> Review of the residents medical record showed they had recently admitted to the facility on [DATE] with a history of a stroke (occurs when a blood vessel or vessels are blocked in the brain) and acute hemolytic anemia (a blood disorder that occurs when red blood cells are destroyed faster than the body replaces them). Review of Resident 215's care plan showed they required staff assistance for activities of daily living (ADLs) except for eating which was independent after set-up. <Breakfast Meal> An observation on 06/22/2025 at 7:51 AM, showed residents in the main dining room had received their breakfast trays. At 7:59 AM additional trays arrived on a cart and staff passed out breakfast trays to the residents seated at the tables. During an observation on 06/22/2025 at 8:17 AM, Resident 215 sat across from another resident who had been served breakfast, Resident 215 did not have a breakfast tray and was watching the other resident eat. Resident 215 stated to staff Can I get some cereal or something to eat? At 8:24 AM staff brought Resident 215 their breakfast tray (33 minutes after serving out had begun). Additionally, the residents seated at Resident 215's table had completed their breakfast and left Resident 215 eating alone. <Lunch Meal> During an observation on 06/23/2025 at 12:04 PM, the lunch trays arrived in the dining room and staff passed them out to the residents seated at the tables. During an observation on 06/23/2025 at 12:12 PM, Resident 25 sat at a table in the dining room. The other residents in the dining room were served their lunch except for Resident 25. The resident stated to staff Can I get some coffee or something? Staff I, Activities Director, left and returned to the dining room at 12:18 PM with Resident 25's lunch tray and stated they had found the resident's tray on a hall cart. Resident 25 did not receive their lunch tray until after all the other residents had been served and were eating. During an interview on 06/24/2025 at 10:57 AM, Staff B, Director of Nursing Services, stated they would expect the residents in the dining room to be served meal trays all together so that other residents without food did not have to wait while the other residents enjoyed their meals. Reference: WAC 388-97-0180(1-4)

Based on interview and record review, the facility failed to explain the arbitration agreement (a legal document that required the use of a third party to resolve a dispute) in its entirety, including the right to cancel the agreement within 30 calendar days, in a manner and language that the resident understood for 3 of 4 residents (Resident 30, 40, and 52) reviewed for binding arbitration. This failure placed the residents at risk for losing legal protection, lack of understanding of the legal document, and the right to a jury or court hearing. Findings included . Review of an undated document titled, Alternative Dispute Resolution Agreement Between Resident and Facility (ADR), showed that signing an arbitration agreement was not a condition of admission and the decision to sign the agreement was entirely voluntary. The agreement could be cancelled by the resident by delivering written notice of the cancellation to the facility no later than 30 days after the resident or their representative signed the agreement. The agreement showed the resident and/or their representative had received a copy of the agreement, had read or had been read by their representative, either or both of whom understands the agreement and had the opportunity to ask any questions related to the agreement. <Resident 30> Review of the medical record showed Resident 30 was admitted to the facility with diagnoses including cerebral infarction (a condition where a part of the brain tissue dies due to a lack of blood supply), respiratory failure, and anxiety. The 04/06/2025 comprehensive assessment showed Resident 30 required partial to moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 30 had an intact cognition. Review of Resident 30's medical record showed they signed an ADR on 10/03/2024. During a Resident Council (a group of residents that meet regularly to improve the quality of life and care in the nursing home) meeting on 06/22/2025 at 4:02 PM, Resident 30 stated they put a bunch of stuff in front of you, and you had to sign it to be admitted . <Resident 40> Review of the medical record showed Resident 40 was admitted to the facility with diagnoses including after care for a surgical amputation (the removal of all or part of a limb or extremity), infection at the amputation site, and respiratory failure. The 06/02/2025 comprehensive assessment showed Resident 40 required partial assistance of one staff member for ADLs. The assessment also showed Resident 40 had an intact cognition. Review of Resident 40's medical record showed they signed an ADR on 04/08/2025. During an interview on 06/23/2025 at 1:12 PM, Resident 40 stated the facility did not explain the ADR in detail. They stated they were not told they could cancel the ADR in 30 days. Resident 40 stated they felt they needed to sign the agreement to be admitted to the facility. They stated they were not told it was optional, but it was presented as we need you to sign it. <Resident 52> Review of the medical record showed Resident 52 was admitted to the facility with diagnoses including aftercare of injuries sustained in a motor vehicle collision, diabetes (a group of diseases that result in too much sugar in the blood), and muscle weakness. The 05/31/2025 comprehensive assessment showed Resident 52 required partial to dependent assistance of one to two staff members for ADLs. The assessment also showed Resident 52 was cognitively intact. Review of Resident 52's medical record showed they signed an ADR on 05/28/2025. During an interview on 06/23/2025 at 1:28 PM, Resident 52 stated the facility did not explain the ADR. They stated they did not know they signed the ADR and were not aware they had 30 days to cancel it. During an interview on 06/23/2025 at 11:53 AM, Staff N, Admissions Director, stated the ADRs were part of the admissions packet. They stated they reviewed all the forms in the admissions packet with the resident or their representative, including the options of not signing the ADR and the ability to cancel the agreement within 30 days of signing. Staff N stated they had trained Staff G, Transportation Specialist/Nursing Assistant, on the process for reviewing ADRs. During an interview on 06/23/2025 at 1:47 PM, Staff G stated they completed admission paperwork and ADRs with new admissions. They stated they explained the ADR was a way to use an arbitrator rather than suing the facility. Staff G stated they informed the new admissions that they had 30 days to cancel their admission paperwork, not specifically the ADR. During an interview on 06/23/2025 at 2:08 PM, Staff A, Administrator, stated the process of completing the ADR included explaining to the resident that it was a binding agreement that was an amicable (friendly or peaceful) way to solve disagreements with the facility that was a quicker process (than using a jury) avoiding costs and time. They stated the ADR was not a condition of admission to the facility. Staff A stated Staff N trained Staff G on completion of the admission paperwork, including the ADR, and was unsure why the residents felt the ADR was not explained to them. Reference: WAC 388-97-1620(2)(b)(i)

Based on observation, interview and record review the facility failed to develop and/or implement comprehensive resident centered care plans for 3 of 6 residents (Residents 21, 27 and 47) reviewed for care planning. This failure placed residents at risk for unmet care needs. Findings included . Review of a policy titled, Care Plans, Comprehensive Person-Centered, revised 03/2022 showed the facility would develop and implement a comprehensive, person-centered care plan that had measurable objectives to meet the resident's physical, psychosocial and functional needs created from the resident's comprehensive assessment. <Resident 21> Review of Resident 21's medical record showed they were re-admitted on [DATE] with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a disease that results in too much sugar in the blood), depression and anxiety. The 03/20/2025 comprehensive assessment showed Resident 21 required substantial/dependent assistance of one to two staff members for activities of daily living (ADLs) and had moderate impaired cognition. Review of Resident 21's social history assessment dated [DATE], showed they chewed tobacco. Review of Resident 21's care plan showed no resident focus areas, goals or interventions for tobacco use. During an observation and interview on 06/21/2025 at 3:32 PM, Resident 21 was lying in their bed with their bedside table next to them. The bedside table contained two opened cans of chewing tobacco. Resident 21 stated they had been chewing tobacco for years and they swallowed the tobacco. During an interview on 06/24/2025 at 11:46 AM, Staff A, Administrator, stated residents who used tobacco would need to be reviewed and the facility would need to determine how to meet their needs. Staff A stated their tobacco usage would need to be identified on their care plans. Staff A stated they were unaware if this had been completed for Resident 21. <Resident 27> Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition caused by a chemical imbalance in the blood that affects thinking, memory, mood and alertness), aftercare for joint replacement surgery, and dementia (a progressive disease that destroys memory and other important mental functions). Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for ADLs and had severely impaired cognition. Review of Resident 27's care plan showed no identified areas related to their diagnoses, medications, nutrition, pain, fall risk, or mood and behavior. <Resident 47> Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs), Post-Traumatic Stress Disorder (PTSD, a mental health condition that can be caused by experiencing or witnessing life-threatening, extremely stressful or terrifying events) and heart complications. The 05/20/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known. Review of Resident 47's social history assessment dated [DATE] showed the resident had been evaluated for significant life events (a tool used to provide insight into a resident's prior trauma history) and five of the 17 questions were marked positive for having occurred with the resident. Record review of Resident 47's care plan, updated 06/12/2025 showed no care plan development had been completed regarding the resident's diagnosis of PTSD or the evaluation regarding the resident traumatic history. During an interview on 06/24/2025 at 12:35 PM, Staff B, Director of Nursing, stated they expected resident care plans to be comprehensive and person-centered. Staff B stated their comprehensive assessment should initiate the care area assessments (CAA-triggered responses related to the resident's problems, needs or strengths) to include nutrition, skin, falls, toileting, pain and diagnoses. The care plan needed to be individualized and encompass the resident's moods, behaviors, medications and any other identified concerns. Reference: WAC 388-97-1020(1)(2)(a)

Based on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission to the facility for 7 of 17 residents (Resident 19, 310, 47, 165, 213, 27, and 221) reviewed for BCP. The facility failed to document resident specific goals, physician orders, dietary orders, therapy services, and social service needs to include Preadmission Screening and Resident Review (PASRR a federally mandated process that ensures residents admitted to a nursing home were properly assessed for their mental health needs and appropriate placement). Additionally, a written summary of the BCP had not been provided to the residents and or their representatives, that included the components of the BCP. This failed practice placed residents at risk for unmet care needs and potential complications in their health status. Findings included . Review of a policy titled Care Plans-Baseline, revised 03/2022, showed the BCP needed to provided effective, person-centered resident care that met professional standards of quality care and included the minimum healthcare information to provide care. The minimum healthcare information included, initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and Pre-admission Screening and Resident Review (PASRR- a federally required form that is used to help ensure individuals were not inappropriately placed in nursing homes for long term care).The policy further showed the resident and/or representative were provided a written summary of the BCP and a summary of their medications and a provision of the summary was documented in their medical record. <Resident 19> Review of the resident's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including cellulitis (a bacterial skin infection that causes redness, swelling and pain) in their lower legs, diabetes (a chronic disease which results in too much sugar in the blood) and depression. Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required substantial assistance for daily care activities involving their lower extremities. Review of the care plan dated 05/08/2025 showed no required components for a BCP had been developed or documented on the resident's care plan within 48 hours of admission to the facility. During an interview on 06/22/2025 at 10:22 AM, Resident 19 stated they had not received a care plan in writing or had their medications reviewed with them when after admitting to the facility and that might have come in handy because I had questions about my medications when I first got here. <Resident 310> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including cellulitis of the face and chest wall and bipolar disorder (a disorder associated with mood swings from depression to manic episodes). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and required moderate assistance for dressing, grooming and personal hygiene. Review of the care plan dated 06/12/2025 showed no required components for a BCP had been developed within 48 hours of admission to the facility. <Resident 47> Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs), Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event) and heart complications. The 05/20/2025 comprehensive assessment showed the resident was cognitively intact, able to make their needs known and had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag). Record review of Resident 47's BCP, dated 05/19/2025, showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their IUC or PTSD. <Resident 165> Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including left leg fracture/hip surgery, long term respiratory failure, cerebral palsy (a disorder developed in early childhood that affects the bodies movement, muscle coordination, that can lead to stiff/weak muscles and involuntary/uncontrollable movements of body parts), asthma and obstructive sleep apnea (a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing). The 06/07/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to understand others and make their needs known. Resident 165 required substantial to maximal assistance from nursing staff for their personal hygiene, mouth hygiene and upper body dressing. Additionally, Resident 165 required special treatment/procedures for their tracheostomy tube (a mechanical device inserted into a surgically created opening made in the neck, known as a tracheostomy, which assists with breathing). Record review of Resident 165's BCP, dated 06/06/2025, showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their tracheostomy tube. <Resident 213> Review of the medical record showed Resident 213 was admitted on [DATE] with diagnoses including cellulitis, pressure ulcers (damage to an area of the skin caused by constant pressure on an area that causes tissue damage), end-stage renal disease ( a condition in which the kidneys lose the ability to remove waste and balance fluids in the body) and dependence on renal (kidney) dialysis (a procedure to remove waste products and excess fluid from the blood). Review of a nursing skilled note dated 06/21/2025 showed Resident 213 required maximum assistance of one to two staff for activities of daily living (ADLs) and was able to make their needs known. Review of Resident 213's BCP dated 06/22/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions. <Resident 27> Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including metabolic encephalopathy (a condition caused by a chemical imbalance in the blood that affects thinking, memory, mood and alertness), aftercare for joint replacement surgery, and dementia (a progressive disease that destroys memory and other important mental functions). Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for ADLs and had severely impaired cognition. Review of Resident 27's BCP dated 05/17/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions. <Resident 221> Review of the medical record showed Resident 221 was admitted on [DATE] with diagnoses including aftercare of healing of broken hip socket, stroke (a medical emergency that occurs when blood flow the brain is disrupted and deprives the brain of oxygen, leading to brain damage, disability or death) with left sided weakness, and respiratory failure. Review of the 06/06/2025 admission assessment showed Resident 221 required substantial/dependent of one to two staff ADLs and had moderately impaired cognition. Review of Resident 221's BCP dated 06/02/2025 showed no resident specific goals or interventions for physician orders, dietary orders, social services or care and treatment of their medical conditions. During an interview on 06/23/2025 at 11:26 AM, Staff K, Resident Care Manager (RCM), stated they completed an assessment of the resident when they were admitted , to develop a care plan that met the basic needs of the resident. Staff K stated the first care plan developed does not include initial goals, physician orders, therapy goals or social services information and further stated I put what they need to have for their basic care needs. During an interview on 06/23/2025 at 11:56 AM, Staff L, RCM stated they included on the initial care plan basic activities of daily care needs which did not include the other required components of a BCP. Staff L stated they would only include medications if the resident asked, I was not aware of this requirement for a BCP to be developed within 48 hours. During an interview on 06/24/2025 at 10:47 AM, Staff M, Assistant Regional Director for Clinical Services, stated they had reviewed Resident's 19, 310, 47, 165, 213, 27, and 221 records and acknowledged that no BCP's had been developed for residents within 48 hours of admission to the facility. Reference: WAC 388-97-1020(3)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASRR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) accuracy and have the required Level 2 referral sent if residents had a positive Level 1 PASRR as required for 3 of 6 residents (Resident 27, 19 and 47) reviewed for PASRR. This failure placed the residents at risk for inappropriate long term care placement and not receiving necessary mental health care and services. Findings included . <Resident 27> Review of the medical record showed Resident 27 was admitted on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions), major depressive disorder (MDD, a mood disorder of persistent feelings of sadness, loss of interest, changes in sleep affecting how a person feels, thinks and behaves) and anxiety. Review of the 05/22/2025 comprehensive assessment showed Resident 27 required substantial/maximal assistance of one to two staff for activities of daily living (ADLs) and had severely impaired cognition. Review of Resident 27's Level I PASRR, dated 05/17/2025, showed no documentation of Resident 27's diagnoses of MDD or anxiety. Further review showed a [NAME] II referral had not been completed. During an interview on 06/23/2025 at 1:22 PM, Staff N, Admissions Director, stated when residents were going to be admitted to the facility, they reviewed PASRR's for accuracy. Staff N stated when the PASRR's were not accurate they reached out to the hospital to ensure they were corrected before the resident was admitted to the facility. Staff N stated they did not catch Resident 27's PASSR prior to their arrival at the facility. <Resident 19> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including depression and cellulitis of the lower legs (an infection of the skin and tissues beneath causing redness swelling and pain). The most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact. The assessment further showed the resident exhibited moderate depression symptoms as indicated by their Patient Health Questionnaire-9 (PHQ-9 a nine item diagnostic tool used to screen for depression). Review of Resident 19's Level 1 PASRR assessment dated [DATE] identified that the resident had a diagnosis of a mood disorder (depression) which would require a referral for a Level 2 PASRR assessment be requested for any follow up with mental health services as needed. The resident's record showed no Level 2 PASRR had been requested or received by the facility. During an interview on 06/24/2024 at 12:16 PM, Staff J, Social Services Director, reviewed Resident 19's record and stated they were unable to find a referral for a Level 2 PASRR as required, It should have been requested by the hospital before the resident was admitted here. <Resident 47> Review of the resident medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a stomach wound, depression, anxiety and Post-Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying event). The 05/20/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 47's PASRR, dated 05/13/2025, showed no documentation of the residents PTSD diagnosis. During an interview on 06/24/2025 at 10:04 AM, Staff J stated they, and another staff member reviewed resident PASRR's after admission to the facility for accuracy. Staff J stated that Resident 47's PASRR was not accurate and it should have had the diagnosis of PTSD. Reference: WAC 388-97-1975(1)

Based on interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered and risks and benefits of the immunizations were provided to 2 of 5 residents (Resident 30 and 42) reviewed for immunization and infection control. This failure placed the residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases. Findings included . Review of a policy titled, Influenza and Pneumococcal Immunizations, revised 10/03/2023, showed the facility would offer the influenza and pneumococcal immunizations to residents. The facility would review the risks and benefits of the immunization with the resident and/or their representative. The resident and/or their representative could refuse the immunizations. Immunization declinations and the reason for the declination were recorded in the resident's medical record. <Resident 30> Review of the medical record showed Resident 30 was admitted to the facility on [DATE] with diagnoses including a stroke (a condition that occurs when a blood clot or broken vessel prevents blood from getting to the brain), immunodeficiency (a weakened immune system that makes it less effective at fighting off infections and diseases), and anxiety. The 04/06/2025 comprehensive assessment showed Resident 30 required partial to moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 30 had an intact cognition. Record review of Resident 30's medical record showed they were not offered an influenza or pneumococcal immunization. The record also showed no documentation of education provided on the risks and benefits of the immunization. During an interview on 06/23/2025 at 1:34 PM, Resident 30 stated they did not remember anyone reviewing immunizations with them. <Resident 42> Review of the medical record showed Resident 42 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection, malnutrition, and repeated falls. The 05/11/2025 comprehensive assessment showed Resident 42 required moderate/maximum assistance of one staff member for ADLs. The assessment also showed Resident 42 had a moderately impaired cognition. Review of Resident 42's medical record showed no documentation that a pneumococcal immunization was offered, or risks and benefits had been provided to the resident or their representative. During an interview on 06/21/2025 on 2:48 PM, Staff D, Infection Control Nurse, stated they reviewed all new admission immunizations upon admission. They stated if the resident did not have influenza or pneumococcal immunizations, they would offer them. Staff D stated they provided education, risks, and benefits for immunizations. They stated when a resident declined immunizations, they would document that on the consent/declination form. During a follow-up interview on 06/23/2025, Staff D stated they spoke to Resident 30 and Resident 42 regarding immunizations. They stated both Resident 30 and Resident 42 did not remember any previous conversations regarding immunizations and both residents declined needing them. During an interview on 06/23/2025 at 1:53 PM, Staff B, Director of Nursing Services, stated the process for ensuring residents were immunized included reviewing the immunizations upon admission, offering the immunizations and obtaining a consent. They stated the resident would have the option to decline the immunization and that would also be documented. Staff B stated the process would include providing risks and benefits to the residents and documenting that. During an interview on 06/23/2025 at 2:05 PM, Staff A, Administrator, stated they were confident the residents were offered immunizations but there was no documentation in the record. Reference: WAC 388-97-1340(1)(2)

Based on observation and interview, the facility failed to ensure expired medications were properly disposed of for 1 of 1 medication rooms (Medication Room) reviewed for medication storage. This failure placed the residents at risk for receiving expired, ineffective, and/or compromised medications. Findings included . Review of the policy titled, Storage of Medication, dated 01/2023, showed outdated medications would be immediately removed from stock and disposed of. An observation on 06/21/2025 at 2:19 PM with Staff E, Licensed Practical Nurse (LPN), showed the medication room contained the following: • Blood collection needles, four boxes, each containing 48 needles, expired 03/31/2025. • Adult multivitamins, one partial bottle containing 32 tablets, expired 02/2025. • Non-steroidal pain reliever, one bottle of 100 tablets, expired 03/2025. • Magnesium with calcium supplement, one partial bottle of 26 tablets, expired 09/2024. • Vitamin D, one partial bottle of 84 tablets, expired 05/2025. • Dairy lactase enzyme supplements, two bottles of 60 caplets each, expired 04/2025. • Vitamin E supplements, one partial bottle of 84 tablets, expired 04/2025. • Allergy medication, one partial bottle (eight tablets), expired 12/2024 and one full bottle (100 tablets), expired 01/2025. • Iron supplement, one partial bottle of 24 tablets, expired 02/2025. • Oral pain relief gel, three tubes, expired 02/2024, 07/2024, and 02/2025. • Moisture mouth gel, eight tubes, expired 12/2024. • Glucose (a source of energy in the body) control solution (used to verify the accuracy of glucose testing meters), one kit, expired 11/14/2023. During an interview on 06/21/2025 at 3:33 PM, Staff F, LPN, stated partial bottles of medications should not be stored in the same area as the full bottles. They stated the expired medications should not have been in with the non-expired medications. They stated they did not know if anyone was responsible or assigned to checking the medication room for expired medications. During an interview on 06/23/2025 at 2:17 PM, Staff A, Administrator, stated the process included the Director of Nursing Services providing oversight. There should be a process for the nurses to perform routine checks and dispose of expired medications. Reference: WAC 388-97-1300(2)(4)(i)

Based on observation, interview and record review, the facility failed to provide the necessary respiratory care and services consistent with professional standards of practice for 1 of 1 resident (Resident 165), reviewed for respiratory care with tracheostomy tubes (a mechanical device inserted into a surgically created opening made in the neck, known as a tracheostomy, which assists with breathing), by failing to ensure; A) residents had the required emergent tracheostomy tube equipment immediately accessible, at the resident's bedside, B) nursing staff comprehensively assessed and documented a residents tracheostomy tube care, C) nursing staff had the required training/competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) to perform tracheostomy care and emergency interventions and, D) policies and procedures for residents requiring specific types of respiratory care/services regarding emergency care along with staffing implementation of emergency intervention and provision (the action of providing or supplying something) of appropriate equipment at the residents bedside. This failure placed the resident at an increased risk for negative outcomes in case of accidental extubation (the unintentional removal of the tracheostomy tube) and unmet care needs. Findings included . Review of the facility's policy titled, Tracheostomy Care, dated April 2022, and Changing a Disposable Inner Cannula (a tube situated inside the tracheostomy tube that can be discharged after its use) reviewed March 2019, showed that facility staff were to perform tracheostomy care per the physician's order, change a tracheostomy's disposable inner cannula at least once per day and that facility staff should refer to the Lippincott Manual (a reference for fundamental nursing tasks according to established standards of practice). Additionally, the policies showed no information on staff training/competencies (a series of knowledge, abilities, skills, experiences and behaviors, which leads to effective performance of staff regarding resident cares) of emergency intervention for respiratory (matters related to the lungs) complications or the appropriate equipment needed at the resident's bedside for immediate access in case of unplanned extubation. Review of Lippincott Nursing Procedures 8th edition, dated 2019, showed during tracheostomy care when changing the tracheostomy ties (straps that hold the tracheostomy tube in place), .research overwhelmingly recommends a two-person technique for changing a tracheostomy tube securing device to prevent tube dislodgment . Review of Lippincott Manual of Nursing Practice 11th edition, dated 2019, showed that residents with tracheostomies needed emergency equipment available at all times, at the residents bedside and included an extra tracheostomy tubes (inner and outer tracheostomy tubes), bag/mask resuscitation device (also called an Ambu bag, is a device for rapidly providing rescue breathing during emergency situations), obturator (a device that guides the outer tracheostomy tube through the surgically created opening in the neck and needed for emergent unplanned extubations). Review of the facility's policy titled, Training Requirements, dated July 2019 showed that new and existing facility staff would receive job specific training. The training would be specific to the facility's resident population and federal and state mandated training requirements. Additionally, the facility would utilize the facility assessment to ensure training addressed the facility resident population. Review of the Facility Assessment for 07/19/2023 to 07/18/2024, showed the facility identified tracheostomies in their resident population and that nursing staff would have the required training/competencies to care for the residents. <Resident 165> Review of the resident medical record showed they were admitted on [DATE] with diagnoses including left leg fracture/hip surgery, long term respiratory failure, cerebral palsy (a disorder developed in early childhood that affects the bodies movement, muscle coordination, that can lead to stiff/weak muscles and involuntary/uncontrollable movements of body parts), asthma (a disease where irritants that are breathed into the lungs can cause the body's airway to constrict and restrict airflow into the lungs) and obstructive sleep apnea (a condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing). The 06/07/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to understand others and make their needs known. Resident 165 needed substantial to maximal assistance from nursing staff for their personal hygiene, mouth hygiene and upper body dressing. Additionally, Resident 165 required special treatment/procedures for their tracheostomy. Review of Resident 165's admission assessment dated [DATE] showed the resident had a tracheostomy and Resident self manages Trach care- nursing to supervise. The record showed no further assessment/evaluation of the resident's level of ability regarding tracheostomy care, how the resident/staff were to participate/assist in the tracheostomy treatment. Review of Resident 165's care plan, dated 06/06/2025 and updated 06/17/2025 showed no resident specific goals, interventions/tasks for Resident 165's tracheostomy. During a concurrent observation and interview on 06/21/2025 at 7:09 PM showed Resident 165 in their bed, tracheostomy in place with brown, thick discharge around the bottom edge of the resident's tracheostomy tube holder. The resident had a Passy Muir (a one valve that allows a resident to speak) and was able to converse. The resident made contradicting (information that was the opposite of the previous information already obtained) statements and was confused on how tracheostomy care was performed/completed at their home versus the last two weeks in the facility and if tracheostomy care was being completed by the nursing staff or not. During a concurrent observation and follow-up interview on 06/23/2025 at 8:07 AM, the resident stated their home care giver (referring to a private care giver that visits the resident while at home to provide care) completed all their tracheostomy care and changed out whole tracheostomy (inner/outer tubes and tube holder) one time every week. Resident 165 stated the inner tracheostomy tube was supposed to be changed every day but had not been changed out in the past two days. The resident then stated that it might have been the facility's nursing staff that was changing out their tracheostomy tubes. Resident 165 informed the surveyor that they were no longer completing their own tracheostomy care due to the increased risk of infections, which was why they had a home care giver that changed it. Additionally, observations showed that tracheostomy supplies in/on the resident nightstand did not have the emergency obturator or Ambu bag with tracheostomy attachment equipment at the resident's bedside. Review of Resident 165 treatment administration record for June 2025, showed: • Orders for staff to change the resident's inner cannula every day and as needed. The documentation showed from 06/07/2025 to 06/23/2025 every day, except 06/23/2025, Staff O, Registered Nurse (RN), Staff P, RN and Staff Q, Licensed Practical Nurse (LPN), documented that Resident 165's tracheostomy care was completed. • Orders for staff to change the resident's tracheostomy ties/tube holder every day and .nursing to supervise resident with task. From 06/09/2025 to 06/23/2025 showed that every day, except 06/23/2025, Staff O, Staff P, RN and Staff Q documented that Resident 165's tracheostomy care was completed per their supervision. • Orders for staff to change the resident's outer/inner tracheostomy tubes every week and nursing was to supervise the resident with the task. Documentation showed that Staff P, per their supervision, completed the care on 06/09/2025 and 06/16/2025. Review of Staff P's progress notes on Resident 165 daily assessments for 06/07/2025, 06/09/2025, 06/10/2025, 06/15/2025 and 06/16/2025, showed the resident was alert/oriented and managed their own tracheostomy care under nurse supervision and emergency tracheostomy suctioning was at the resident's bedside. The documentation showed no further assessment/evaluation of the resident's level of ability regarding their tracheostomy care, how the resident/Staff P might have participated, or what type of supervision was needed regarding the resident's tracheostomy care. Review of Staff O's progress notes on Resident 165 daily assessments for 06/07/2025, 06/08/2025, 06/11/2025, 06/12/2025, 06/13/2025, 06/14/2025, 06/17/2025, 06/18/2025, 06/19/2025 and 06/20/2025, showed that tracheostomy care was completed and no further evaluation of the resident's level of ability regarding their tracheostomy care, how the resident/Staff O might have participated in the residents tracheostomy care, or what type of supervision was needed regarding the resident's tracheostomy care. Review of Staff Q's progress notes on Resident 165 daily assessments for 06/21/2025 and 06/22/2025 showed the resident was alert/oriented, with no assessment of the resident's level of ability regarding their tracheostomy care, how the resident/Staff Q might have participated in Resident 165's tracheostomy care, or what type of supervision was needed regarding the resident's tracheostomy care. During an interview on 06/23/2025 at 12:36 PM, Staff K, Resident Care Manager, stated that when a resident was admitted to the facility with a tracheostomy, they put orders for tracheostomy care, which included changing out the inner tracheostomy tube, the tube holder and tracheostomy ties every day. Staff K stated that an obturator and Ambu bag were to be placed at the resident's bedside. Staff K stated that when a resident performed their own tracheostomy care, an evaluation of the resident's ability to perform the task would be completed. During an interview over the phone on 06/23/2025 at 2:15 PM, Staff Q stated they were not the routine nurse that cared for Resident 165 .I may have done something (regarding Resident 165's tracheostomy care) but I do not recall . During an interview over the phone on 06/24/2025 at 2:18 PM, when asked about completing Resident 165 tracheostomy inner/outer tube changes and tracheostomy ties/tube holder changes, Staff P stated they had offered to do Resident 165's tracheostomy care but the resident had refused, and Staff P had not competed tracheostomy care. Staff P stated they had not observed Resident 165 change out the tracheostomy tube, tube holder, and ties but had verified that the resident could communicate how to perform their own tracheostomy care. During an interview on 06/24/2025 at 2:38 PM, Staff A, Administrator, was informed that Staff O still needed to be interviewed for the ongoing investigation and discussed the need to complete interviews with Staff Q and Staff P. Staff A stated that Staff O, Q and P had not completed training or competencies regarding resident tracheostomy care (staff were unavailable for contact). During an interview on 06/24/2025 at 2:49 PM, Staff K stated that an assessment should have been completed regarding Resident 165's level of ability to perform their tracheostomy care, how the resident participated/completed their tracheostomy care and what supervision would be required by staff. Staff K stated they had not completed an assessment regarding the resident's ability to perform their tracheostomy care. Staff K stated the orders to have the inner/outer tracheostomy tube changed were not correct because that would mean staff would be changing out the whole tracheostomy tube, which was not what the staff should be completing. Staff K stated the correct process with Resident 165's tracheostomy care was not being followed, and nursing staff should not be charting that it was completed. During an interview on 06/24/2025 at 3:03 PM, Staff D, Infection Control Nurse and Staff R, Central Supply, Staff D stated that during Resident 165's admission, an assessment of the resident's ability to perform their tracheostomy care and what supervision would be required by the nursing staff should have been completed. Staff D and Staff R stated that emergency equipment, an Ambu bag, had not been in the resident's room. Staff D stated they did not know when the obturator was placed in the resident's room, but it had been in plain view on 06/24/2025, inside the resident's nightstand and would have been seen by the surveyor if it was there on 06/23/2025, but Staff D confirmed that it was currently at the resident's bedside. During an interview on 06/25/2025 at 7:43 AM, Staff B, Director of Nursing Services, stated they were unable to find an evaluation of Resident 165's ability to perform their own tracheostomy care in the resident's record and so Staff B completed one. Staff B stated that Resident 165 could not perform their own tracheostomy care and needed assistance from nursing staff. Staff B stated Resident 165 knew the process for their tracheostomy changes but required staff to complete the task. During an interview on 06/25/2025 at 8:59 AM, Staff B and Staff D stated they expected that nursing staff would have the required training/competencies completed and that emergent tracheostomy tube equipment would have been readily available at the resident's bedside, but the correct process was not followed. When inquired about nursing staff documenting supervision/completion on Resident 165's treatment administration for the tracheostomy inner/outer tube change out and the tracheostomy ties/tube holder change out, even though Resident 165 was unable to perform their own tracheostomy care, Staff B and Staff D were unable to comment nor present any documentation. During an interview on 06/25/2025 at 11:41 AM, Staff M, Assistant Regional Director for Clinical Services, stated that it was expected that nursing staff would conduct an evaluation regarding Resident 165's ability to perform their own tracheostomy care. Staff M stated the expectation would be for nursing staff to have received the training/competencies if a newly admitted resident had a tracheostomy. Reference: WAC 388-97-1060(3)(j)(iv)

Based on interview and record review the facility failed to ensure implementation and maintenance of an effective training program for new or existing staff, prior to staff independently providing services to residents and annually, related to; A) effective communications, resident's rights/facility's responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention/control, and compliance/ethics program trainings for 1 of 3 staff (Staff Q) reviewed for training requirements and, B) Quality Assurance and Performance Improvement (QAPI, a process to maintain and improve safety/quality of residents in a nursing home) training for 3 of 3 staff (Staff Q, O, and P) reviewed for training requirements. This failure placed residents at increased risk for unmet care needs and inadequate care from unqualified staff. Findings included . Review of the facility's policy titled, Training Requirements, dated July 2019 showed that new and existing facility staff would receive job specific training. The training would be specific to the facility's resident population and federal and state mandated training requirements. Additionally, the facility would utilize the facility assessment to ensure training addressed the facility resident population. Review of the Facility Assessment for 07/19/2023 to 07/18/2024, showed the facility identified their resident population and that nursing staff would have the required training to care for the residents. During an interview on 06/24/2025 at 1:51 PM, Staff A, Administrator, stated that nursing staff completed their annual required training through Relias (an electronic/online training platform for healthcare). Review of staff personal records for Staff Q, License Practical Nurse, hired 01/31/2025, showed no documentation that Staff Q had completed the required training regarding effective communications, resident's rights/facility's responsibilities, abuse/neglect and dementia management regarding abuse prevention, infection prevention/control, compliance/ethics and QAPI. Review of the 2024/2025 Relias training records for Staff O, Registered Nurse (RN), hired 02/03/2015, showed no documentation that Staff O had completed the required annual training for QAPI. Review of the 2024/2025 Relias training records for Staff P, RN, hired 07/28/2020, showed no documentation that Staff P had completed the required annual training for QAPI. During an interview on 06/27/2025 at 10:50 AM, Staff A stated they were still looking for QAPI training for Staff O and Staff P. Staff A stated that Staff Q was a new staff member and they were still looking for all of the staff members required training. Staff A stated they would be setting up a better process next year with obtaining and documenting the required training on new and existing staff. Reference: WAC 388-97-1680(2)(b)(i, ii)(c)

Based on interviews and record review, the facility failed to report an incident of neglect regarding a fall to the State agency as required, involving 1 of 3 residents (Resident 1), reviewed for falls. This failed practice placed residents at risk for harm and diminished protection and oversight from the State agency. Findings included . Review of the facility policy titled, Abuse - Screening, Training, Identification, Investigation, Reporting, and Protection, revised on 01/2023, showed if the allegation involves neglect, that does not involve abuse or serious injury, the incident is reported within 24 hours to the state survey agency, as required. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated 12/07/2024, showed Resident 1 had severe cognitive loss. Review of Resident 1's plan of care, dated 12/17/2024, showed Resident 1 required two staff to assist with transfers and toileting. Review of a facility investigation report, dated 12/26/2024 at 4:02 PM, showed Resident 1 had a witnessed assisted fall to the floor when being transferred from their bed to the wheelchair by Staff A, Nursing Assistant. Despite the resident's plan of care showing they required two staff for transfers, Staff A transferred the resident alone and was not strong enough to hold the resident. Resident 1 did not sustain any injuries from the fall. On 01/15/2025 at 3:08 PM, Staff D, Administrator, stated the incident involving Resident 1 was not reported to the state agency as they did not see it as an incident of neglect. Refer to F689 for additional information. Reference (WAC) 388-97-0640(6)(c) This is a repeat deficiency from the Statement of Deficiencies dated 08/12/2024.

Based on interviews and record review, the facility failed to supervise to ensure staff provided care according to the resident's plan of care and facility policy to prevent falls for 1 of 3 residents (Resident 1), reviewed for falls. This failed practice resulted in potential injuries to Resident 1 when they fell to the floor. Failure to follow residents' plans of care placed residents at risk for injury, falls, and a diminished quality of life. Findings included . Review of the facility policy titled, Gait Belt Policy and Procedure, not dated, showed it was the policy of the facility to use a gait belt with any resident that was not independent. If the resident was unsteady with their gait or unable to transfer independently, a gait belt should be used. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors). Review of a comprehensive assessment, dated 12/07/2024, showed Resident 1 had severe cognitive loss. Review of Resident 1's plan of care, dated 12/17/2024, showed Resident 1 required 2 staff to assist with transfers and toileting. Review of a fall assessment, dated 12/04/2024, showed Resident 1 was at high risk for falls. Review of Progress Notes, dated 12/26/2024 at 8:37 PM, showed Resident 1 was being transferred from bed to wheelchair by one staff. The resident's knees buckled and the Nursing Assistant (NA) guided the resident to the floor on their knees. The resident did not sustain any injuries. The resident was unable to assist with the transfer at all due to their inability to bear any weight. Review of the facility investigation report, dated 12/26/2024 at 4:02 PM, showed at approximately 4:00 PM Resident 1 was being assisted from their bed to the wheelchair by Staff A, NA. The resident was unable to assist with any part of the transfer. Review of a post-fall assessment for Resident 1's fall on 12/26/2024, dated 12/30/2024, showed the resident was unable to independently come to a standing position, exhibited a loss of balance with standing, required hands-on assistance to move from place to place, and they had a decrease in muscle coordination. Staff A was transferring the resident alone and they were not strong enough to hold the resident when the resident did not assist with the transfer. On 01/15/2025 at 9:25 AM, Staff B, Physical Therapist, stated Resident 1 had poor body control with weakness and fatigue. The resident's head and shoulder would lean to the left side and they required significant assistance to stand. The resident needed two staff to assist with mobility. On 01/15/2025 at 2:32 PM, Staff A, stated they had transferred Resident 1 by themselves at the time of the fall on 12/26/2024. Staff A stated they had received report from the day shift NA who stated the resident required one staff for transfers with a gait belt. Staff A stated the resident's spouse was in the room at the time of the fall and had stated prior to the fall that often the resident was tired after meals. Staff A stated they transferred the resident and they buckled and fell on the floor on their knees. The resident's spouse informed Staff A the resident required two staff to assist with transfers and the care directives showing that were on the inside of the resident's closet door. Staff A stated it did not appear they used a gait belt during the transfer of Resident 1. On 01/15/2025 at 11:38 AM, Staff C, NA, stated the resident's spouse was in the resident's room at the time of the fall on 12/26/2024. Staff A was not using a gait belt at the time of the fall, as Staff C had to ask for one to transfer Resident 1 back into bed following the fall. On 01/09/2025 at 11:50 AM, Resident 1's spouse, stated a NA came into the resident's room on 12/26/2024 and was going to transfer the resident by themselves. The spouse informed Staff A the resident required two staff per their plan of care and the instructions on the inside of their closet door. Staff A grabbed the back of the resident's sweat pants and proceeded to stand the resident up, which resulted in them falling to the floor. The spouse stated Staff A did not utilize a gait belt during the transfer. The resident was six feet tall and weighed 230 pounds (review of the resident's medical record showed the resident's weight on 12/22/2024 was 220.5 pounds). Reference (WAC) 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 08/12/2024.

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 2 of 4 residents (Resident 1 and 2) reviewed for discharge planning process. The failure to develop and implement a discharge plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a condition in which the body doesn't have enough oxygen in the tissues), heart disease, and kidney disease. The 10/28/2024 comprehensive assessment showed Resident 1 required substantial/maximum assistance of one staff member for activities of daily living (ADLs) and had a severely impaired cognition. The assessment also showed Resident 1's overall goal for discharge was to return to the community. Resident 1 discharged to home from the facility against medical advice on 11/20/2024. Review of Resident 1's comprehensive care plan dated 11/21/2024, showed no documentation that a comprehensive, person-centered discharge plan had been initiated for the resident. The care plan did not include information that identified the resident's discharge goals, needs, barriers to discharge, or the potential discharge location. During an interview on 12/23/2024 at 3:44 PM, Resident 1's Representative (RR) stated they had caregivers in place at home to care for Resident 1. The RR stated, all they (Resident1) wanted was to be at home. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including heart failure, pneumonia (an infection of the lungs that causes inflammation of the air sacs), and kidney failure. The 12/11/2024 comprehensive assessment showed Resident 2 required supervision/partial assistance of one staff member for ADLs. The assessment also showed Resident 2 had an intact cognition and wanted to discharge to the community. Resident 2 discharged from the facility to the hospital on 12/20/2024. Record review of Resident 2's care plan dated 12/05/2024, showed no documentation that a comprehensive, person-centered discharge plan had been initiated for the resident. The care plan did not include information that identified the resident's discharge goals, needs, barriers to discharge, or the potential discharge location. During an interview on 12/30/2024 at 1:21 PM, Staff B, Social Services Director, stated the process for discharge planning started during their initial meet and greet meeting when the resident first arrived at the facility. They stated they set up an initial care conference, completed a social services assessment, and determined the resident's/representative's goals for discharge. Staff B stated after gathering the information, they added the discharge plan to the resident's care plan. Staff B stated they had a conversation with Resident 1's Representative on the same day Resident 1 had admitted to the facility. They stated the RR wanted to take Resident 1 home right away and had told Staff B that they did not think the facility was the right place for Resident 1. Staff B stated Resident 1 had caregivers at home through Veterans Administration (VA) services, along with a provider that made house calls, and therapy services from the VA. Staff B stated the RR would stop by their office almost daily, stating they wanted to take Resident 1 home. Staff B stated Resident 2 wanted to discharge to home and had services in place. Staff B stated it was their responsibility to ensure residents had a discharge plan entered on their care plan. During an interview on 12/31/2024 at 3:38 PM, Staff A, Administrator, stated discharge goals were identified at the initial care conference. They stated a discharge plan should have been included on the resident's comprehensive care plan. Reference: WAC 388-97-0080(3)(a)(5)(7)(a-c)

Based on observation, interview, and record review, the facility failed to ensure the prevention, development, and worsening of a facility-acquired pressure injury (PI) for 1 of 4 residents (Resident 23) reviewed for PIs. The facility did not consistently provide ordered wound treatments, perform/document skin assessments, or obtain/implement Durable Medical Equipment (DME, medically necessary equipment used by people with a medical condition, disability, or injury) as ordered. Resident 23 experienced harm when they developed an avoidable PI that was not present upon admission. This failure placed Resident 23 at risk for further wound complication and unmet care needs. Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 PI is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable PI is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. <Resident 23> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include an in-operable left fibula (lower, outer leg bone) fracture, diabetes (a condition that happens when the sugar [glucose] in your blood is too high), and end stage kidney disease. The 05/26/2024 comprehensive assessment, showed the resident's cognition was severely impaired and required the assistance of one to two staff for all activities of daily living. The assessment further showed the resident admitted without pressure injuries. During an observation on 08/05/2024 at 2:05 PM, Resident 23 was lying in their bed, had a Podus boot (PB, an off-loading device that floats [suspending in the air] the heel, eliminating pressure or friction, and enhances blood circulation for healing) over a soft, white splint (a device that supports and protects a broken bone or injured tissue) to their left lower extremity (LLE). The splint was placed underneath the back part of the leg and extended from their toes to their upper thigh, and their leg was internally rotated (the leg was turned towards the center of the body), with the inner part of the LLE lying flat on the bed. The boot had an attached phalange (an arm that keeps the leg from rotating and acts like a kickstand) that was to be used to maintain proper positioning of the LLE, but the phalange had not been used to maintain the LLE in an upward/correct position (toes to the ceiling). During an observation on 08/07/2024 at 9:18 AM, Resident 23 was lying in bed, they had a gauze wound dressing to their LLE below the knee, with 08/04/2024 handwritten in black marker, that was saturated with areas of red and brown drainage. Staff J, Nursing Assistant (NA) and Staff K, NA, repositioned Resident 23 while providing care, the LLE lied flat and internally rotated on the bed and did not move or turn when moving the resident from side to side. Neither Staff J or K positioned the phalange on the PB, nor did they provide any positioning of the LLE so that Resident 23's leg was in the correct position. Additionally, the top of the white soft splint had brownish stains, which Staff J and Staff K identified as dried bowel movement. A concurrent observation and interview on 08/07/2024 at 11:52 AM, Staff I, Registered Nurse (RN), and Staff D, Licensed Practical Nurse/Resident Care Manager, provided wound care to Resident 23. Staff I removed the PB from the LLE, then the soft white splint, followed by a dressing to the top of the left foot and another to the heel. Under the dressing to the top of the foot was a dime-sized wound, reddened, top layer of skin missing, and on the heel was an opened wound the size of a golf ball that had blackened areas, white areas, and areas of red flesh, the wound dressing was moist with brown and red wound drainage. The wound was identified by Staff D as pressure injuries obtained from the soft white splint. Neither Staff I nor Staff D positioned the phalange on the PB to the appropriate position when the wound care was completed. At the top of the LLE, towards the outer part of the knee area showed 08/07/2024 handwritten in black marker and Staff I stated they had replaced that prior to this wound care because it was saturated with wound drainage. An observation on 08/08/2024 at 2:41 PM, showed Resident 23 was sitting in their wheelchair (w/c) with their LLE resting, internally rotated, on the elevated footrest of the w/c. The PB phalange was not positioned to keep the LLE positioned correctly and there were no positioning devices in place to assist with maintaining the LLE in the correct position. Review of the Orthopedic Surgeon's (specialist who focuses on injuries and diseases affecting the musculoskeletal system) orders on 05/31/2024 showed orders for decubitus [wounds that occur from prolonged pressure on your skin] precautions and a PB with a side phalange to prevent rotation of the LLE. Further review, showed an order on 06/26/2024 for a Hip-Knee-Ankle-Foot Orthosis (HKAFO, used for rotation control of the lower extremity) that was to be supplied by a named DME clinic (No follow-up, notes, or orthosis had been obtained regarding the order). Review of Resident 23's 05/23/2024 care plan (CP) showed no directive for positioning of the LLE, no directives for the PB with the phalange, and no updates for current skin integrity status since 06/03/2024. The care plan showed decubitus precautions with no further directives. Review of Resident 23's June 2024 Treatment Administration Record (TAR), showed a treatment order on 06/18/2024 to an unstageable PI on the left outer knee that was discontinued on 06/19/2024, an order on 06/19/2024 to an unstageable PI on the left heel to be completed twice daily and as needed (PRN)( eight of 23 treatment opportunities were not completed) and on 06/20/2024 an order for a blister on the left outer knee to be completed daily and PRN (six of 11 treatment opportunities were not completed). Review of the July 2024 TAR showed the left heel had 10 out of 36 treatment opportunities not completed, and for the left outer knee, 12 out of 30 treatment opportunities were not completed. During an interview on 08/08/2024 at 2:53 PM, Staff D stated they had attempted to refer Resident 23 to an outside wound provider, but Resident 23 was denied services by the provider due to their current medical coverage. Staff D stated they were informed it would be double dipping [obtaining money from two mutual sources at the same time] because the facility already contracted with another wound provider. Staff D stated the resident could not receive services from the facilities contracted wound care provider because they received dialysis treatments (a treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to) at an outside dialysis facility on Tuesdays, Thursdays, and Saturdays for approximately eight hours and would leave the facility at 7:00 AM. Staff D stated the contracted wound care provider could only see residents in the facility on Tuesdays and was unable to see Resident 23 due to their conflicting schedules. Staff D stated neither the contracted wound care provider nor the dialysis facility was willing to adjust their schedules to meet the needs of the resident. Staff D stated the Resident's Representative (RR) allowed Resident 23 to miss a dialysis treatment on 07/30/2024 to accommodate the contracted wound care provider's schedule, so the resident could be seen. An observation on 08/09/2024 at 12:45 PM, showed Resident 23 lying in bed, their LLE placed on the top of a pillow, the PB was on but the Velcro that held the boot closed was not attached, causing the white soft portion of the splint to slide off the hardened portion of the splint, leaving the LLE with no support. The LLE was internally rotated, resting on the bed. During an interview on 08/09/2024 at 12:48 PM, Staff J stated they were normally assigned to Resident 23 and when provided care to the resident, required two staff because their LLE always had to be kept straight. Staff J stated they were told to float Resident 23's legs on a pillow and were not provided training on the PB phalange placement. Staff J stated they were allowed to remove the boot for cares but not the soft splint . Review of the May 2024 through July 2024 Licensed Nurse (LN) Tasks document showed an order on 05/29/2024 for weekly skin checks to be completed every Wednesday on evening shift. On 05/23/2024 an order to monitor the circulation, motion, sensation (CMS) and skin breakdown to the LLE soft cast every shift and document assessment daily. The LNs were to document a plus (+) and minus (-) signs as additional documentation, but the record showed no documentation from 05/23/2024 to 06/17/2024. During an interview on 08/09/2024 at 1:22 PM, Staff L, RN, stated the splint was originally placed on the outer portion of the left foot/leg to support the fracture of the outer bone and when Resident 23 developed pressure injuries from the splint, the splint was moved to the underside of the left foot/leg. Staff L stated they checked the skin under the brace every shift and documented their findings in their daily progress notes. During an observation on 08/12/2024 at 11:00 AM, Resident 23 was lying in bed, PB phalange was not positioned, and no positioning devices were used to keep the LLE in the correct position. The LLE was internally rotated. During an interview on 08/12/2024 at 11:10 AM, Staff K stated they had not been provided specific training on the positioning of the LLE or the placement of the PB phalange. Staff K stated they positioned Resident 23 so that their LLE was floated on a pillow. Review of Nursing Progress notes on 06/07/2024 at 1:31 PM, showed the first documentation on the status of the left lower extremity CMS intact to left lower extremity (LLE) but nothing about the skin underneath the brace (15 days after admission). Notes on 06/10/2024 at 2:17 PM, 06/11/2024 at 6:00 PM, on 06/17/2024 at 12:55 PM, and on 06/18/2024 at 5:27 PM, showed the CMS was intact to the LLE and no documentation about removing the brace or the status of the skin. A note on 06/19/2024 at 9:51 AM, showed the care staff reported skin concerns to the resident's LLE. Two nurses then went in to assess Resident 23's skin. Review of the 06/19/2024 Skin Evaluation assessment, showed the left knee (outer) had a four centimeter (cm, a unit of measure) by 2.2 cm circular intact blister. The left heel showed a 3.9 cm by 3.2 cm circular unstageable PI, the left shin had a 0.2 cm by 0.2 cm circular abrasion, and the left inner thigh had a five cm by 0.3 cm irregular shaped abrasion with a pink wound bed. The 07/17/2024 skin assessment showed the left outer knee blister had deteriorated and changed to an unstageable PI which measured at 3.9 cm by 4.7 cm by 0.1 cm depth with an irregular shape, dead tissue, and moderate red clear drainage. The left heel measured at 4.2 cm by 6.3 cm by 0.1 cm depth with dead tissue. Review of the contracted wound provider notes on 07/30/2024 (41 days after wounds developed), showed Resident 23 had splint on lower extremity and when splint was removed/loosened in order to change, areas of breakdown were noted. Resident 23's wounds were assessed as; 1) left heel, stage 3 PI, measured 3.3 cm by 5.4 cm by 0.2 cm depth with dead tissue, 2) left outer knee, stage 3, measured 3.0 cm by 1.3 cm by 0.7 cm depth, with yellow fibrin (dead tissue within a wound), and undermining at 11 o'clock of 0.8 cm with moderate drainage. The note showed the left heel and outer knee PIs needed to be surgically debrided (a procedure to remove debris or infected/dead tissue from a wound for the wounds to heal). Measurements after debridement showed the left heel was 3.4 cm by 5.5 cm by 0.3 cm depth and the left outer knee was 3.1 cm by 1.4 cm by 0.8 cm depth and both PIs were full thickness PIs. During an interview on 08/12/2024 at 11:30 AM, Staff B, Interim Director of Nursing Services, stated the NA's had not been trained on the PB with the phalange, or the proper positioning of the residents LLE to keep the leg from internally rotating and did not find any directives on the Kardex (nursing directives for a resident's plan of care). Staff B further stated the nurses were to document their skin checks underneath braces if the Orthopedic Surgeon did not have orders to not remove the brace. Staff B further stated Resident 23 had a referral to an outside wound provider but in Resident 23's case, they were unable to see them. During an interview on 08/13/2024 at 7:58 AM, Collateral Contact (CC) stated they received a wound referral for Resident 23 on 07/10/2024 and had to send it back to the prescribing provider to update with additional information that was needed. The CC stated they did not deny Resident 23 wound care services and when they received the updated information they needed from the provider, they reached out to the RR of the resident to schedule an appointment on 07/29/2024. The CC stated the time lapse of 19 days between receiving the referral, returning it to the prescriber, and receiving it back would have depended on how quick the provider sent them the updated referral information they requested. The time lapse was not on the part of the CC. During an interview on 08/15/2024 at 1:33 PM, Staff D stated Resident 23 was seen by their Orthopedic Surgeon after they obtained the PIs, and the surgeon did not order any additional treatment interventions for treating the PIs. Staff D stated the RR wanted them to obtain a second opinion after the 06/26/2024 visit because they did not agree with the surgeon not having a better treatment plan. Staff D stated Resident 23's RRs had attended that appointment with the resident but did not provide notes pertaining to the outcome of the visit and the facility did not call the surgeon's office to request the appointment notes so were not aware the Orthopedic Surgeon had ordered the HKAFO orthosis (Staff D was informed of the orthosis during a telehealth meeting with the family on 08/13/2024). Staff D stated following that meeting, they had given the order for the orthosis to Staff A and Staff B for their review since the orthosis was costly. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had required level II referral if residents had a positive level I PASARR, for 4 of 5 residents (Residents 43, 5, 23, and 34 ) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive level I PASARR screen (that would then require a referral for a level II PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or Sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, nursing facilities will ensure residents with a positive level I PASARR screen have been evaluated by the designated state-authority through the level II PASARR process and approved for admission prior to admitting to the nursing home. <Resident 43> Review of the resident medical records showed they were admitted to the facility on [DATE] with diagnoses including multiple heart complications, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease) and Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves, causing shaking movements). The comprehensive assessment dated [DATE] showed the resident had a moderately intact cognition, was able to understand others and make their needs known. Review of Resident 43's PASARR, dated 07/09/2024 showed SMI indicators, in section 1A, were checked marked for Resident 43's diagnosis of depression and anxiety (a positive level I PASARR). No level II referral was completed and showed .No Level II evaluation indicated . During an interview on 08/08/2024 at 12:54 PM, Staff M, Social Service Director (SSD), stated their process was to have hospitals complete the level II evaluation prior to the resident being admitted , but that it had not been happening. Staff M stated that Resident 43 should have had a level II PASARR evaluation completed upon admission, due to the resident having a positive level I PASARR. <Resident 5> Review of Resident 5's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of anxiety. Review of the comprehensive assessment dated [DATE], showed the resident's cognition was intact. Review of Resident 5's physician orders showed that the resident had been prescribed Cymbalta ( a brand of medication given for depression and anxiety). Review of Resident 5's July and August 2024 Medication Administration Record (MAR), showed that the resident had been receiving Cymbalta daily as ordered. Review of Resident 5's PASARR, dated 06/25/2024 showed the SMI indicators, in section 1A, had not been checked for the residents diagnoses of anxiety. During an interview on 08/08/2024 at 11:01 AM, Staff E, Licensed Practical Nurse/Resident Care Manager, stated that the admissions director worked with the hospital to ensure that residents had their PASARR completed accurately. Staff E stated that they received the information once the resident was admitted , and that medical records scanned the information into the resident's medical record. In an interview on 08/08/2024 at 11:05 AM, Staff T, Admissions Director, stated they assisted with the PASARR when residents were being admitted to the facility. Staff T stated they contacted the hospital and worked with them to ensure an admitting resident had a PASARR. Staff T stated that they were aware of the change to PASARR process, and they had seen more level II PASARR's. Staff T stated that once a resident admitted to the facility the social services department took over the process. <Resident 23> Review of the resident's medical record showed the resident admitted to the facility 05/23/2024 with diagnoses to include depression, anxiety, and insomnia (a sleep disorder that makes it hard to fall asleep or stay asleep). The 05/26/2024 comprehensive assessment, showed the resident's cognition was severely impaired. Review of Resident 23's August 2024 MAR, showed the resident received psychotropic (any drug that affects behavior, mood, thoughts, or perception) medications as follows; Sertraline (a brand of anti-depressant medication) daily, Trazodone (a brand of anti-depressant medication also used for Insomnia) daily at bedtime, and Alprazolam (a brand of anti-anxiety medication) twice daily. Review of Resident 23's PASARR, dated 05/23/2024, showed no diagnoses for anxiety or insomnia even though the resident received medications for those SMI disorders. <Resident 34> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with a diagnosis of anxiety. Review of the 07/10/2024 comprehensive assessment, showed the resident's cognition was intact. Review of Resident 34's July 2024, and 08/01/2024 to 08/06/2024 MAR, showed the resident had an order for ativan (a brand of anti-anxiety medication) every six hours as needed for anxiety. Review of Resident 34's PASARR, dated 07/03/2024, showed no diagnosis for the SMI disorder. During an interview on 08/08/2024 at 10:00 AM, Staff M stated they, along with the admissions nurse reviewed PASARRs on admission for accuracy, required level IIs if needed to be submitted for an assessment. Staff M stated if PASARRs were not accurate they would ensure they were accurate prior to admission or if after admission, they would correct them. Reference: WAC 388-97-1915 (1)(2) 45642 44922

Based on interview and record review the facility failed to develop a baseline care plan (BCP) within 48 hours of admission that included resident specific initial goals and treatment plans, nor provide a summary of the required information from the BCP to the resident for 3 of 6 residents (Residents 7, 58, and 52) reviewed for baseline care plans. This failure placed the residents at risk for a lack of knowledge regarding the initial plan for delivery of care/services and unmet care needs. Findings included . <Resident 7> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a recent fall with a head laceration (a deep cut or tear in skin) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the resident's comprehensive assessment dated [DATE], showed Resident 7 required extensive assistance of one caregiver for activities of daily living (ADL's) and was cognitively intact. During an interview on 08/08/2024 at 10:08 AM, Resident 7 stated they were not provided a BCP within 48 hours of admission that discussed their specific goals or treatment plan while in the facility. Resident 7 stated, I wish they would have so I would have known what the plan was for getting better and being able to go home. 43280 44922 <Resident 58> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include multiple fractures from a motor vehicle accident and Chronic Obstructive Pulmonary Disease (a chronic lung disease that makes breathing difficult and causes cough, mucus and wheezing). The 07/16/2024 comprehensive assessment, showed the resident's cognition was intact. The record further showed no baseline care plan had been developed. During an interview on 08/05/2024 at 3:01 PM, Resident 58 stated they had not received a BCP summary of their initial goals, medications, dietary instructions, services/treatment that were to be administered by the facility nor the details of their BCP. During an interview on 08/08/2024 at 9:43 AM, Staff M, Social Services Director, stated they would complete their first assessment, I would assume that is our portion of the baseline care plan on the History/Discharge document for social services within day one to day seven of admission. Staff M further stated they did not give a copy of that to the resident or the Resident Representative (RR). Review of the 07/16/2024 history/discharge document showed the document had not been started until seven days after admission and not developed within the 48 hours after admission. During an interview on 08/08/2024 at 10:23 AM, Staff D, Licensed Practical Nurse (LPN)/Resident Care Manager, (RCM) stated they used the Kardex as the baseline care plan and would go over that with the resident or RR on admission. Staff D stated if the resident or RR had questions regarding their medications then they would print off their physician orders and go over the medications with them. Staff D stated they did not give the resident or RR a copy of the documents unless they asked for one. Review of Resident 58's 08/12/2024 Kardex, showed a box that was labeled Requirements of Participation: that showed no information for diet, what type of wounds and where, a summary of orders, or treatments, and a signature line for the resident or the RR to sign and acknowledge that they were offered a copy of their plan of care. Surveyor: [NAME], [NAME] P. 45642 <Resident 52> Review of the medical record showed that the resident was admitted to the facility on [DATE] with diagnosis to include heart complications, vascular dementia (Problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and anxiety . The comprehensive assessment dated [DATE] showed that Resident 52's cognition was impaired and unable to make sound decisions. In an interview on 08/06/2024 at 9:46 AM, Resident 52's RR, stated they had not reviewed the BCP with staff 48 hours after admission to the facility. In an interview on 08/09/2024 at 11:13 AM, Staff E, LPN/RCM, stated that they review the residents' plan of care during the care conferences. Additionally, that they did not discuss the BCP with the residents or provide them a copy of the care plan. Reference: WAC 388-97-1060 (3)

Based on observation, interview and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 3 of 5 residents (23, 34 and 35) reviewed for unnecessary medications. The facility failed to ensure residents had an appropriate diagnosis for use of psychotropic medications, had person-centered behaviors being monitored to reflect adequate need for the medications or implement non-pharmacological interventions to attempt prior to administering psychotropic medications. Additionally, the facility failed to complete an Abnormal Involuntary Movement Scale (AIMS, to assess for the presence and severity of abnormal movements of the face, limbs, and body) prior to beginning the psychotropic medications. These failures placed the residents at an increased risk for receiving medications they no longer needed and/or increased behaviors due to inadequate dosing of medication. Findings included . <Resident 23> Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include depression (a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease about an imminent event or something with an uncertain outcome), and insomnia (the inability to sleep). The 05/26/2024 comprehensive assessment showed the resident's cognition was severely impaired. A concurrent observation and interview on 08/09/2024 at 9:05 AM, showed Resident 23 lying in bed, hair uncombed, eating their breakfast. The resident is alert, smiling, pleasant to talk with, and answered questions as appropriate as they were able to. Review of Resident 23's August 2024 Medication Administration Record (MAR), showed an order on 08/01/2024 for alprazolam (a brand of anti-anxiety medication) 0.25 milligrams (mg, a unit of measure) by mouth two times daily for anxiety, an order on 05/23/2024 for trazodone (a brand of anti-depressant medication) 100 mg by mouth daily at bedtime for depression and insomnia, and an order on 05/24/2024 for sertraline (a brand of anti-depressant medication) 50 mg by mouth daily for depression. Further review of Resident 23's medical record showed no AIMS assessment had been completed since admission, there were no person-centered behaviors specific to Resident 23 being monitored, and the resident's sleep pattern had not been monitored to ensure effectiveness of the medications. <Resident 34> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include anxiety. Review of the 07/10/2024 comprehensive assessment, showed Resident 23's cognition was intact and received anti-anxiety medication. During an interview on 08/05/2024 at 3:46 PM, Resident 34 was sitting up in their wheelchair, talkative, alert and answered questions appropriately. Resident 34 stated they were receiving a medication for their anxiousness, but the prescription ran out and they no longer received it. Resident 34 stated the cancer would cause them anxiety and would get in my head. Review of the July 2024 MAR, showed on 07/03/2024 an order for ativan (a brand of anti-anxiety medication) 0.5 mg every six hours as needed for 14 days for their anxiety and agitation (ended on 07/17/2024). Resident 34 received the medication three times during that period. Further review of the medical record showed there was no person-centered behavior monitoring specific to Resident 34 nor were there person-centered non-pharmacological interventions attempted prior to administering the ativan. Additionally, no AIMS assessment had been completed prior to the start of a psychotropic medication. During an interview on 08/08/2024 at 10:10 AM, Staff M, Social Services Director, stated nursing and Social Services were to implement behavior monitoring and non-pharmacological interventions for residents on psychotropic medications. That the interventions were placed on the care plan and the Kardex so the nursing assistants could document on them. Staff M stated they used standard behaviors and interventions to monitor until they get familiar with the resident. Staff M further stated that if a resident had been receiving an as needed medication or had been in the facility since 05/2024 then they would have experienced some type of behavior, and their care plan should have been updated to reflect the behavior. Staff M stated they were not responsible for completing the AIMS assessments. 35676 <Resident 35> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a right hip fracture, dementia (the loss of thinking, remembering, and reasoning- to the extent that in interferes with ADL's), severe with other behavioral disturbances, disorientation, and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep). Resident 35's comprehensive assessment dated [DATE], showed they required substantial assistance of 1 to 2 caregivers for activities of daily living (ADLs), cognition was severely impaired. An observation on 08/05/2024 at 11:24 AM, showed Resident 35 in a wheelchair in the hallway. Resident 35 acknowledged staff by speaking to them, smiling and nodding their head. An observation on 08/07/2024 at 12:34 PM, showed Resident 35 had wheeled themselves into the dining room. Resident 35 was smiling and stated hello when spoken to. During an observation and concurrent interview on 08/08/2024 at 10:10 AM, showed Resident 35 being laid down in bed by Staff V, Nursing Assistant (NA). Resident 35 was smiling and compliant with care during the transfer from the wheelchair to the bed and while being provided personal care. Staff stated they had cared for Resident 35 since their admission, and they had always been compliant with all care and had never shown any agitated or aggressive behaviors. Staff V stated Resident 35 was kind and did not speak often. During an interview on 08/12/2024 at 11:46 AM, Staff W, Registered Nurse (RN), stated they had taken care of Resident 35 since their admission and had never seen them agitated or difficult to care for. Staff W stated Resident 13 was slow to respond to questions however they would answer when given time and was always very kind and easy to care for. During an interview on 08/12/2024 11:36 AM, Staff C, Registered Nurse, Resident Care Manager (RN/RCM), stated Resident 35 had not shown any type of agitated or combative behavior before. Staff C stated Resident 35 could be impulsive and attempt self-transfers but had always been a gentle, nice person who would communicate with staff appropriately when provided enough time to respond in conversations. Review of Resident 35's physician orders showed the medication Olanzapine [an antipsychotic (A type of drug used to treat symptoms of psychosis) medication used for mental disorders including Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function)] was ordered to be administered every evening beginning on 06/25/2024. Review of Resident 35's MAR for June, July and August 2024 showed, Olanzapine 5 mg tablet was administered every evening. Review of Resident 35's care plan dated 08/02/2024, showed a problem for behavior monitoring related to the use of Olanzapine. Care plan interventions were to monitor for pinching/scratching/spitting/wandering/threatening behavior/rejection of care/kicking/hitting/grabbing/biting/abuse language and sexually inappropriate behaviors. The care plan further showed if behaviors were exhibited staff were to refer to the system listed interventions and assist Resident 35 to a quiet area, offer snacks, allow them to express concerns, music in room, redirect, and toileting assistance. Review of Resident 35's June, July and August 2024 MARs showed there was no monitoring for the behaviors that were listed on the care plan related to the use of Olanzapine. Review of a provider visit note dated 07/05/2024, showed Resident 35 had diagnoses of unspecified dementia severe, unspecified dementia type, unspecified whether behavioral, psychotic, or mood disturbance or anxiety. Review of a Resident 35's pharmacy review dated July 2024, showed, Resident is receiving Olanzapine an antipsychotic, but behavioral monitoring is not present. Specific behaviors need to be added to the Physician orders. Reference WAC : 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure protection of residents from their Alleged Perpetrator (AP), after allegations of abuse/neglect were reported to the facility for 1 of 6 residents (Resident 51) reviewed for abuse/neglect. This failure placed all residents at an increased risk for unidentified abuse and/or further abuse, and unmet psychosocial care needs. Findings included . <Resident 51> Review of the resident's medical record showed the resident admitted to the facility with diagnoses of a coccyx (the bone at the end of the spinal column) fracture and heart failure. The 06/26/2024 comprehensive assessment showed the resident was cognitively intact and experienced frequent pain. During an interview on 08/05/2024 at 10:59 AM, Resident 51 made an allegation against a male staff member that worked at night. Resident 51 described the staff member as light skin colored, slightly balding head, taller than average, with a mustache/beard. Later identified as Staff F, Licensed Practical Nurse. Resident 51 stated they were afraid when Staff F worked, they would not get adequate pain management because they felt like Staff F was singling them out and judging them as if they were a junkie [a slang term for a drug addict or a fan of something] for asking for pain medication. Resident 51stated they felt they needed to lie about their pain level to get their pain medication from Staff F which made it look as if their pain was always bad. Resident 51 stated Staff F made them stick their tongue out after they received their pain medication to ensure Resident 51 swallowed the pills and then would return five to ten minutes later to ask if the pain medication was effective. Staff 51 further stated they no longer wanted Staff F providing them care. During an interview on 08/06/2024 at 4:00 PM, Staff A, Administrator, was reported Resident 51's allegation and the identified staff member. Staff A stated they would immediately start an investigation. Additionally, at 5:30 PM, Staff A stated that Staff F had been moved to another hall. Review of an undated document provided by Staff A, on 08/09/2024 at 11:36 AM, showed a partially completed investigation summary into Resident 51's allegation. The document showed a post incident action that Staff F would be removed from Resident 51's care. An observation and concurrent interview on 08/09/2024 at 2:40 PM, Staff F was observed sitting on the edge of Resident 51's bed, leaning in towards the resident to talk to the resident about their pain medications and how Resident 51 must have misunderstood Staff F's assessment of their pain medications. Staff F told Resident 51 that they needed to tell them their real pain level and then would be back to reassess their pain, because that's what they are supposed to do as a nurse. Staff S, LPN, was also present in the room with Staff F but not sitting on the bed. Both Staff F and Staff S exited the room. Then, Staff F was asked about the discussion with Resident 51, Staff F while shaking? their head to the left and right, stated Resident 51 thought Staff F had been trivializing (minimizing) their pain .and was singling [Resident 51] out. Staff F stated they sat on the resident's bed to get down on their level and tell [Resident 51] face to face. When Staff F was asked about the investigation into the allegation made against them by Resident 51, Staff F stated they could not remember what was told to them by Staff A, other than Resident 51 thought Staff F singled them out. Staff F stated in a surprised voice oh s**t, I forgot all about [Staff A] telling me that I was supposed to change rooms with somebody so there weren't any further concerns and I forgot to do that. A concurrent observation and interview on 08/09/2024 at 2:44 PM, showed Resident 51 lying in their bed, and stated [Staff F] freaked me out and sat on the edge of my bed. Resident 51 in an angry voice stated, you assured me [Staff F] wasn't coming back in here, and here [Staff F] was! Resident 51 stated Staff F began to apologize to the resident and explain to them what their job was as a nurse and that Resident 51 needed to make sure they told them the honest truth about their pain level when they brought in their pain medications. During a follow-up interview on 08/12/2024 at 11:04 AM, Resident 51 stated they felt afraid when Staff F came into their room because they did not know what to expect when they sat on their bed. Resident 51 did not understand why Staff F could not have just stood and talked to them. During an interview on 08/09/2024 at 3:18 PM, Staff B, Interim Director of Nursing Services, stated Staff A did not communicate to them that Staff F was no longer allowed to provide care to Resident 51. Staff B stated they had checked with the scheduling coordinator, and they were not aware either. Staff B stated they had removed Staff F from Resident 51's care and going forward would no longer be providing care to Resident 51. During an interview on 08/09/2024 at 4:38 PM, Staff A stated they educated Staff F on the allegation outcome earlier in the week and informed Staff F they were no longer allowed in that room. Staff A stated Staff F should not have gone in that room. Reference: WAC 388-97-0640 (6)(a)

Based on observation, interview, and record review, the facility failed to report allegations of abuse and/or neglect to the State Agency for 2 of 6 residents (Residents 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and ongoing abuse/neglect. Findings included . Review of the Code of Federal Regulations 483.12 (c)(1), F609, Reporting of Alleged Violations showed, facility's must Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and the other officials (including to the State Survey Agency . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated January 2023, showed the facility was to report all allegations of abuse to the appropriate state agency. <Resident 27> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and a bladder infection. The comprehensive assessment dated [DATE], showed the resident had a moderately intact cognition, was able to understand others, and make their needs known. During an interview on 08/06/2024 at 9:15 AM, Resident 27 stated their former roommate tried to stab me with scissors. Resident 27 stated the former roommate (Resident 30) had moved out of their room the same day the incident had taken place, and they were unsure of what staff member they informed but had told facility staff about the incident. Review of the facility incident reporting log for July and August 2024, showed no allegation of abuse had been reported regarding Resident 27 being threatened with scissors by Resident 30. During an interview on 08/07/2024 at 1:03 PM, Staff C, Registered Nurse (RN)/Resident Care Manager (RCM) stated Resident 27 had informed them that Resident 30 had been yelling at Resident 27 to turn down the volume on the TV and then threatened Resident 27 with a pair of scissors. Staff C stated they had started to fill out a grievance form on 08/02/2024 but had not completed it. Review of an uncompleted grievance form dated 08/02/2024, showed Resident 27 reported to Staff C that during the night of 08/01/2024 to 08/02/2024, (Resident 27) has been telling various staff members that (Resident 27's) roommate threatened (Resident 27) with scissors during the night. During an interview on 08/08/2024 at 10:47 AM, Staff A, Administrator, stated they were unaware of Resident 27 being threatened by Resident 30 with scissors. Staff A stated that was an allegation of abuse from Resident 27, which should have been reported. <Resident 52> Review of Resident 52's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart complications, vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), and anxiety (a feeling of worry, nervousness, or unease). The comprehensive assessment dated [DATE] showed that Resident 52's cognition was impaired and unable to make sound decisions. An observation on 08/07/2024 at 9:30 AM, showed Resident 52 wandering and exiting another resident's room (Rm 308). Resident 52 came out of room [ROOM NUMBER], walked down the 300-hall and wandered into room [ROOM NUMBER] and sat on the side a bed next to the window. In an interview on 08/07/2024 at 9:46 AM, Staff O, Nursing Assistant (NA), stated Resident 52 gets turned around (to become lost, to lose one's way) and wandered around the facility, in and out of other resident rooms. An observation on 08/07/2024 at 9:49 AM, Resident 52 was fully dressed, wander guard (bracelets that residents wear, sensors that monitor doors and that sends safety alerts in real time) to their left wrist and ambulating with a family member down the 100-hall. Resident 52 opened the exit door of the 100-hall (which had a keypad alarm) that did not alarm when the resident walked out the door. In an interview on 08/08/2024 at 10:36 AM, Staff Q, RN, stated that Resident 52 wandered through out the facility and sometimes when they tried to redirect the resident, they would get combative. Review of Resident 52's elopement (a resident who is incapable of adequately protecting themself, and who departs the health care facility unsupervised and undetected) risk assessment dated [DATE], showed the resident was a low elopement risk. The resident had not been reassessed for an elopement risk until after the second elopement incident on 08/06/2024. Review of the incident reporting log for July and August 2024, showed the resident had elopement incidents logged but were not reported to the State Agency. In an interview on 08/08/2024 at 3:15 PM, Staff B, Interim Director of Nursing Services, acknowledged that Resident 52 had an elopement on 08/06/2024 and stated they had started their investigation. In an interview on 08/12/2024 at 10:56 AM, Staff A stated they were aware of Resident 52's elopement incidents and were correlating the incidents to the resident's visits from friends and family. Additionally, Staff A stated they did not report it to the State Agency. Reference: WAC 388-97-0640 (6)(c) 45642

Based on observation, interview, and record review, the facility failed to conduct a thorough investigation into an allegation of abuse and/or neglect and prevent an elopement for 2 of 5 residents (Resident 27 and 52) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified and/or continued abuse, recurrent elopements, and unmet care needs. Findings included . Review of the facility's policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting, and Protection, dated January 2023, showed that all allegation of abuse were to be thoroughly investigated. <Resident 27> Review of the resident's medical records showed they were admitted to the facility on [DATE] with diagnoses including heart complications and a bladder infection. The comprehensive assessment dated [DATE], showed the resident had a moderately intact cognition, was able to understand others and make their needs known. During an interview on 08/06/2024 at 9:15 AM, Resident 27 stated their roommate (Resident 30) attempted to stab them with scissors during the night. Resident 27 stated they informed a facility staff member about the incident and then remembered Resident 30 being moved out of their room the same day the incident had taken place. During an interview on 08/07/2024 at 1:03 PM, Staff C, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 27 had informed them that Resident 30 had threatened them with scissors during the nighttime after yelling at them to turn down the television volume. Staff C stated Resident 27 did not have any behaviors and had never made any allegations towards other residents before but did not think that Resident 30 could have got up on their own to threaten Resident 30. Staff C had started filling out a grievance form but was waiting for Resident 27's Representative to get back to them about the possibility that they had picked up the scissors, so Staff C had not completed it yet. Review of an uncompleted grievance form dated 08/02/2024, showed Resident 27 reported to Staff C that during the night of 08/01/2024 to 08/02/2024, Resident 27 informed various staff that Resident 30 had threatened them with scissors during the night. This should also be reworded. Same exact statement in F609. During an interview on 08/08/2024 at 10:47 AM, Staff A, Administrator, stated they were unaware of Resident 27 being threatened by Resident 30 with scissors and it had not been reported to them. Staff A stated that Resident 27's statement was an allegation of abuse and should have been investigated. <Resident 52> Review of Resident 52's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include Vascular dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), anxiety (a feeling of worry, nervousness, or unease). The comprehensive assessment dated [DATE], showed Resident 52's cognition was impaired and they were unable to make sound decisions. An observation on 08/07/2024 at 9:30 AM, showed Resident 52 wandering and exiting another resident's room (Rm 308). Resident 52 came out of room [ROOM NUMBER] looking down at the floor with a frown on their face, shaking their head. The resident then walked down the 300-hall wandered into room [ROOM NUMBER] where they sat on the side of another resident's bed next to the window. An observation on 08/07/2024 at 9:49 AM, Resident 52 was fully dressed, wearing a wander guard ( bracelets that residents wear, sensors that monitor doors and that sends safety alerts in real time) to their left wrist and ambulating with a family member down the 100-hall. Resident 52 opened the exit door of the 100- hall (which had a keypad alarm) which did not alarm when the resident walked out the doorway. Review of the facility's incident reporting log for July and August 2024 showed that the resident had elopement incidents logged. Review of Resident 52's elopement risk assessment dated [DATE], showed the resident was a low elopement risk. The resident had not been reassessed for an elopement risk until after the second incident on 08/06/2024. In an interview on 08/08/2024 at 3:15 PM, Staff B, Interim Director of Nursing Services, acknowledged that Resident 52 had an elopement on 08/06/2024 and they had begun their investigation. In an interview on 08/12/2024 at 10:56 AM, Staff A stated that they were aware of Resident 52's elopement incidents and were correlating the incidents to the resident's visits from friends and family. Staff A stated they did not report the elopements to the State Agency, that they acknowledged that the risk of elopement was not on the resident's care plan timely, until after the 2nd elopement on 08/06/2024. Reference: WAC 388-97-0640 (6)(a)(b)(c) 45642

Based on observation, interview and record review, the facility failed to implement an effective pain management regime for three of five sampled residents (45, 36, and 156) reviewed for pain. This failure resulted in ongoing, unrelieved pain, causing distress, physical and psychosocial harm. The failure of the facility's lack of understanding of effective pain management, resulted in an Immediate Jeopardy (IJ) on [DATE] for residents 45, and 36. On [DATE] at 5:30 PM, the facility was notified of an IJ at CFR 483.25 (k) F697 related to the facility's failure to identify ongoing, untreated pain. The facility removed the immediacy on [DATE] with a validation date of [DATE] at 3:40 PM by re-educating staff (during or prior to their next scheduled shift) regarding effective pain identification and assessment, to ensure an effective system was in place to keep residents free from ongoing pain. Additionally, the facility completed a facility wide audit to ensure effective pain management for all other residents. The facility completed Situation, Background, Assessment, and Recommendation (SBAR) for the identified residents with pain issues and notified the provider. Findings included . Record review of the facility policy titled Pain Management, dated ,d+[DATE], showed that an initial pain plan was developed, pharmacological and non-pharmacological interventions to relieve pain were determined and the plan would be re-assessed until optimal pain relief was obtained. The policy further showed that a pain level would be assessed before and after pain interventions to monitor for effectiveness. Resident 45. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive assessment, dated [DATE], showed Resident 45's cognition was moderately impaired for orientation and recall. The assessment further showed the resident frequently experienced seven out of 10 pain, which was limiting to their day-to-day activities. Review of the facility's Pain Evaluations, completed on [DATE] and [DATE] showed the resident's satisfied level of pain was a two out of 10 on a numerical pain scale of zero to ten, with zero being no pain and ten being severe. The evaluation further showed the resident's pain was worse with physical activity and exercises, and during repositioning. During a concurrent observation and interview on [DATE], at 3:01 PM, Resident 45's lunch tray was on the bedside table with less than 50% eaten. The resident was lying in bed, moaning, and grimacing in pain. The resident also had subcutaneous (under the skin) fluids infusing. When interviewing Resident 45, their answers to questions were non-sensical. Staff Y, Nursing Assistant (NA), had just provided incontinent care to the resident and stated, that the resident was moaning because they were in a lot of pain and needed fluids. During a concurrent observation and interview on [DATE], at 2:03 PM, the resident was heard yelling out from the hallway. Staff BB, NA, entered the room and observed Staff AA, NA, providing incontinent care to the resident. Resident 45 was lying in bed and yelled out in pain with repositioning or care. Staff BB stated, the resident had pain because they had left hip surgery and had a very raw and sore bottom with open areas. Staff BB and Staff AA asked the resident several times during care if they were experiencing pain but continued providing care even though the resident yelled out responses of 12 over and over when asked about pain. The staff made no attempt to clarify what the resident meant by their repeated statement of 12. Additionally, Staff AA and Staff BB were observed turning the resident side to side, allowing the resident's legs to cross over one another with each turn, and then placed a pillow in between the resident's legs by lifting the left leg straight up in the air, above the level of the resident's head, while the resident yelled out in pain and despite the resident having hip precautions. Staff BB stated, this was their first time they worked with this resident so was not familiar with the resident. Review of the resident's in-room care plan, dated [DATE], showed the resident's weight bearing status was full weight bearing. Staff K, Physical Therapy Director (PTD) wrote in additional instructions on [DATE] for hip precautions as follows, no active abduction (the lower limb moves away from the body's midline), crossing of the legs, rotation of the hip, or extension of the leg. An additional review of the resident's [DATE] care plan, showed the resident will yell, shout and moan out due to pain and/or incontinence. During an interview on [DATE] at 2:21 PM, Staff K, PTD, stated hip precautions for a hip repair should be followed to avoid injury or pain. The precautions should include: not leaning too far forward, no crossing of the legs, no external/abduction rotation of the hips, or no sudden and fast movements. Staff K further clarified that the resident's weight bearing status had not been changed from weight bearing as tolerated. Review of Resident 45's nursing progress notes showed: *On [DATE] through [DATE], and [DATE] through [DATE] showed the resident frequently yelled out words no .help .ow .reciting numbers '12' and '20' . and wailed loudly . *On [DATE] at 9:44 PM, the resident had redness to their perineal area and buttocks that was very painful and tender to touch during incontinet care. *On [DATE] at 8:25 PM, the resident yelled out in pain whenever they soiled their brief or were provided incontinent care. *On [DATE] at 5:01 PM, the resident yelled out in pain to their left hip with no relief from routine acetaminophen (Tylenol). *On [DATE] at 8:29 PM, the resident complained of pain and pointed to their left hip. *On [DATE] at 5:01 PM, the resident complained their private area hurt. Nurse Practitioner (NP) aware of the vaginal discharge and redness. *On [DATE] at 9:38 PM, the resident was found on the floor next to their bed and complained of pain to their groin area. Review of the Physical Therapy Treatment Encounter Notes, dated [DATE], showed the resident reported severe pain, an eight out of 10 pain scale, and refused therapy. Review of the Physical Therapy Treatment Encounter Notes, dated [DATE], showed the resident experienced six out of 10 pain scale to both lower extremities and upon entering the gym, the activities were discussed, and the resident became very emotional and declined therapies. Review of the Physical Therapy Treatment Encounter Notes, dated [DATE], showed the resident was unable to reach a full stand due to unrated discomfort to both lower extremities. Review of the Physical Therapy Treatment Encounter Notes, dated [DATE], showed the resident was unable to ambulate due to an eight out of 10 pain scale to both hips. Review of the Physical Therapy Treatment Encounter Notes, dated [DATE], showed the resident had eight out of 10 pain scale determined by the face expression pain scale. Therapy attempted to motivate the resident to increase participation in therapy. The note further showed the resident's weight bearing status continued to be weight bearing as tolerated, not full weight bearing. Review of the resident's [DATE] Medication Administration Record (MAR) showed pain medication orders on [DATE] for routine Tylenol (used to treat mild to moderate pain) 1000 milligrams (mg) three times daily. There was an additional Tylenol order for 650 mg every four hours as needed for pain, that could be given in addition to the routine order. The resident received the as needed Tylenol 650 mg on a total of seven days between [DATE] and [DATE] in addition to the routine order. The [DATE] MAR also showed a [DATE] order for [MEDICATION(S)] (a pain medication) every eight hours as needed for three days: the order was used four times on [DATE] through [DATE]. The record further showed an order on [DATE] for pain assessments that were completed every shift. The record showed from [DATE] through [DATE], the resident experienced pain on 19 different shifts. Review of the record showed 15 of those 19 shifts showed no documented pain levels to monitor effectiveness of the interventions provided. During an interview on [DATE] at 2:00 PM, Staff M, Registered Nurse (RN), stated on [DATE] at 5:01 PM they called the on-call provider, due to the resident's uncontrollable pain, to obtain orders to continue the [MEDICATION(S)] that expired on [DATE]. Staff M stated the provider gave them a verbal order for [MEDICATION(S)] but they had difficulty getting the medication until a script was obtained. That did not happen during their shift which ended at 10:30 PM. Staff M further stated they did not process the verbal order received because they did not have the medication and assumed the next shift would do that. Additionally, Staff M stated they were scheduled off for the next few days so had no idea if the medication was ever received or if the order had been processed. During an additional interview on [DATE], at 4:00 PM, Staff M stated on [DATE], the resident had been yelling out in pain, pointing to their left hip, and would not take any medications. The resident was anxious and burrowing their head in their pillow. The resident was then transferred to the hospital before dinner with uncontrollable pain. Review of physician's orders for [DATE], did not show any orders for [MEDICATION(S)] or any other pain interventions after the [DATE] order had expired. During an interview on [DATE], at 10:57 AM, the Resident's Representative (RR), stated the resident resided with them prior to admission to the facility and when the resident experienced pain, the resident would roll up in bed, yell out 'ow', and not eat. The RR stated they did not know the pain medication [MEDICATION(S)] was only a three-day order and that the resident only had Tylenol to manage their pain since [DATE]th, 2022. The RR further stated that the resident had been recovering from three hip fractures, broken down skin, and was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RR was present at the resident's bedside on [DATE] and observed the resident in severe pain, not eating, not able to sleep, and yelling out ow, ow repeatedly. The RR stated the staff had been discussing possibly sending the resident out to the hospital, but the RR interrupted and told them they wanted the resident sent to the hospital. The RR additionally stated the facility told her the resident did not have 'new' fractures because the hospital could not determine the age of the fractures, but the RR stated they were specifically told by the hospital staff the fractures were new. Review of the hospital orthopedic surgeon notes, dated [DATE], showed the resident had acquired two new fractures, one to each femur (the strongest and longest bone in the body, occupying the space of the lower limb, between the hip and knee joints). During a telephone interview, on [DATE] at 10:19 AM, Staff QQ, Hospital Orthopedic Surgeon (HOS), stated the resident had acquired two new fractures, one to each femur, and there were no hardware issues from previous surgeries. During an interview on [DATE], at 3:15 PM, Staff A, Administrator (AD), stated when an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A stated they could use a satellite pharmacy (a local pharmacy that can provide the facility with medication within 4 hours) but that it is a toss-up of how long it will take them to get here. During an interview on [DATE] at 2:02 PM, Staff C, Nurse Practitioner (NP), stated they had a policy that their after-hours or weekend on-call providers could be notified of pain issues, but they would not manage or change the resident's pain regimen. The resident would need to be sent to the emergency room if the facility could not manage their pain with what they were currently ordered. We have eleven on-call providers, and none of them are comfortable managing narcotics on residents they do not see in person. Resident 36. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive assessment, dated [DATE], showed Resident 36's cognition was moderately impaired. Review of the resident's in-room care plan, dated [DATE] showed the resident's weight bearing status as full weight bearing. The care plan showed the care plan did not address communication issues or information regarding hip precautions. During a concurrent observation and interview, on [DATE] at 10:40 AM, the resident was lying in bed, complaining of pain to their left leg, and had some [CONDITION(S)] (impairment of language, speech, comprehension, and the ability to read and write). The RR arrived while interviewing the resident and stated the facility had not provided any additional remedy or attempts to help relieve the ongoing pain to the lower left leg. During a concurrent observation and interview on [DATE] at 12:20 PM, the resident had not received lunch yet, and the RR had to go and ask staff where the resident's lunch was. The resident was aphasic and became emotional that he is hard to understand, and was observed crying and in significant pain. The RR stated the resident was emotional because they couldn't explain the level of pain they were experiencing due to the [CONDITION(S)]. During a concurrent observation and interview, on [DATE] at 12:29 PM, upon entry of the resident's room Resident 36 was attempting to hit Staff V, Nursing Assistant (NA) by swinging their arms towards Staff V. Staff V stated the resident had become more combative with cares and their pain had increased in the past week. Staff V stated they attempted to change the resident's brief but couldn't due to the resident started swinging at Staff V and hitting them. During an observation on [DATE] at 11:40 AM, the resident was lying in bed, with a gown on and no covers. The left lower extremity (from the upper thigh to the foot) was noticeably larger in size compared to the right leg. During a telephone interview on [DATE], at 8:54 AM, the RR stated the resident experienced an unwitnessed fall two weeks ago and increasingly began to decline. The RR stated the facility obtained x-rays (test which produces images of structures in body, especially bones using high energy electromagnetic waves) and found nothing broken. The RR stated the resident was in excruciating pain and had increased swelling to their left leg and the staff were made aware. The RR further stated the resident would communicate their pain by the resident sliding their own hand up and down their own leg. The staff had a hard time understanding [the resident]. The RR stated the staff would assess the resident's pain while lying still in bed, but the resident experienced terrible pain when they moved the left leg during transfers, care, or repositioning, not while they were lying still. Additionally, the RR stated they voiced their concerns of the resident's pain to the resident's case manager, Staff H, Resident Case Manager (RCM), and wanted the resident sent to the hospital. The RR stated, Staff H kept attributing the pain to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lastly, the RR stated the facility had x-rays completed and ruled out a blood clot, and the provider discussed the resident possibly having a soft tissue injury with some nerve damage, but that nothing after that was done to rule that out. The RR stated they asked to have the resident sent to the hospital for further follow-up or evaluation and the NP denied that request. During a telephone interview on [DATE], at 7:08 PM, Staff O, Licensed Practical Nurse, stated they did not feel the resident had any changes after their falls that they could not contribute to their [CONDITION(S)]. Staff O also felt the resident's respiratory infection accelerated the progression of the resident's [CONDITION(S)]. Staff O stated the resident would deny pain during their verbal assessment of pain, unless the resident tried to get up, then Staff O would see pain afterwards. Staff O denied knowing the resident had swelling to their left lower extremity and stated the RR brought it to their attention the day the resident was sent out to the hospital. Most of the time the resident is covered up in bed so I didn't notice it. Staff O further stated they felt the resident's pain was from their previous surgery and my overall general impression of the resident was this was a guy that is declining, and hip fractures are one of the top killers of the elderly. Review of the facility's Pain Evaluation, dated [DATE], showed the resident frequently experienced sharp, crushing hip pain with a 4 out of 10 pain scale (using a numeric pain scale). Further review showed the resident's pain increased with physical activity/exercises and repositioning. Lastly, the resident's tolerable pain level was rated at a two out of 10-pain level. Review of the facility's SBARs, completed by the licensed nursing (LN) staff, showed on [DATE], the resident's left thigh was larger than the right, which was new. On [DATE], therapy reported to the LN staff that the resident continued to complain of left knee pain after having two falls. On [DATE], the RR was concerned about the resident's cognition, speech, and swelling. The note further showed that Resident 36 had three plus pitting [CONDITION(S)] (swelling caused due to excess fluid accumulation in the body tissues, rated from one plus [mild] to four plus [severe]) with 10 out of 10 pain level, and decreased mobility. Review of the provider's notes showed, on [DATE], the resident complained of increased left foot pain, five out of 10 pain level, while bearing weight after sustaining a fall on [DATE]. The provider ordered an x-ray, and the x-ray showed no fractures. On [DATE], the resident presented with increased peripheral [CONDITION(S)] (swelling due to fluid accumulation, usually in the lower limb) to their left leg. The note further showed the resident's speech was garbled (made unclear or confusing: distorted or mixed up) per baseline. On [DATE], the hip x-ray obtained due to the resident's complaint of pain after a fall on [DATE], was negative for fracture. On [DATE], the resident complained of migrating/changing pain to the left knee that was limiting the resident's therapy and mobility, a knee x-ray was ordered. The note further showed the resident had worsening, asymmetrical (two sides or halves that are not the same) left leg [CONDITION(S)] and discussed with the RR the possibility of a suspected soft tissue injury with nerve involvement. Review of the Physical Therapy (PT) Treatment Encounter Note dated [DATE] by Staff TT, PT, showed the resident had six out of 10 pain scale to their left hip, and the resident's left leg continued to be swollen. Staff TT reported this to the LN. Review of the PT Treatment Encounter Note, dated [DATE] by Staff UU, Physical Therapy Assistant (PTA), showed the RR reported concern to the PTA about the resident having increased [CONDITION(S)] to their left leg, I'm really worried about it. The PTA stated they would notify the RN and write it in the 24-hour nursing book. Review of the PT Treatment Encounter Note dated [DATE], by Staff UU, showed they received a report from the RN that the resident experienced a fall the evening prior and while assessing for pain to the LE's, the resident resisted moving them due to pain. The note further showed the resident was unable to sit up at the edge of the bed. The resident had a five out of 10-pain scale. Review of the PT Treatment Encounter Note dated [DATE], by Staff UU, showed the resident had sharp 10 out of 10 pain scale to their left LE that caused the resident to yell out in pain while performing minimal exercises. The note further showed Staff UU stopped the therapy session and reported the high levels of pain to the PT director, Staff K. Review of the PT Treatment Encounter Note dated [DATE] by Staff UU, showed the resident had shooting, eight out of 10 pain scale to the left knee area. The note further showed the resident stood for one to two minutes and reported shooting pain from the knee down and that the left LE continued to be very swollen. Review of the PT Treatment Encounter Note dated [DATE] by Staff TT, PT, showed the resident continued to have eight out of 10 pain scale to their left LE and swelling continued. Review of the PT Treatment Encounter Note dated [DATE] by Staff TT, showed the resident had nine out of 10 pain scale to their left LE and Staff TT discussed with the RR their concern about the resident's out-toeing (when the feet point outward while walking or running). Review of the PT Treatment Encounter Note dated [DATE], by Staff TT, showed the resident had increased physical limitations with loss of balance and rigidity during sitting down and not being able to follow commands with weight shifting. Review of the PT Treatment Encounter Note dated [DATE] by Staff UU, PTA, showed the RR reported to Staff UU that the resident was having increased hallucinations, could not stand up well, and continued with pain to their left LE. The PTA noted the resident appeared to be having increased [CONDITION(S)] symptoms. The note further showed the RR had talked with the RCM about the resident being sent to the hospital. The note showed no pain level. Review of the PT Treatment Encounter Note dated [DATE] by Staff UU, showed the resident had five out of 10 pain scale and groaned in pain with movement of their left LE. The note further showed the resident was presenting very lethargic and appeared to have a change in their condition. Review of the PT Treatment Encounter Note dated [DATE], by Staff UU, showed Staff UU found the resident kneeling on their bedside mat next to their bed and both upper extremities were on the bed. Staff UU reported the finding to the nursing staff. The note further showed the resident was very confused and therapy was unable to continue PT due to the fall. Review of the Occupational Therapy Treatment Encounter Note, dated [DATE] by Staff EE, Occupational Therapy Assistant (OTA), showed the resident did not experience pain unless the resident had movement to the left LE. During an interview on [DATE], at 9:58 AM, Staff EE, OTA, stated the resident had been progressing well with therapy until they started to decline a few weeks ago after Staff EE was told the resident had sustained a fall. The resident began to hallucinate and frequently self-transferred. During that same time the resident started experiencing problems with their left leg that had become swollen, very painful, and had trouble moving it. Staff EE stated they started doing therapy that did not require working with the left LE and mainly focused on the upper extremities. Staff EE further stated that the resident began to not eat as much and would mumble and speak slowly, which was different than the fast talking, funny resident Staff EE knew before. Staff EE further stated that the RR voiced their frustration about the resident's decline, and how they wanted the resident to be evaluated by the doctor, but the staff didn't listen. During an interview on [DATE], at 10:00 AM, Staff UU, PTA, stated the resident had progressed well, then declined when the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff UU stated the resident then began to have falls off and on, increased confusion, decreased mobility, and then started having swelling in their left leg. Staff UU stated the pain in the left leg increased and the resident could not tolerate any touching of the left leg and would yell out in pain. Staff UU stated they informed Staff K, PTD, who assessed the resident's left leg. Staff UU stated the resident had pain when Staff K would move the leg, but once it got moving, the pain would decrease, but the resident would still have pain and swelling, and that would cause concern to the RR. Staff UU further stated they had not talked to nursing about pre-medicating the resident prior to therapy but they had a difficult time determining when to do therapy due to the resident became resistant to therapy with both legs. Lastly, Staff UU stated on [DATE] the resident had self-transferred to the floor mat next to their bed, and they observed increased swelling to the left lower extremity, increased from when Staff UU had previously seen it, and they also noticed the resident had decreased mobility. They notified Staff L, RN of the fall. Review of the resident's [DATE] MAR, showed Resident 36 had an order on [DATE] for pain assessments to be completed each shift. The resident was shown to have experienced pain during one shift out of 70 shifts, on [DATE]. The record further showed an order on [DATE] for [MEDICATION(S)] 50mg every 6 hours as needed for mild pain that was administered five times between [DATE] and [DATE]. The [MEDICATION(S)] order was decreased due to decreased alertness on [DATE] to 25mg every 6 hours as needed for sever pain greater than ,d+[DATE] pain level not controlled with Tylenol or muscle spasm medication. This order was used once on [DATE] for a pain level of ,d+[DATE]. Additionally, an antianxiety medication was also decreased. Further review of the record showed an order on [DATE] for [MEDICATION(S)] (a medication used for muscle spasms) 5mg every 8 hours as needed for muscle spasms for 14 days. This was given five times between [DATE] and [DATE]. There was also an order on [DATE] for Tylenol 1000 mg three times daily. There were no post pain interventions for effectiveness documented on the MAR for any of the pain medications given or non-pharmacological interventions tried prior to administration of pain medications. Review of the resident's nursing progress note entered as a late entry note on [DATE] at 12:22 PM, showed the RR approached Staff H, RCM, and demanded there was something wrong with the resident and wanted the resident to be seen by a doctor. The resident had had a change in condition. The note further showed that Staff H reiterated to the RR that the resident could be sent to the emergency room if the resident wanted to but the resident had negative x-rays and was negative for a blood clot to the resident's left hip and knee. Staff RR stated the resident had an appointment scheduled with their [CONDITION(S)] provider. Staff H further noted that the resident denied pain, but the RR insisted the resident was in pain. Staff H then further discussed the disease process of [CONDITION(S)] and that the resident's hallucinations and falls were a part of the disease process. During an interview on [DATE], at 3:58 PM, Staff BBB, NA, stated the resident started experiencing pain and swelling in their left leg after experiencing a fall. Staff BBB could not recall which fall and further stated the resident would experience pain during a transfer, but once sitting, the pain would decrease. Staff BBB stated the RR did voice their concerns to them regarding the resident's pain. During an interview on [DATE], at 4:08 PM, Staff BB, NA, stated the resident verbalized pain to their left leg during repositioning and provision of care. Staff BB stated they would report the pain to the nurses. Staff BB stated the resident's pain would increase if they were up for long periods of time in their wheelchair. Staff BB stated they were not aware the resident had sustained any falls, but did notice swelling to their left leg that improved with therapy. Review of the resident's nursing progress notes dated [DATE] at 9:59 PM, showed the resident was sent to the hospital due to the resident having creamy, mocha colored urine, and increased confusion. Review of the hospital admission notes, dated [DATE], showed the resident had suffered a new left hip fracture, a bladder infection, and [CONDITION(S)] (an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). Further review of the notes, showed the resident's left leg was swollen from the hip down, was externally rotated, slightly shortened, and the resident did withdraw to pain. Additionally, the resident's abdomen was distended up to their naval and when the urinary catheter was placed, the resident had four liters of urine drained. During an interview on [DATE] at 12:24 PM, requested by Staff A, AD, in the presence of Staff B, Director of Nursing (DNS), and Staff GG, Regional Corporate Consultant (RCC), Staff A stated that Resident 36 did not have a new fracture due to the hospital notes showing a bridged and calloused (a part of the body having an area of hardened skin) formation, meaning that fracture didn't recently happen because the area had already calloused over. During a telephone interview, on [DATE] at 10:19 AM, Staff QQ, Hospital Orthopedic Surgeon (HOS), stated the resident had acquired a new hip fracture, distal (situated away from the center of the body or from the point of attachment) from the previous fracture that had some callous formation. Staff QQ stated the fracture had to have occurred sometime between discharging from the hospital on [DATE] to admitting back into the hospital on [DATE] . if the fracture was present prior to the [DATE] hospital stay, it would have been seen on the images obtained on my initial assessment of the previous fracture. Resident 156. Record review showed they were admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's comprehensive assessment, dated [DATE], showed they had moderate impairment with thinking, reasoning and/or remembering. Record review of physician's orders showed Tylenol was ordered on [DATE] to be administered as needed for pain every four hours. In addition, on [DATE] [MEDICATION(S)] (narcotic pain medication) was ordered every two hours as needed for air hunger. Review of the Physical Therapy (PT) Treatment Encounter Notes, dated [DATE] by Staff K, PT/Rehab Director, showed the resident had 5 out of 10 pain (using a pain scale of 0 to 10 with zero being no pain and ten being severe pain) to top of right foot, sharp pain with increased weight bearing and it limited their activities. Review of the Physical Therapy (PT) Treatment Encounter Notes, documented by Staff CC, PT Assistant dated [DATE], showed the resident's back pain was four out of 10 on the above designated pain scale. That statement was written in the 24 hour report by Staff CC on [DATE]. Review of the PT Treatment Encounter Notes, dated [DATE] by Staff DD, PT, showed the resident reported they had right leg pain during range of motion exercises measuring five out of 10 on the pain scale. Review of the Occupational Therapy Treatment Encounter Notes, dated [DATE] by Staff EE, showed the resident had sharp pain in both heels measuring six out of 10 on the pain scale, which limited their functional activities. Review of the Physical Therapy (PT) Treatment Encounter Notes, dated [DATE] by Staff CC, showed the resident reported occasional right leg and heel tende[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of four residents (35, 45) reviewed for quality of care. This failure placed both residents at risk for adverse consequences, medical complications, and resulted in physical and psychosocial harm to Resident 35 who experienced an avoidable hospitalization due to dehydration and acute kidney failure (an abrupt reduction in the kidneys' ability to filter waste products, which occurs within a few hours or a few days). Findings included . Resident 35. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Modified Admission Minimum Data Set (MDS), an assessment tool, dated 03/19/2022 documented Resident 35 was cognitively intact and had minimal depression, and required two-person extensive assistance from staff for bed mobility, transfers, and toileting. The care plan, dated 03/17/2022, did not identify the resident was at risk for rehospitalization or dehydration. During an interview on 04/20/2022 at 10:35 AM, Resident 35 stated they had a hospitalization for dehydration during their stay. Resident 35 said the provider told them that their kidneys were almost not functioning. The resident said the hospital administered intravenous fluids and antiemetics (a medication to prevent nausea and vomiting) during their two days in the hospital. Resident 35 said they did not recall getting any labs or intravenous fluids at the facility prior to hospitalization . During an interview on 04/25/2022 at 10:50 AM, Resident 35 stated they were sick for about two days prior to going to the hospital. The resident said the staff gave them a pill every so often, but it did not really work. The resident was not offered broth or jello, but it would not have made a difference because they were not able to keep anything down. Staff did not check on the resident except to deliver meals that they were not able to eat. Resident 35 said they requested to go to the hospital, was so weak, and knew they needed to get to the hospital to get fluids. The resident said staff did not ask or talk to them about getting labs drawn or having intravenous fluids at the facility. Resident 35 did not know what else to do. Review of Resident 35's April 2022 MAR revealed the resident was given [MEDICATION(S)] (an antiemetic) at 12:05 PM on 04/08/2022 with effective results documented. [MEDICATION(S)] was documented as given again at 1:42 PM on 04/09/2022 with effective results. On 04/09/2022 at 5:19 PM a Progress note documented: Resident (complained of) nausea and vomiting (two times) today. PRN (as needed) [MEDICATION(S)] administered. At 5:56 PM the [MEDICATION(S)] was documented as effective. On 04/09/2022 at 8:22 PM an SBAR Progress Note documented: Resident is recently COVID recovered and (complained of) chills and (nausea/vomiting three times) on evening shift. No diarrhea. (As needed) [MEDICATION(S)] administered. Ineffective . just (for your information) in case follow up is needed. On 04/10/2022 at 12:52 PM a progress note documented: (patient complained of) nausea and emesis at beginning of shift. Stated [Resident 35] is unable to tolerate any (oral intake) since yesterday including medications. Pt. (patient) shivering even with heavy clothing and blankets on. [Resident 35] . wants to go to ER(emergency room ). Vitals taken, BP (blood pressure) elevated 184/73, pulse 73/ BPM (beats per minute), Temperature 96.6, SP02(oxygen level) 96% RA(room air.) RN called . for pt. to be transported to [hospital]. Resident 35's Fluid Intake on the Nutrition Task Documented: On 04/03/2022 intake was 960 milliliters (mls), on 04/04/2022 intake was 360 mls, on 04/05/2022 intake was 720 mls, on 04/06/2022 intake was 480 mls, on 04/07/2022 intake was 420 mls, on 04/08/2022 intake was 840 mls, and on 04/09/2022 intake was 660 mls. (adequate daily fluid intake ranges from 2.7 to 3.7 liters-=2700 to 3700 milliliters). Hospital History and Physical dated 04/10/2022 documented Resident 35 was admitted for Acute Chronic Kidney Injury, nausea and vomiting, and dehydration. The hospital's Assessment and Plan documented: Acute Kidney Injury over CKD stage IV. Likely prerenal due to dehydration due to GI (the passage way of the digestive system) loss due to vomiting Resident 35 was given Intravenous Fluids, antiemetics, and their diuretics (a medication used to reduce extra fluid in the body) were held. Hospital Discharge Summary, dated 04/12/2022, documented: Resident 35 admitted on ,d+[DATE] with a chief complaint of intractable (hard to control) nausea and vomiting x 2 days-admitted for acute on chronic kidney disease stage IV. [The resident]was admitted to hospital because of acute on chronic renal failure. More likely secondary to volume depletion. There was no documentation in Resident 35's medical record that a provider was contacted regarding the resident's status, to request diagnostic labs for the resident, or whether diuretics should have been held and/or intravenous fluids offered to the resident. During an interview on 04/27/2022 at 1:45 PM, Staff LL, Registered Nurse (RN), stated that when residents experience nausea or vomiting they would administer whatever PRN (as needed) medications the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff LL said they did not routinely review residents' fluid intake unless they were on a fluid restriction. If the residents were not taking in enough fluid, Staff LL would encourage them to drink more and offer popsicles or soups. Staff LL said if they noticed a change in the resident, they would notify the provider. Staff LL said Resident 35 requested to go to the ER and they thought that was a good idea. Staff LL was not aware if labs were ordered for this resident, but the facility had the ability to do labs and initiate intravenous fluids. During an interview on 04/27/2022 at 1:55 PM, Staff F, Resident Care Manager, stated if a resident was experiencing nausea and vomiting, they would expect staff to administer antinausea medication, if it was prolonged, they would expect them to obtain labs to monitor electrolytes. They felt that prolonged would be a couple of days, maybe three, unless the resident was projectile vomiting. Staff F said they do not monitor fluid intake on residents unless they are on a fluid restriction. Staff rely on monitoring if their (the residents) mouth was dry, or skin turgor was poor. Staff F was not aware of any way the staff could determine how much fluid the resident took in. Staff F said if the resident was not able to keep anything down for 48 hours, they would expect staff to assess, encourage fluids, and if still not effective, probably have a provider assess and go by what their determination was. During an interview, on 04/28/2022 at 3:25 PM, Staff B, Director of Nursing Services (DNS), stated they would expect the nursing staff to assess the hydration status of a resident experiencing nausea and vomiting. Staff B said they should be trying to find the cause, encourage fluids, and decrease the risk of dehydration. Staff B would expect to see this documented in the progress notes, and expect the nurses to review the resident fluid intake, and to notify the provider. Staff B would expect staff to call the on-call provider if it was a weekend. Staff B said they could obtain labs and administer intravenous fluids to the residents. Resident 45. Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive assessment, dated 04/10/2022, showed Resident 45's cognition was moderately impaired for orientation and recall. The assessment further showed the resident was incontinent of urine, and frequently incontinent of bowels, required surgical wound care, and no other skin issues. Additionally, the resident required two staff assistance for bed mobility, transferring, dressing, toilet use, and one person staff assistance for personal hygiene. Review of the resident's re-admission skin assessment, dated 04/07/2022, showed skin issues of a surgical incision to the right hip. Review of the resident's care plan, dated 03/18/2022 showed Resident 45 had a surgical wound on their right hip related to left surgical wound, surgery wound to left leg, diabetes (A metabolic disorder in which the body has high sugar levels for prolonged periods of time), anticoagulant (a medication that prevents blood clots) use, bowel and bladder incontinence, and impaired mobility. Review of the resident's March 2022 Treatment Administration Record (TAR), showed weekly skin assessments on 03/23/2022 with no documentation, and 03/30/2022 that displayed a check mark, and no plus or minus documented. Review of the April 2022 TAR, showed an order on 04/07/2022 for Dermaseptine (a skin protectant which provides a barrier to prevent irritation from moisture and promote healing) twice daily to be applied to the resident's bottom. The order showed no indication for use. On 04/08/2022 an order that showed [MEDICATION(S)] powder (used to treat fungal infections) was to be applied twice daily to the perineum (the area between the genitals and the tailbone) for skin rash. The record further showed weekly skin assessments for 4/16/2022, no plus or minus documented, and no other skin assessments. Review of the resident's nursing progress notes showed; on 04/09/2022 the resident had loose stools, and their bottom and perineum had bleeding and excoriation (a raw, irritated, wearing off of the skin). On 04/10/2022 at 4:40 PM the resident continued to have loose stools multiple times per day. The nurse sent an Situation, Background, Assessment, Recommendation (SBAR) to the provider. On 04/12/2022 the resident had extreme redness and skin breakdown to their buttocks and perineum. On 04/13/2022 at 9:44 PM, the resident had redness to their perineum area and buttocks that was very painful and tender to touch during incontinent care. On 04/15/2022 at 8:20 PM the resident continued to have multiple loose stools. On 04/17/2022, the resident continued to have loose stools with each bowel movement. Review of Resident 45's bowel records, dated 03/18/2022 through 04/20/2022 showed the resident experienced 30 episodes of diarrhea (loose stools). Review of the resident's March 2022 Medication Administration Record (MAR), showed three orders on 03/18/2022 for Loperamide (a medication used to treat diarrhea) (1) four milligrams (mg), as needed every six hours up to a maximum of eight capsules, (2) two mg as needed every six hours up to a maximum of eight capsules, and (3) two mg after each loose stool up to a maximum of eight capsules/day. The medication was used twice on 03/19/2022 and 03/27/2022. All three orders were discontinued on 03/28/2022. Review of the April 2022 MAR, showed an order on 04/11/2022 for Loperamide every six hours as needed, may give two tablets for first loose stool, for a maximum of six tablets in 24 hours. This medication was given once, on 04/15/2022. A total of three doses of the Loperamide were administered for 30 episodes of loose stools. During an interview on 04/22/2022 at 11:04 AM, Staff Z, RN, stated when a new skin issue was found, they notified the RCM, the RCM then completed their own skin assessment, and determined if the skin issue needed to be evaluated by the wound provider who came to the facility every Tuesday. The provider was then notified by the SBAR and the RCM added the resident to the provider's list. During an interview on 04/28/2022, at 11:11 AM, Staff AA, Nursing Assistant (NA), stated the resident would have loose stools frequently. Staff AA would report the loose stools to the nurses, but the nurses already knew about the diarrhea and had medication for that. During an interview on 05/02/2022 at 12:40 PM, Staff FFF, NA, stated when a resident had loose stools, they would report it to the nurse and after three loose stools they would give them medication. Staff FFF further stated they reported loose stools throughout the shift and not just when they first happen. During an interview on 05/02/2022, at 2:49 PM, Staff F, RN, stated they initiated the Dermaseptine cream as a precaution due to the resident having incontinence, and could not recall why the resident was using the [MEDICATION(S)] even though they obtained the order. Staff F further stated they did not initiate alert charting because the licensed nurses monitored effectiveness of the ointment during treatments. When the nurses assessed the area they should document their findings in their daily medicare notes. Staff F further stated when a treatment was not effective, the nurses were to complete an SBAR to the provider and make the appropriate changes. During an interview on 05/03/2022 at 9:48 AM, Staff N, RN, stated there was no alert charting started to monitor for adverse side effects (ASE) for the new medications Dermaseptine and [MEDICATION(S)] powder. Staff N stated they didn't know they needed to monitor for ASE. Staff N further stated they felt they documented on the MAR each time they would give the Loperamide for loose stools. Review of the nursing SBAR notes showed: on 04/12/2022 the resident cried out due to redness and skin breakdown to buttocks and perineum area, appears as if it is macerated (soften or become softened by soaking in a liquid), and tender to touch The note recommended the provider assess the area as it looked very angry. On 04/13/2022 the resident had redness to their perineum and buttock with serosanguinous (type of wound drainage, or exudate, secreted by an open wound in response to tissue damage) drainage, causing severe pain. On 04/17/2022, the resident had chronic loose stools since admission despite the order for the as needed Loperamide. The stool culture on 03/19/2022 was negative for infection. On 04/16/2022, the resident continued to have loose stools, causing further skin irritation. The resident yells out in pain with each incontinent episode and during incontinent care. Notes on 04/12/2022 and 04/13/2022 showed documentation by nursing that the resident was added to the wound provider's (Staff PPP, Wound Provider) list for the next visit on 04/19/2022. Review of response to the nurses SBAR notes showed: - On 04/12/2022, Staff C, Nurse Practitioner (NP), may continue as needed Loperamide and notify them for stool frequency greater than three times daily. - On 04/13/2022, a Medical Assistant (MA) from Staff PPP's office documented the resident was to be seen by Staff PPP for skin breakdown to buttock and extreme redness to the perineum area. - On 04/14/2022, Staff C ordered an oral medication used to treat vaginal yeast infections. - On 04/18/2022, Staff C ordered an oral antibiotic that was used to treat a wide variety of infections, and to continue the yeast medication and continue incontinent care. Review of the notes showed no changes to the topical skin treatment the resident had received. Review of Staff PPP, WP, notes, on 04/19/2022, showed the resident had skin breakdown to thier buttocks that measured 2.1 centimeters long, by 0.7 centimeters wide, by 0.1centimeters in depth. Staff PPP debrided (A procedure to remove debris or infected/dead tissue from a wound) the wound and noted the wound to be a partial thickness ulcer. The note further showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 45's record, showed the resident was sent to the hospital on 04/20/2022 for uncontrollable pain. Review of the hospital records on 04/21/2022, showed the resident had excoriation, denudement (the skin is gone due to chemical means [urine, feces, sweat]) and moisture damage to both the buttocks, a rash to both labia's ( the fleshy folds that surround the opening of the vagina), and a pressure injury to the coccyx. During an interview on 05/03/2022 at 10:06 AM, Staff B, DNS, stated the facility did not have a charting policy. Staff B further stated they did not monitor all new medications for side effects, it just depended on the medication and the nature of the medication. Staff B further stated they were not aware that Dermaseptine was a medication or that they should have treated it as a new medication. Additionally, Staff B stated they would have expected the nurses to administer the Loperamide to the resident to control their loose stools. Reference WAC: 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice for two of five residents (156, 35) reviewed for pressure injuries. The facility failed to perform skin assessments as ordered and failed to identify new or worsened skin impairments for Resident's 156 and 35, resulting in harm. Findings included . Record review of the facility policy and procedure titled, Skin at Risk/Skin Breakdown, revised on September 2020, showed a full body skin evaluation was to be completed weekly by the Licensed Nurse (LN). Completion of the skin audit was documented as no shows no new skin impairment, and yes shows new skin impairment. The LN monitors bruises, skin tears and abrasions on the resident's Treatment Administration Record (TAR). All other non-pressure skin concerns are documented on the Skin - Wound form. Resident 156. Review of the resident's medical record showed they were admitted to the facility from the hospital on 04/07/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the resident's initial skin assessment, performed on 04/07/2022, showed they had scattered bruises to both lower legs. Record review of the resident's plan of care, dated 04/07/2022, showed they had actual/potential skin impairments related to reduced mobility, diabetes, and medications. Record review of physician's orders showed Dermaseptine (a skin protectant which provides a barrier to prevent irritation from moisture and promote healing) was ordered on 04/07/2020 to be applied to both buttocks and coccyx (tailbone) every shift after pericare for skin redness. It was discontinued on 04/19/2022 due to observation of worsening skin problems. Record review of the resident's April 2022 TAR, showed between 04/07/2022 through 04/19/2022 there were omissions in documentation for six of the 35 shifts regarding the application of Dermaseptine. Record review of the Occupational Therapy Treatment Encounter Notes, dated 04/15/2022 by Staff EE, showed the resident had sharp pain in both heels measuring six out of 10 on the pain scale, which limited their functional activities. Record review of the Physical Therapy (PT) Treatment Encounter Notes, dated 04/18/2022 by Staff CC, showed the resident reported occasional right leg and heel tenderness. The statement of pain voiced by the resident was written in the 24 hour report by Staff CC, PT Assistant, on 04/18/2022. During an interview on 04/27/22 at 9:55 AM with Staff K, Physical Therapy Director (PTD), stated they worked with the resident from 04/08/2022 through 04/22/2022 with the resident refusing PT sessions between 04/19/2022 through 04/22/2022. The resident had a sudden change of condition with activities of daily living during their time in the facility. Staff K stated on 04/28/2022 at 2:10 PM that the rehab staff used a 24 hour report form on a daily basis to address issues they encountered during their therapy sessions. At the end of the day the form was given to the Administrator, Director of Nursing, Resident Care Managers (RCM) and Social Services as a communcation tool. On 04/19/2022 at 11:00 AM Staff HH, Nursing Assistant, was observed changing the resident's disposable brief. The area around the coccyx was deep red in color and there were areas measuring approximately seven inches of redness to both buttocks. As Staff HH turned the resident toward them the skin over the coccyx area split causing a small opening in the skin. The top layer of skin was peeled off above the coccyx area. The resident's left heel had a deep purple area, and the right heel and under the right foot had deep bluish areas. On the back of the left lower leg there was a small scabbed area. Staff L, Registered Nurse, was also in the room at the time of the observations. Record review of a facility investigation report, dated 04/19/2022 at 12:06 PM, documented by Staff L, Registered Nurse (RN), showed the resident was on comfort care, end of life care. An excoriation (shallow wound that occurs when skin was rubbed or torn off) to the sacrum (forms the posterior pelvic wall, strengthens and stabilizes the pelvis) measured 8 by 8 centimeters (cms), bruising to the left heel measuring 3.5 cms, and a scrape to the back of the left leg measuring 6 cms. The resident had a recent decline in condition with weakness and incontinency. They had purple intact skin to the buttocks and skin discoloration to both heels due to unavoidable end of life skin care changes. Record review of the weekly skin checks on the resident's TAR for April 2022, showed staff was to document using a - sign if no new skin impairments and a + sign if a new skin impairment was present; which was not the information stated in the facility policy. On 04/12/2022 Staff L documented a no on the weekly skin assessment. On 04/19/2022 Staff L initially documented a no, but later that same day documented a yes. During a telephone interview on 04/27/2022 at 3:40 PM between Staff L, Staff A, Administrator, Staff B, Director of Nursing Services (DNS), and the surveyor, Staff L stated they had performed a skin assessment on 04/12/2022 and there were no new skin impairments. Staff L stated, despite documenting a no initially on 04/19/2022, she had not performed any skin assessment at that time. Following the surveyors observations at 11:00 AM on 04/19/2022 of multiple skin issues, Staff L then documented a yes on the weekly skin check. With the exception of the admission assessment on 04/07/2022, and prior to 04/19/2022 with the observed multiple skin issues, and documentation by therapy staff on 04/15, 18/2022 of heel pain/tenderness, staff had not performed a thorough assessment of the resident's skin to determine the effectiveness of the treatment order, changes in skin condition and plan of care. Resident 35. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Modified Admission Minimum Data Set (MDS), an assessment tool, dated 03/19/2022 showed the resident was cognitively intact and had minimal depression, and required two-person extensive assistance from staff for bed mobility, transfers, and toileting. The care plan, dated 03/17/2022, documented the resident was at risk for impaired skin integrity. On 04/04/2022 a progress note documented: Two open/partially scabbed-over areas noted to buttocks. One on the left upper buttock and one in the intergluteal cleft. On 04/05/2022 a progress note documented: [Staff PPP, Wound Provider], assessed area on 4/5/22. New orders for Dermaseptine three times daily. He will not follow wounds at this time. A 04/06/2022 physician's order documented: Dermaseptine apply to bilateral buttocks every shift after(perineal) care to prevent skin breakdown. On 04/10/2022 a progress note documented: Resident 35 was admitted to the hospital. On 04/12/2022 a progress note documented: Resident was readmitted to the facility. An undated skin care report care admission assessment (later identified by Staff F, RCM, as being completed on 04/12/2022) documented MASD (moisture associated skin damage) and a circle on buttocks of resident back diagram. During an interview on 04/19/2022 at 10:01 AM, Resident 35 said they tested positive for COVID, two days after admission, and got a bed sore on their buttocks due to sitting in wet briefs for too long while they were in quarantine. In an interview on 04/20/2022 at 10:30 AM, Resident 35 said they had a bed sore that happened during their quarantine time. When they went to the hospital on 04/10/2022 there was a dressing on it and they were not sure if the wound was draining, but it was very painful, and the hospital placed another dressing on it. Resident 35 said facility staff do not look at the wound. On 04/21/2022, the Treatment Administration Record (TAR) showed: Weekly Skin Checks every day shift every (Thursday) for skin checks Document: (-) No new Skin impairment. (+) New Skin impairment present. Follow Skin at Risk policy. The TAR documented (-) on 04/21/2022 indicating the LN performed a skin assessment and did not identify any new skin issues. During an interview on 04/21/2022 at 2:57 PM, Resident 35 said the nurse did not look at their skin or ask about their buttock wound today. On 04/22/2022 at 6:38 AM a Health Status Note showed: Noted skin blister to the right heel area .Covered the dressing to prevent the leakage of fluids. Covered with heel foam dressing and applied bandage to protect the area. During an interview on 04/22/2022 at 10:48 AM, Resident 35 became tearful while speaking. I hope I don't get emotional, but I feel like I will. Everyone knows I am a severe diabetic; I have a history of foot infections that can get into the blood stream. Resident 35 said they woke up that morning and there was a blister on the back of their heel. Resident 35 noticed the area was painful yesterday but was unaware of the blister. The resident reported it to the staff that morning and they wrapped it with gauze. Staff told the resident the provider was not going to be in that day. Resident 35 said their buttock wound was nearly healed now, she had been applying the cream from a tube that was left for them in their room. All of a sudden a tube of cream appeared and so I thought they wanted me to put it on, so I have been. Resident 35 reported they could not see the wound but felt it was getting better because it did not hurt as much. Resident 35 said staff do not look at their skin regularly. The resident reported staff had not looked at their bottom since they returned from the hospital. On 04/22/2022 at 11:02 AM Staff F, RN/RCM, said resident skin was monitored weekly, the nurses went into the resident room with a ruler and visually inspected the arms, legs, and buttocks. Staff F stated if a new issue were identified the nurse would complete a progress note, implement a standing order if appropriate, notify the RCM, print the new order up for the provider to sign. Staff F also said that for new skin issues an incident report would be completed and reviewed by the RCM and DNS. Staff F said that existing skin issues were monitored by the TAR with a treatment. Staff F said they were aware of the heel wound identified that morning, had assessed it and would be doing an incident report. Staff F notified the provider but was not sure when they would be in the building. Staff F acknowledged Resident 35 had a lot of anxiety regarding the new heel wound. On 04/22/2022 at 11:18 AM, Resident 35 made their own appointment with their Podiatrist. On 04/22/2022 at 2:36 PM, Resident 35 returned from the podiatry visit and said the podiatrist told them it was a good thing they got there when they did. The podiatrist removed a bunch of skin from the resident's heel, and the podiatrist was recommending a boot to keep pressure off of the heel and was starting the resident on an antibiotic. On 04/25/2022 at 10:17 AM Staff LL, RN, performed wound care to the resident's right heel. The area encompassed the medial (mid body) and posterior (back) area of the heel. The wound bed was red with darkened areas. There was no drainage or odor noted. Staff LL applied Vaseline gauze, a nonstick pad, an absorbent pad and wrapped it with gauze. On 04/25/2022 at 10:22 AM, Resident 35 said their heel wound now made it difficult for them to transfer as it was the foot they used to pivot on. Resident 35 said it was painful, it feels like I stuck my foot in a fire. The resident felt the wound had worsened since Friday and said staff did not change wound dressing on Sunday. Resident 35 said the staff did not provide any interventions regarding offloading of their heels prior to the development of the heel wound. The resident said they did help put pillows behind their back when they first got the wound to their buttocks. Resident 35 said again that staff had not assessed their skin or asked any questions regarding their skin. On 04/26/2022, a Facility Provider Visit note showed: (Right) heel Diabetic Foot Ulcer noted measuring 3.6 x 4.6 x 0.1 centimeters. Granulation tissue noted across the majority of the base with a small, unstageable area of dark necrotic (dead) tissue noted centrally measuring less than half a centimeter. Rolled edges noted in periphery. No active drainage or purulent (consisting of, containing, or discharging pus) discharge noted. No surrounding macerated (softened from liquid/wet substance) tissue. Surrounding [CONDITION(S)] (redness of the skin) is noted. The area is tender to palpation (the process of using one's hand to check the body). Some surrounding dried, necrotic skin from blister is noted as well. On 04/25/2022 at 4:10 PM, observation of Resident 35's wound located on theirr coccyx (tailbone): area was reddened with raised flaking skin to the center. Resident said the area was still sore, describing it as a burning pain when they put the cream on it, usually two to three times daily. Resident 35 said facility staff had not looked at it or asked about the area stating, No, they have forgotten about it. During an interview on 04/27/2022 at 9:05 AM, Staff LL said they did weekly skin checks on residents, usually on their shower day. The Nursing Assistant (NA) would report if something was noticed during the shower. Staff LL said when a new skin issue was identified they completed an SBAR that went to the physician, implemented a treatment, and entered a progress or wound note. Staff LL said the only monitoring of existing skin issues was through the treatment that was being ordered via the TAR; the Facility MD completed weekly wound documentation on existing issues. Staff LL said the only skin issue for Resident 35, that they were aware of, was the right heel. Staff LL was not aware of an issue on the resident's coccyx (tailbone). Staff LL said they were unable to perform the skin assessment on 04/21/2022 due to the resident not being in their room on two attempts. Staff LL said they should have not documented there were no issues and should have told the oncoming shift or completed it the following day. Staff LL did not visually inspect the resident or their heel. Staff LL said they were aware the resident had an area to their bottom upon readmission but thought the dermaseptine was more prophylactic (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff LL was not aware if the resident was applying it themself. On 04/27/2022 at 9:31 AM, Staff F, RN/RCM, stated they did not know why the prescribed ointment/cream was initiated on 04/06/2022, but the resident was incontinent and would sit in their chair most of the day. When asked if they had ever visually assessed the resident's tailbone area, Staff F said, I know the facility MD was following her. During an interview on 04/27/2022 at 9:58 AM, Staff B, DNS, stated skin assessments were completed every week for residents, new issues were identified, an incident report would be initiated, the family, MD and RCMs were notified. Treatments were then started, and the facility had a wound MD who rounded weekly on Tuesdays. On 04/27/2022 at 4:47PM, Staff B said they spoke with the facility wound MD and they reported that On 04/05/2022 when he visited the resident, (Resident 35) was sitting in (their) chair, and didn't want to get up; (The wound MD) felt there wasn't anything relevant that would need something more than Dermaseptine. Review of the electronic medical record showed no wound notes for Resident 35, relating to the buttock wounds documented on 04/04/2022. The facility was unable to provide documentation that an incident report was logged for the initial 04/04/2022 progress note documenting the wounds to resident buttocks. The facility was unable to provide documentation that the buttock wounds initially identified on 04/04/2022 were assessed by any staff member or provider. When the resident was readmitted to the facility on [DATE], MASD was identified, and again no further assessment or documentation was found in the electronic medical record to show the area was being monitored. Reference WAC: 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to ensure infection control interventions intended to mitigate the risk for spread of COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) and other contagious bacteria, were consistently implemented in the areas of: A) Screening - failed to complete the COVID-19 screening process for 10 of 14 sampled staff (U, C, W, F, D, E, G, H, I, L) to determine if personnel could enter the facility to work; B) Personal Protective Equipment (PPE) - failed to use PPE per Centers for Disease Control and Prevention (CDC) guidelines for donning (putting on PPE) and N95 (respirator/mask) fit testing for 12 of 12 sampled staff (B, BB, E, J, Z, AA, M, D, CC, DD, EE, W); C) Disinfection - Facility staff could not state how they were going to clean reusable equipment between residents in a shared room. The resusable equipment consisted of a blood pressure cuff to measure heart reate and blood pressure, pulse to measures oxygen levels and thermometer for monitoring resident's temperature. The facility also failed to follow the manufacturer's instructions for the disinfection contact time (contact time is the amount of time where a disinfectant needs to remain wet while wiping down equipment or surfaces); On 09/23/2021 at 4:30 PM the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.80(a)(1)(2) for F880-Infection Prevention and Control, related to the facility's failure to ensure and to properly prevent and/or contain COVID-19 from further spread in the facility, and from containing the transmission rate in the community. The facility removed the immediacy on 09/27/2021, with a validation date of 09/29/2021 at 2:30 PM, by implementing a removal plan with policy changes, education/training for PPE and screening/testing to ensure protection of the residents from further risk. Findings Included . Screening Review of the facility's 04/01/2020 Infection Control Program/Skilled Nursing Facility COVID-19 Management Folder policy reviewed on 05/20/2021, showed the screening of all who enter the facility with signs and symptoms COVID-19, (e.g., temperature checks, questions about and observations of signs and symptoms of COVID-19 to include fever or chills; cough; shortness of breath; fatigue; muscle or body aches; headache; new loss of taste or smell; sore throat; congestion or runny nose; nausea or vomiting; diarrhea) and denial of entry of those who have signs and symptoms and/or close contact or exposure to someone with COVID-19. Review of the facility's 02/2019 Emergent Infectious Disease Preparedness Plan showed staff will be educated on the facility's plan to control exposure with guidance of public health authorities showed, reporting suspected exposure to their supervisor .removal of all employees who report actual or suspected exposure. Screening for signs and symptoms when reporting to work .prohibiting staff from work if they are sick .use of the 12/14/2020 Employee COVID-19 Health Screening Follow-up was to be used to assess the information of symptoms present upon entering the facility .or until cleared by appropriate medical authorities . Review of the 09/10/2021 CDC guidelines showed that the facility was required to identify anyone entering the facility, regardless of their vaccination status, who have any of the following so they would be properly managed: 1) positive [CONDITION(S)] COVID-19 test, 2) symptoms of COVID-19, or 3) who meets the criteria for quarantine or exclusion from work. Additionally, the 09/10/2021 CDC guidelines showed .anyone, with even mild symptoms of COVID-19, regardless of vaccination status .to include asymptomatic staff with high-risk exposure, should have a series of two [CONDITION(S)] COVID-19 tests .testing is recommended (but not earlier than 2 days after the exposure) and if negative, again in five to seven days after exposure. Excluded are staff who have had COVID-19 and are asymptomatic in the last 90 days. For Health Care Providers who are symptomatic, if results are negative from at least two consecutive respiratory specimens collected greater than 24 hours apart (total of two negative specimens) tested using an Federal Drug Administration (FDA)-authorized laboratory-based nucleic acid amplification test ([CONDITION(S)] test) to detect (Corona Virus/COVID-19) before returning to work. The CDC 09/10/2021 Interim Guidance for Managing Healthcare Personnel with a COVID-19 Infection or Exposure to COVID-19 showed, 1) In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of work restriction of fully vaccinated Higher-risk Health Care Providers (HCP) with higher-risk exposures. 2) HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed COVID infection .Work Restrictions for Unvaccinated HCP should be exclude from work for 14 days after last exposure, perform COVID-19 testing immediately (but not earlier than 2 days after the exposure) and, if negative, again five -seven days after the exposure, advise HCP to monitor themselves for fever or symptoms consistent with COVID-19. Review of the CDC Recommendations to Prevent COVID-19 Spread in Nursing Homes showed HCP should not work while acutely ill, even if COVID-19 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens. Staff U. During a telephone interview on 09/21/2021 at 11:50 AM, Staff U, Licensed Practical Nurse (LPN), stated that their scheduled shift on 09/13/2021 was on the 200 hallway (COVID unit) from 2:00 PM to 10:00 PM and was screened before working. During Staff U's shift they had direct contact with residents during cares and medication pass. About 2 1/2 hours into their shift, Staff U felt feverish and took their temperature which measured orally 100.2 degrees Farenheit (F). Staff U reported their symptoms to Staff B, Registered Nurse (RN)/Infection Preventionist (IP) and a COVID-19 rapid test was done. Staff U, who was symptomatic, was instructed by Staff B that if the COVID-19 test came back positive they would find them. Staff U returned to the 200 hallway at the medication cart. Staff U became foggy and could not get their plan for the day together. During the telephone interview with Staff U, they stated they were told after a time (15-20 minutes), that they had tested positive for COVID-19 and was sent home. Staff U was fully vaccinated for COVID-19. Staff U was instructed to return to the 200 hallway by Staff B, RN/IP, and was not isolated while waiting for the rapid COVID test results, thus exposing residents and staff. Eventually, Staff U was instructed to go home to isolate. Staff C. Review of Staff C's, Registered Nurse (RN), rapid test results showed they tested positive for COVID-19 on 09/14/2021, and had symptoms of muscle aches, cough, and headache. Staff B had asked them to come into drive through testing at the facility. Staff C was not vaccinated, and the last shift worked was 09/11/2021 and stated they had worked with Staff U and had close contact at the shared nurse's station. Staff C was sent home on 09/14/2021 to isolate (for 10 days) due to positive symptoms of COVID-19 on 09/14/2021 and returned to work on 09/20/2021 (six days later) to work in the COVID Unit. The daily screen for signs and symptoms of COVID-19 on 09/20/2021 at 1:42 PM showed Staff C stated yes to cough, headache and nausea but worked four hours with residents and staff on the COVID unit. During an interview on 09/22/2021 at 12:55 PM Staff C stated they still had a cough, headache and nausea but was working in the COVID unit. The same day, during a return phone call from Staff C at 1:49 PM, they stated they also had additional symptoms to include congestion in their chest and had taken a decongestant to help their cough and dry up the phlegm in their chest. A review of the 09/22/2021 daily COVID-19 screen showed Staff C documented yes to cough and congestion signs and symptoms of COVID-19. Staff C was allowed to work with continued signs and symptoms of COVID-19. A secondary screening form to assess signs and symptoms of COVID-19 was not completed and Staff C was allowed to return to work even though Staff C continued to show positive signs and symptoms of COVID-19. There was no secondary health assessment by the facility. During a phone interview with the Local Health Jurisdiction (LHJ), RN for COVID-19 Outbreak Mitigation for Long Term Care, on 09/22/2021 at 11:00 AM, they stated Staff C could only return to work if they were asymptomatic seven to ten days (without any signs or symptoms of COVID-19) after testing positive for COVID-19. The LHJ stated they were not informed by the facility of Staff C's positive status or early return to work (6 days after testing positive with continued signs and symptoms). Additionally, the LHJ Epidemiologist RN, stated that if the facility was testing symptomatic staff with the rapid test for COVID-19 and they continued to test negative, a FDA-authorized laboratory-based nucleic acid amplification test (Virus test) from an approved laboratory should be conducted to rule out potentially positive COVID-19 results. During an interview on 09/21/2021 at 11:50 AM, Staff B RN/IP, stated Staff C, RN, returned to work on 09/20/2021 for half a shift on the COVID unit, post positive test as they were currently asymptomatic, however the 09/20/2021 daily screening log showed Staff C, RN, was symptomatic. Staff B, RN/IP was unaware of Staff C's positive symptoms and did not complete a secondary assessment to determine if Staff C was able to work. Staff W. During a phone interview on 09/30/2021 at 2:00 PM, Staff W, LPN, stated that they worked for other Long-Term Care facilities in the area with a staffing agency and had placement in other facilities as well. Staff W stated they tested at one of the other facilities and had contact at that facility with a COVID positive dietary staff around 09/15/2021 or 09/16/2021. Staff W stated the positive staff at the other facility had prepared their puddings, ice and liquids on their medication cart which they used to give medications. On 09/13/2021 Staff W took over Staff U's shift from 5:40 PM to 11:43 PM (on the COVID unit) after Staff U was sent home with a positive COVID-19 test with symptoms. Staff W had worked on 09/18/2021 at this facility on the COVID unit with positive symptoms of runny nose and diarrhea but did not disclose on the screening log. On 09/19/2021 during routine testing at this facility Staff W was positive for COVID-19 and was symptomatic (running nose and congestion) but continued to work at the facility. Additionally, Staff W worked on 09/21/2021, 09/23/2021, 09/28/2021 on the COVID unit and attended an in-service on 09/25/2021 at this facility despite the fact they remained symptomatic. Staff F. Review of the 09/17/2021 daily screening log showed Staff F Nursing Assistant (NA) worked on the COVID unit and had reported at 10:45 PM symptoms consistent with COVID-19 (muscle aches, congestion and headache). During a telephone interview with Staff F's representative on 09/29/2021 at 4:49 PM, they stated that Staff F was in the hospital related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . They also stated that they had gone to work that night (09/17/2021) and they had reported symptoms of muscles aches, headache, and fogginess. A rapid test was performed with positive results. Staff F was not vaccinated for COVID-19. Staff A, Administrator, was called regarding the positive test results and was provided information on Staff F's symptoms. Staff F stated they were told they could continue to work if Staff F felt like it, even though they were COVID positive and symptomatic. There was no further assessment of their symptoms. Staff F stayed for the remainder of the shift as they felt the facility would be short-staffed if they did not stay to work. Staff D. The daily screening log showed Staff D, RN, screened with positive symptoms of COVID-19 on 09/20/2021 at 1:53 PM and had incomplete answers for section A (close physical contact with person known to have COVID-19) and section B (within the last 3 days have you received the COVID-19 vaccine). Staff D was referred to their supervisor and cleared to work, however a secondary screening form was not completed and continued to work their shift. Additionally, on 09/21/2021 at 2:00 PM, Staff D answered yes to section A, and no to section B, and left section C (temperature), section D (signs and symptoms), section E (referred to supervisor), section F (secondary screening form completed), and section G (cleared to work) blank and worked their shift. Staff E. Review of the daily screening log, showed Staff E, Housekeeper, screened with positive symptoms of COVID-19 on 9/21/2021 at 8:00 AM with congestion and runny nose. The health screen was blank for the yes response referred to supervisor and blank for supervisor completed employee COVID-19 health screening. There was no secondary assessment to determine if this housekeeper was cleared to work with residents this shift. Staff E stayed and worked the entire shift on 09/21/2021. During an interview on 9/22/2021 at 12:15 PM with Staff A, Administrator, they stated Staff E reports symptoms and should have a health screen. Staff E's last rapid test for COVID was 09/18/2021. Staff G. Review of the daily screening log, showed Staff G, NA, screened with positive symptoms of headache and runny nose on 09/15/2021 at 10:00 PM with no evidence of a secondary assessment referral to a supervisor or an employee health screening to determine if Staff G was cleared to work this shift on the COVID unit. Staff G was not tested for COVID and did stay for their entire shift that day. Staff H. Review of the daily screening log showed Staff H, NA, screened with positive symptoms of COVID-19 of cough, chills, and congestion on 09/16/2021 at 5:51 AM. There was no evidence of a secondary assessment to determine if Staff H was cleared to work. Staff H had a facility rapid test on 09/16/2021, 09/18/2021, and 09/22/2021 with negative results and was allowed to work with symptoms. There was no follow up testing after two negative rapid tests as recommended by the CDC guidelines released on 09/10/2021, recommending testing using a follow-up [CONDITION(S)] test for COVID-19 to accurately confirm the facility's rapid test results. Due to their continued symptoms of nasal congestion, cough, shortness of breath, and sore throat, Staff H completed a rapid test on 09/24/2021, six days after the second negative test, which showed positive for COVID-19. Staff I. Review of the 09/13/2021 at 5:49 AM daily screening log showed Staff I, LPN, documented yes to exposure to COVID-19. There was no information documented on the log except talk to Staff B. For the cleared to work section on the daily screening log N/A was circled without any additional information or documentation of an investigation or contact tracing of Staff I's exposure disclosure. Staff I stayed to work the entire shift on 09/13/2021. During an interview on 09/22/2021 at 10:00 AM, Staff B stated that Staff I told them they had a positive COVID-19 close exposure with another co-worker at their other job at a clinic. Staff B stated that they would just let the clinic deal with the exposure since it was not at this facility. Staff L. Review of the daily screening log showed Staff L, Maintenance, screened with positive symptoms of COVID-19 of shortness of breath/difficulty breathing, cough, congestion/runny nose, and nausea/vomiting on 09/23/2021 at 7:04 AM. A secondary screening was performed by Staff B, RN Infection Preventionist, which indicated Staff L woke this morning, hard to breathe and woke this morning with Bad headache. Documentation by Staff B, RN showed Rapid test negative, Personal Protective Equipment and hand hygiene instruction given and was cleared to report for duty. During an interview on 09/22/2021 at 2:05 PM, Staff B, RN/IP stated the RN's check the screening log in the COVID unit and they should notify Staff B, RN/IP of symptomatic staff. The process was an additional screening form would be used to determine if they were able to work. This screening form would be reviewed by the Director of Nursing Services (DNS) and/or Staff A, Administrator. Staff B, RN/IP stated they try to review the COVID unit daily screening log at least once a day, but they don't always get back there to do the monitoring. During an interview on 09/22/2021 at 4:07 PM, Staff A, Administrator, stated they forgot about the log back there in reference to the daily screening log in the COVID unit. Staff A also stated that did not always check the daily screening logs at the end of the day. Staff A stated they did not review the previous day (09/21/2021) screening log in the main entry way for completeness and accuracy. During the outbreak, there had been two screening areas for staff entry which was an outside back entry to the COVID unit and an entry through the front main entrance of the facility. During an interview on 09/22/2021 at 1:26 PM, Staff Y, RN, Resident Care Manager (RCM) on the COVID unit stated they try to review the screening logbook, but sometimes it's crazy, staff usually would call the DNS themselves if symptomatic because they don't always have time to review them. Personal Protective Equipment Review of 05/20/2021 Facility's Infection Control Program which included 03/30/2020 Center for Disease Control and Prevention (CDC) Caring for Patients with Confirmed or Suspected Covid-19 showed that staff were to be fit tested for a National Institute of Occupational Safety and Health (NIOSH) approved N-95 (used to reduce the wearer's exposure to inhalation of certain airborne particles and limit the potential spread of suspected or known respiratory infections) masks when caring for confirmed or suspected COVID-19 residents. According to these CDC guidelines, if the respirator had a nosepiece, it should be fitted to the nose with both hands, not bent or tented, .Do not pinch the nose piece with one hand. Respirator/facemask should be extended under the chin. Both your mouth and nose should be protected. Do not wear respirator/facemask under your chin or store in scrubs pocket between patients. Respirator straps should be placed on crown of head (top strap) and base of neck (bottom strap). Perform a user seal check each time you put on the respirator . Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated September 10, 2021 stated facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. Review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated September 10, 2021 stated Eye protection (goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. Additionally, the 09/10/2021 guidance recommended HCP caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) and that the door to the room remain closed to reduce transmission of [CONDITION(S)]-CoV-2. Review of the facility's 7/2020 Respiratory Protection Program-Fit Test showed that an N95 respirator is to be fitted and tested to ensure proper user seal-check. When placing an N95 and maintaining proper fit and seal of the mask the straps are to be placed at the back of top of the head and around the back of the neck. Staff with long hair should place the bottom strap of N95 directly under the hair next to the neck. This is to maintain the respirator seal. An observation on 09/21/2021 at 11:50 AM showed Staff B, RN/IP, was wearing an N95 respirator with the straps crossed at the sides, in the front of the mask. An observation on 09/21/2021 at 1:10 PM showed Staff BB, Hospitality Aid/Screener, was wearing an N95 respirator with the bottom strap around their chin in the front. The bottom strap was not around the back of the head. During an observation 09/22/2021 at 12:50 PM, Staff B, RN/IP, entered the COVID unit wearing an N95 respirator with the straps crossed at the sides and face shield. All doors to the residents' rooms were open to the main hallway. Staff B, RN/IP, proceeded to walk to the medication cart and spoke with staff for five minutes. An observation on 09/22/2021 at 12:55 PM showed Staff E, Housekeeper, was working in the COVID unit, N95 respirator straps were crossed in the back of their head. An observation on 09/22/2021 at 1:05 PM showed Staff J, NA, wore an N95 respirator with the straps crossed at the back of their head. An observation on 09/22/2021 at 1:10 PM showed Staff Z, RN, working in the COVID unit, with the N95 straps crossed on the back of their head. An observation on 09/22/2021 at 1:26 PM showed Staff AA, NA, was working in the COVID unit, entered a resident's room (203) to put a newly admitted residents' belongings away. Staff AA was not wearing gown or gloves, as required. The resident was in the restroom at that time. An observation on 09/22/2021 at 3:00 PM showed Staff M, RN, was at the 200/300 hallway nurses station with an N95 respirator on and no eye protection or face shield as required. An observation on 09/22/2021 at 3:10 PM showed Staff D, RN, had walked from the COVID unit into the main building (non-COVID area) without eye protection or faceshield as required. During an observation and interview on 09/22/2021 at 3:50 PM, Staff K, RN, Staff DD, Medical Records, and Staff EE, RN, were seated in close proximity (their elbows were touching - less than six feet apart and not socially distanced) at the nurse's station located by the 100 hallway. During an interview on 09/22/2021 at 4:00 PM, Staff EE had their goggles on top of their head, stated that they were being trained by Staff K and viewing the computer program. Staff DD was using another computer at the same nurse's station imputing resident data. Staff K stated, How are we going to train the new employee if we cannot sit next to each other? During an interview on 09/22/2021 at 3:57 PM, Staff B, RN/IP, stated that staff continully fail to wear their PPE properly, or at all and that they had to remind them almost consistently but staff do not comply. Staff B who also witnessed the events went to speak with staff. During a phone interview on 09/30/2021 at 2:00 PM, Staff W, LPN, stated they did not wear their PPE goggles on 09/19/2021 when transferring Resident 3 who tested positive for COVID-19 that day. Staff W also tested positive for COVID on 09/19/2021 and provided direct care for residents. During an interview on 09/22/2021 at 4:15 PM, Staff A, Administrator, stated that they were surprised at the lack of proper use of required PPE and that they would look into it. Disinfection Review of the September 10, 2021, CDC guidelines Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic showed; all non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer's instructions and facility policies before use on another patient. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA (Environmental Protection Agency)-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for COVID-19 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. Once the patient has been discharged or transferred, HCP, including environmental services personnel, should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles [more information (to include important footnotes on its application) on clearance rates under differing ventilation conditions is available]. After this time has elapsed, the room should undergo appropriate cleaning and surface disinfection before it is returned to routine use. During an interview on 09/22/2021 at 12:15 PM, Staff A Administrator, stated that Staff J, NA/Screener was on light duty and responsible for wiping down the front lobby screening area, handrails, furniture, coffee station, cubbies, and bathroom. During an observation and interview on 09/22/2021 at 1:05 PM, Staff J stated they cleaned the front lobby area with Clorox bleach spray and Sani-cloth wipes on the furniture, tables, goggles that staff store in the front area. When asked how clean the area, Staff J stated that they just wipe it. Review of the undated product chemical list showed that the clorox spray contact (contact time) was to be three minutes, and the Sani-wipes wipes to be effective needed to have a contact time of two minutes. In interview on 09/22/2021 at 12:25 PM Staff J stated they were unaware of the guidelines for disinfection instructions. During an interview on 09/22/2021 at 12:55 PM, Staff E, Housekeeper in the COVID unit stated after cleaning rooms when a resident changes rooms or discharges, they come in right away and start cleaning. Staff E stated they use bleach for everything and wait but stated I honestly don't know how long it sits. An interview on 09/29/2021 at 10:24 AM, Staff FF, NA stated they should clean the portable vital signs machine between patients with bleach wipes but stated I have no idea how long to wait when asked about the contact dry time. Contact time on the label showed 4-minute contact time. Staff FF stated they had been doing this but had not known there was a certain amount of time to wait. On 09/29/2021 an observation at 10:42 AM showed Staff GG, Housekeeper, cleaning a resident's room, used clorox spray and a rag. Staff GG, sprayed the surface of the sink and immediately wiped it with the rag, not adhering to contact dry times. Staff GG was unable to state what the contact time was for the product she was using. Contact dry time was one minute for Coronavirus and three minutes for C-Diff. On 09/29/2021 an observation at 1:26 PM showed Staff HH, NA, with vital signs machine, going to obtain vital signs for two separate residents Cohorting in room [ROOM NUMBER]. There were no cleaning products on the equipment stand. Staff HH, was unable to state how they were going to clean the equipment between the residents, also stated they were unaware of the contact dry times for the various cleaning products in the COVID unit. Reference WAC: 388-97-1320(1)(a)(2)(a-c)(5)(c-d)

Based on observation, interviews, and record review, the facility failed to ensure risk factors related to a fall were identified and addressed, and failed to ensure bed equipment was properly assessed for appropriate fit and safety to prevent falls for one of three residents (#1) reviewed for falls. This failure resulted in actual harm to the resident who fell from her bed, which had an alternating pressure mattress on it, two consecutive nights following the mattress being placed on the bed, with the last fall resulting in a fractured left leg. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] from the hospital following left hip surgery. Other [DIAGNOSES REDACTED]. Review of the resident's comprehensive assessment, dated 09/30/19, showed the resident had moderate cognitive impairments; and required two staff to assist with turning in bed, transfers, and toileting. Review of a fall assessment, dated 10/09/19, showed the resident was at high risk for falls. Review of the resident's weight record showed she weighed 101 pounds on 10/13/19. During an interview on 10/29/19 at 1:30 PM with Staff B, Maintenance Supervisor, he stated he placed an air mattress on the resident's bed on 10/12/19 at some time during the day. He stated he sets all the air mattresses in the facility on an alternating pressure at full air volume then locks the settings in so they are not altered. Staff B stated he sets the air mattresses on full as that kept residents from lying in a trough. An air mattress, same model as placed on the resident's bed, was then observed with Staff B. Staff B showed the state investigator the various features of the control panel, which was located at the foot of the bed. On 10/30/19 at 12:07 PM a telephone interview was conducted with the Chief Executive Officer of the company which supplied the air mattress utilized by the resident. He stated the volume of air placed in the mattress was based on the resident's weight. He stated the high volume of air in the mattress for a resident of approximately 100 pounds was a contributing risk factor for falls. Any movement by the resident in bed increased the potential for falls as the mattress was basically flat when inflated at full volume. Review of the resident's medical record, and a facility investigation report documented by Staff C, Licensed Practical Nurse, showed on 10/12/19 at 11:30 PM the resident was found lying on her side on the floor next to her bed. The resident was assessed and no injuries were found. The investigation report showed the resident did not use her call light and attempted to self transfer from her bed, lost her balance, which resulted in the fall. Review of a witness statement, documented by Staff D, Nursing Assistant (NA), showed following the fall the resident stated she did not want to lay down and was crying, thus she was placed in a chair. Potential contributing factors were weakness from recent sugery, impaired balance, cognitive deficit, and poor safety awareness. Despite the air mattress just being placed on the resident's bed earlier that day (10/12/19), and she had not had any falls out of bed prior to the air mattress, it was not identified as a potential risk factor in the resident's fall. The investigation did not show the conclusion of the resident self transferring out of bed was reasonably related to her condition. During a telephone interview with Staff C on 10/29/19 at 7:50 PM, she stated she had assumed the resident was trying to get out of bed as she did not want to go back to bed after the fall. Staff C stated she did not recall the resident trying to get out of bed prior to the fall. She stated she never considered the air mattress when she conducted the fall investigation. Staff C stated, very possible that she slid out of bed. Staff D stated during telephone interviews on 10/29/19 at 2:30 PM and 10/31/19 at 3:40 PM, that the resident was screaming at staff, following her fall on 10/12/19, that she did not want to go back to bed. Staff D stated she never saw the resident attempting to get out of bed, nor had she ever requested to sit in a chair during the night. The resident was incontinent during the night shift, thus staff did not take her to the bathroom during the night shift but rather changed her disposable brief. She stated the resident's habit every night she worked was to take off her blankets using her arms as she would get too warm. Staff D stated at the time of the fall the resident's bed was in a low position, and her call light had not been activated. Review of a facility investigation report, documented by Staff E, Registered Nurse (RN), showed on 10/13/19 at 9:24 PM the resident was found lying on the floor next to her bed. The resident's bed was in the low position with an air mattress. The investigation stated it appeared the resident had slid off the mattress onto the floor. The resident spoke very little but was grimmacing and stated her left hip hurt. The resident's family was notified and the resident was transferred to the emergency room (ER). Review of hospital records, dated 10/13/19, showed x-rays taken in the ER showed the resident had sustained a fractured left leg. During an interview on 10/29/19 at 2:46 PM with Staff E, she stated she found the resident lying on her right side on the floor the evening of 10/13/19. She did not feel the resident had self transferred out of bed but rather had slid out of bed from the air mattress. Staff F, RN, stated on 10/29/19 at 1:40 PM regarding the resident's fall out of bed on 10/12/19, the resident just would not try to self transfer, whatever happened it wasn't a self transfer. A telephone interview on 10/29/19 at 10:04 AM with the resident's collateral contact, who visited the resident daily in the facility, stated the resident would not try to stand up on her own. She stated the resident would squirm in bed when she got uncomfortable. Interviews conducted on 10/30/19 at 1:45 PM with Staff G, NA and 1:50 PM with Staff H, NA, assigned caregivers for the resident, they stated they had not observed the resident attempting to get out of bed or her wheelchair unassisted. An interview on 10/30/19 at 1:55 PM with Staff I, NA, she stated the resident utilized her call light for assistance. She observed the resident several times trying to reposition herself in bed. She would put her legs slightly to the edge of the bed but was unable to put them down to the floor. Staff H stated she never observed the resident trying to sit up in bed or get out of bed. Staff J, Physical Therapist, stated on 10/30/19 at 11:10 AM, that she did not see the resident attempting to self transfer as she would not put her left foot down, and was unable to stand. She stated the resident didn't initiate hardly anything. The air mattress on the resident's bed was narrow and slippery. Reference (WAC) 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 06/27/19.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (#45) reviewed for accidents, had bed equipment in proper working order to prevent serious injury. This failure resulted in harm to Resident #45, who sustained a laceration to the left lower leg, which required surgical intervention to stop the bleeding and for the repair. Findings included . Resident #45. Review of the medical record showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment, dated 06/07/19, showed the resident had moderately impaired cognition and required extensive assistance of two staff for transfers. The (MONTH) 2019 Facility Assessment showed under the Physical Environment, Technology, and Equipment section, .We regularly check and maintain equipment needed to meet patient needs and allows staff to safely provide care for patients. We check that equipment out in a number of ways .to ensure that it is functioning properly and ready for safe use . An observation on 06/20/19 at 9:42 AM showed Staff R, Registered Nurse (RN), providing wound care to the resident's left lower leg. The laceration was closed with staples and was approximately six inches in length. The dressing the RN removed had a minimal amount of bloody drainage on it. As the RN was providing the wound care, she assessed the wound and stated it required a daily dressing change and the objective was to keep the wound clean and dry due to the resident's history of significant [MEDICAL CONDITION] (skin infections) [MEDICAL CONDITION] (a serious condition resulting from the presence of microorganisms in the blood or other tissues and the body's response to their presence. potentially leading to the malfunctioning of various organs, shock, and death). During an interview on 06/20/19 at 8:55 AM with Resident #45, he recalled the incident where he was injured on the bed frame as he was trying to get into the bed from the wheelchair. The resident stated the area on the bed frame was sharp and caused him a wound that bled everywhere, resulting in a trip to the hospital for surgical repair. During an interview on 06/20/19 at 9:09 AM with Collateral Contact A, she stated she was called when the incident occurred in the evening on 06/07/19. The collateral contact explained the resident had been in the facility two weeks at the time and had been slowly gaining strength with therapy. She stated she arrived to the facility before the resident was sent out to the hospital and observed the exposed pipe on the bed frame. She stated the staff explained to her the cause of the injury and she observed and felt the exposed piping on the bed frame. It felt rough and uneven. She pointed out the part of the bed frame in which she was told the resident had contact with the exposed pipe, causing the laceration. There were six black, circular, plastic caps, approximately two inches in diameter, which covered the exposed piping along the left side of the bed frame. The exposed piping was the end of an approximate 1.5 - 2 inch open area in the hollow pipe, with an approximate 0.5 centimeter of perimeter metal thickness. The collateral contact stated, the evening of the incident, the two areas of exposed piping closer toward the foot of the bed, were not covered with plastic caps. She further explained both sides of the bed frame were missing the exact two plastic caps over the piping on the bed frame (the two of six located closest to the foot of the bed). She stated the facility later explained there were several beds in the facility identified with the same missing plastic caps on both sides of the bed frame. The collateral contact stated the resident was taken to the local emergency department and sent back to the facility the same evening and the bed still had the exposed pipe areas on the bed frame. She stated she refused to have the resident placed in the bed until the facility staff switched beds or made it safe for the resident to be in it. The collateral contact stated she felt the accident slowed the resident's progress down and set him back a couple of weeks. During an interview on 06/24/19 with Staff S, Nursing Assistant (NA), he stated he was present during the incident and intervened when he observed the resident attempting to self-transfer from his wheelchair to the bed. The NA stated he was able to apply a gait belt on the resident and assist him to the bed to prevent a fall. During the process, the NA stated the resident fell on to the mattress of the bed, causing the mattress to slide over, then he noticed the resident grabbed his leg and noticed blood on the sheet that was lying over the bed. The NA stated after the incident, he looked around the bed to see what might have cut the resident's leg and noticed the bed frame with the exposed hollow piping and missing plastic caps. The NA stated, It was a little bit sharp .I'm guessing with his weight .it caused (the laceration). During an interview on 06/25/19 at 10:17 AM with Collateral Contact B, he stated the accident was unfortunate and may have only resulted in a bruise if the plastic cap was on the exposed piping on the bed frame, instead of the laceration, which required surgical repair. During an interview on 06/26/19 at 9:36 AM, Staff N, Licensed Practical Nurse (LPN), stated she was working with the resident the evening of his accident. She was called to the room by Staff S due to the resident obtaining an injury. When she entered the room, the resident had a full thickness (skin layer loss) laceration . The LPN stated she could see adipose tissue (the fat tissue located under the top two layers of skin) when she went in to observe the wound. The LPN and Staff S had to apply pressure to the wound due to the significant bleeding, then called 911 for an emergency transport to the local hospital. Staff N stated when the resident returned from the hospital, the collateral contact was adamant about not wanting the resident in the same bed (which was still in the same condition with the exposed pipe areas on the bed frame). The LPN stated a staff member removed some caps from a bed not being used in a different room and placed them on Resident #45's bed. The LPN stated the collateral contact was so concerned because (Resident #45) [MEDICAL CONDITION] so easily . In regard to the uncapped piping on the bedframe, Staff N stated, I guess with the cap gone, it was a definite possibility that it contributed to the (severity) of the wound, as she further discussed the fragility of the resident's skin integrity. During an interview on 06/26/19 at 9:57 AM with Collateral Contact C, he stated it was reported to him that the exposed piping on the bed frame was supposed to be a smooth edge, but actually had some roughness or some spurs on it. The (accident) maybe hampered with the therapy he was receiving .he was slowed down on therapy. During an interview on 06/21/19 at 12:44 PM, Staff F, Maintenance Director, stated the Joerns Bed Frames, identified as the group of bed frames with the missing plastic caps, were delivered when he first started working with the facility several years ago. He stated he recalled the bed frames were delivered already assembled and were placed in the rooms. Staff F stated his process was to check over any equipment when it was first delivered to the facility, and also as an ongoing task in his safety rounds. Staff F stated there was a bed safety audit in which he was required to complete monthly. He stated the focus of the bed audits was to ensure functionality and to prevent entrapment risks due to the beds constantly being moved around in the facility. The maintenance director stated he had not been checking the bed frames to ensure the placement of the plastic caps on the exposed piping. Review of the monthly facility inspection reports for the bed frames from (MONTH) (YEAR) to (MONTH) 2019 showed adjustment/replacement of hardware, tightening of loose bolts, or documentation of a faulty mattress with replacement, and the presence of medical assistive devices. The 04/30/19 inspection showed documentation by Staff F that read, .All beds and mattresses in this facility are checked regularly to ensure proper operation and safety as well as wear and tear . The monthly facility inspection reports did not show identification of the missing plastic caps on Resident #45's bed or any of the other identified beds with missing caps in the facility. The Joerns (YEAR) User-Service Manual - Joerns Bed Frames - Easy Care Bed page 14, showed under the Preventative Maintenance section to, .Check monthly for loose bolts, nuts, pins and other retaining hardware .Contact Joerns Healthcare to order any appropriate service parts . Review of the 06/07/19 facility investigation of the incident showed the resident .scraped his left leg against the bed frame causing a skin laceration. Cap to the bed frame was not present at the time of the incident . The laceration was 6.3 inches in length and 3.5 inches in width. The investigation showed the resident required electrocauterization (the use of a heated medical device to burn/sear a body part that required closing) for two vessels, which .despite the electrocautery there is two pumping vessels which required to be tied off (with two absorbable stitches) . The facility concluded in the investigation, .feel as though the combination of (Resident #45's) fragile skin and [MEDICATION NAME] edged pipe caused the severity of the injury . During an interview on 06/21/19 at 12:56 PM with Staff A, Administrator, she stated the beds were purchased several years ago when the facility changed ownership. The Administrator stated when the facility received the beds, the maintenance staff look it over to ensure it was functioning and safe. She stated during the investigation of the incident, the facility identified several Joerns Bed Frames with the same missing plastic caps on both sides of the bed frame. Staff A stated the facility investigation concluded the exposed piping on the bed frame caused the resident's injury. Reference: WAC 388-97-1060(3)(g) This is a repeat deficiency from Statement of Deficiency dated 05/10/18.

Based on record review and interviews the facility failed to perform necessary assessments, care, and treatment in response to changes in the condition of 1 of 3 residents (#1) reviewed for change in condition. This failure to timely and accurately assess Resident #1's change in condition and administer pain medication caused harm to Resident #1 and placed all residents at risk for inadequate care and treatment. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital due to [DIAGNOSES REDACTED]. Cholangitis is an infection of the common bile duct which carries bile from the liver to the gallbladder and intestines. Signs and symptoms included abdominal pain, fever, and jaundice. review of the resident's medical record revealed [REDACTED]. Review of Progess Notes between 10/18-11/2/13 revealed the resident had no complaints of abdominal pain. On 11/3/13 documentation by Staff A (Licensed Nurse) at 8:15 a.m. stated the resident was given Tylenol for complaints of abdominal pain with some relief noted. An assessment performed at that time for abdominal "rebound tenderness" noted the resident stated the pain occurred when the Licensed Nurse (LN) pushed on her abdomen, rather than when she pulled away. An interview on 11/21/13 at 1:45 p.m. with above Staff A noted the resident ate less than 25% of her breakfast meal the morning of 11/3/13 and usually she ate more. She stated it seemed the resident did not feel good. At approximately 1:00 p.m. the resident complained of abdominal pain to her family; however, when the LN got to her room she was sleeping, thus she stated "didn't think it was anything." Review of documentation by the Physical Therapy Assistant (PTA) on 11/3/13 noted the resident was experiencing intermittent abdominal pain (7 out of 10 with 10 being severe pain) during the session. Nursing was aware and the pain limited her functional activities. Further review of physical therapy Progress Notes revealed the following documentation: 10/31 - resident with back pain of 5 out of 10 which limited her functional activities 10/29 - resident reported back pain was bad but was unable to provide a rating 10/28 - resident with back pain of 9 out of 10 with limited her functional activities 10/27 - resident with back pain of 6 out of 10 which limited her functional activities 10/24 - resident with back pain of 3 out of 10 which limited her functional activities 10/22 - resident with back pain of 6 out of 10 with movement/activity 10/21 - resident with back pain of 6 out of 10 - documentation stated "notified nursing of issue" 10/20 - resident with back pain of 5 out of 10 which limited her functional activities - stated nursing gave resident a Tylenol for pain 10/18 - resident with back pain of 6 out of 10 with movement There were no scheduled therapy sessions on 11/2 and 10/26/13. A telephone interview on 11/21/13 at 12:00 noon with the above PTA revealed on 11/3/13 the resident was having abdominal pain, not feeling good and felt "very weak". He stated that due to the resident's condition therapy was not performed that day. He stated he saw the resident before lunch that day. Review of Progress Notes dated 11/3/13 at 11:44 p.m. by Staff B (LN) revealed the resident's family was in the facility and stated the resident was "deteriorating and is weaker." The resident's family called 911 and had the resident transported to the hospital at 7:15 p.m. Staff B stated during an interview on 11/21/13 at 2:50 p.m. that dayshift staff had stated in shift report on 11/3/13 that the resident's family had voiced concerns earlier that day of the resident "deteriorating and with abdominal pain". He was unable to recall what the resident ate for dinner that evening. He stated he was not familiar with the resident as he had not worked on that unit. Despite family concerns of the resident's condition Staff B stated he had not performed an abdominal assessment on the resident, nor had he administered any pain medication. An interview on 11/21/13 at 1:20 p.m. with Staff C (Nursing Assistant caring for the resident on the evening shift of 11/3/13) revealed that at approximately 4:30-4:45 p.m. the resident complained of pain in her lower back area and he had reported the concern to Staff B at that time. Despite the above frequent complaints of back pain by the resident during therapy sessions review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. It was also administered on 11/1/13 at 11:30 p.m. for pain/anxiety with no assessment of location of pain, and on 11/2/13 at 5:00 p.m. for general aches. Review of the hospital History and Physical dated 11/3/13 revealed the resident was admitted to the hospital for intravenous antibiotics and fluids due to her abdominal tenderness with evidence of cholesystitis (gall bladder inflammation). Signs and symptoms of cholesystitis include severe, steady pain in right side of abdomen that can radiate to the right shoulder or back; fever; and tenderness over the abdomen when it is touched. A telephone interview on 11/26/13 at 10:50 a.m. with an ambulance staff member revealed his assessment of the resident the evening of 11/3/13 was fever of 100.0 degrees, right sided lateral rib pain, right sided abdominal pain, and weakness. Review of the resident's meal intake noted she ate less than 25% at breakfast, no documentation of her lunch meal, and she did not eat any dinner. The preceding day on 11/2/13 revealed she ate 76-100% for breakfast, less than 25% at lunch, and no documentation of the dinner meal. There was no evidence vital signs were obtained on the resident on 11/3/13 until ambulance staff transported her to the hospital at which time her body temperature was elevated at 100.0 degrees. Despite the resident's change of condition on 11/3/13 and concerns voiced by the family regarding her declining condition and weakness there was no further nursing assessment of the resident's condition following the abdominal assessment by Staff A at 8:15 a.m. on 11/3/13. In addition, there was no evidence staff had assessed the resident's frequent complaints of back pain during therapy sessions, consulted with the physician regarding her pain, or consistently administered pain medication for her complaints of pain.

Based on observation, interview and record review the facility failed to thoroughly investigate and take immediate corrective action related to unsecured oxygen tanks. Failure to recognize and develop an action plan to mitigate the risk of known potential avoidable environmental hazards placed all residents at risk of serious injury. This constituted an immediate jeopardy (IJ) being called on 10/21/13. In addition, facility failed to respond to fluctuations in water temperatures throughout the facility. The facility failed to assess, evaluate and revise the comprehensive plan of care to prevent further occurrences of falls for 1 of 2 current residents (# 214) and 3 of 4 discharged residents (#s 222, 182 and 263) reviewed for accidents/injuries. Failure to evaluate existing interventions and implement new interventions after each fall placed the residents at risk for serious harm or injury. Findings Include: <Oxygen> On 10/21/13 at 9:30 a.m., Resident #253 had a portable oxygen tank secured with one knot to the back of her wheelchair with a standard size pillowcase. At 9:45 a.m., Licensed Nurse (LN) A stated, "oxygen tanks are very dangerous, we could have an explosion if the bag is not secured" LN A added, the Nursing Assistants (NA's) are responsible for making sure the bag was in place. At 9:56 a.m., two, 4 feet high e-cylinder style oxygen tanks were observed unsecured in the oxygen storage room. The oxygen tanks were full. The oxygen storage rack had space available for the tanks to be secured. At 10:00 a.m., NA D verified there were two free standing e-cylinder oxygen tanks 4 feet high in the oxygen storage room. She stated, "The canisters should be secured in the rack. The reason I know the canisters are full is because the sticker is still on it. It could be they delivered extra and that's why they are on the floor." At 11:03 am, NA P and Q assisted Resident #253 to transfer from the wheelchair to the toilet. As the resident stood up and pivoted to the toilet, the wheelchair tipped backwards onto the anti-tip bars. The pillowcase containing the portable oxygen tank swung freely. NA Q stated she always used an oxygen cover as the tank had to be covered for privacy. When asked about using a pillowcase to secure the portable oxygen tank, NA P stated, "My supervisor said it was okay." NA P said the oxygen tanks needed to be covered for privacy. NA P indicated the facility was out of oxygen tank bags and they were on order. At 11:17 a.m., the Central Supply Person (CSP) stated she knew the facility had been out of the oxygen bags and she had ordered them. She had not notified the the ADM or the DNS that the facility was out of xygen bags. At 11:50 a.m., the DNS stated oxygen tanks should be secured to wheelchairs in black bags. She was not aware the facility was out of bags. The DNS stated, "We can call the company we get oxygen from if needed and they can bring bags over to us. The staff should let us know if the supply is out." The DNS was asked about storage of tanks in the storage room, she stated, "The portable tanks in the storage room should be in the metal racks and not free standing as the tank could shoot across the room if bumped." The DNS stated, "Security and safety of oxygen tanks, is everyone's responsibility as all staff go in and out of the rooms or storage room. Not one person is specifically assigned the task." At 12:05 p.m., the DNS observed Resident #253's oxygen tank in a pillowcase on the back of the resident's wheelchair. The DNS shook her head side to side, stating this was not acceptable and would correct the situation. Record review revealed seven in-service training sign-in sheets regarding checking oxygen tanks dated back to 10/11/12. An in-service dated 8/14/12, "Do not leave oxygen tanks sitting (free standing) anywhere. Even empty tanks must be secured as soon as they have been exchanged for a full tank..." An in-service dated 12/28/12, "Oxygen tanks (again) 1) do not leave full or empty O2 (oxygen) tanks free-standing in resident rooms. This seems to be almost a daily issue-Particularly on the 200 hall-This {is} not a safe practice-even an empty tank can become a projectile if it falls over. 2) When taking empty tanks out to the O2 room be sure you place them in the wire rack. Again, No tanks should be free standing!" An in-service dated 4/15/13, "O2 tanks-This is a very serious issue-Every shift is telling me O2 tanks are being left unsecured in resident rooms-Friday there was one a therapist didn't see and knocked it over. The regulator broke and O2 was leaking out. The tank could have become a projectile causing injury to anyone near it. Even an empty tank is dangerous when unsecured..." An undated in-service, "Portable oxygen tanks MUST be secured at ALL TIMES. They may be secured by the bags on the back of a wheelchair or in the oxygen rack. AT NO TIME CAN THEY BE FREE STANDING OR PROPED AGAINST THE WALL. Disciplinary action will be taken immediately if this safety measure is not adhered to." Although, the facility implemented several trainings over the past year, the staff continued to use oxygen tanks in an unsafe manner. The Administration did not evaluate the effectiveness of the trainings or develop additional plans of actions to ensure avoidable environmental hazards placing all residents at risk of serious injury. <Water Temperatures> On 10/22/13 at 9:00a.m., a surveyor tested the water temperature at the sink in room #209. She quickly withdrew her hand as it felt hot. Resident #246 stated the water at the sink was "pretty hot and usually you can't put your hand under it." At 9:32 am, the water temperature at the sink in room #s 101, 104 and 106 were checked by the surveyor with her hand. The surveyor quickly withdrew her hand as the water felt hot. At 10:15am, surveyors used a digital thermometer to check various other water temperatures in resident rooms and shower rooms. At 10:22a.m.-11:30a.m., the water temperature in room #306 was 135.6. In room #309 the water temped at 124.6. In room #308 the hot water temped at 122.9. Due to hot water temperature concerns it was determined to have the facilities Maintenance Assistant (MA) accompany the surveyors to take water temperatures concurrently with the surveyors. Temperatures below are from the MA's thermometer. At 1:30p.m. - 2:20p.m., the water temperature in room #101 was 130 degrees. In room #102 the water temped at 138 degrees. In room #209, the water temped at 122degrees. In room #104 the water temped at 133.7 degrees. At 2:26p.m, Meeting with the ADM, MA, DNS and the Consulting Director of Nursing (CDNS). The ADM stated, "We called in a plumber, I knew the water temps were fluctuating." The MA called a plumber last week, (Monday 10/14/13) after he notified me...I was not in the building. When asked to see a bill or report from the plumber the facility called to evaluate the hot water concerns none was provided. The MA stated," He (the plumber) did not leave any information and did not charge for the visit, he said everything was fine and he could find no problems." When asked for the name and telephone number of the plumber none was provided. The MA opened up a phone book to the plumbing section in the yellow pages, however, failed to provide a name, telephone number or date of a plumber's visit prior to 10/22/13. The ADM stated, since the time I was made aware of the hot water temperatures in the building last week (10/14/13), we have been doing constant adjustment and monitoring." When asked to see documentation of water temperatures being monitored none was provided from 10/14/13 - 10/22/13. The MA stated, "I did not write anything down. At 3:55p.m., the beautician stated, "Yeah, the water gets really hot, it never stays one temperature ..." At 9:38a.m..."NA B stated, the water situation had been worse over the past " two weeks, maybe a month." At 12:00p.m., NA C stated, " Yes the water temperatures vary ... Sometimes it is really hot ... too hot for my hands..." <Falls> Resident 214 Resident 214 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the record and the daughter, the resident had a history of [REDACTED]. The fall assessment done on admission indicated the resident was at high risk for falls and the Minimum Data Set (MDS), a comprehensive assessment, dated 8/20/13 also indicated the resident was at risk for falls. A review of the record and the accident/incident reports revealed the following: On 8/17/13 the resident was found sitting on her floor next to her bed. The incident report was initiated but never completed for this fall. No assessment or recommendations done. On 8/19/13 the resident was found sitting on the right side of her bed on the floor. The resident had a tab alarm in place but the string was too long and the alarm did not go off. It is unclear from the records when the tab alarm was started. Recommendation was to change the tab alarm to a pressure alarm and place one side of the bed against the wall. On 8/21/13 a progress notes indicated the resident attempted to get out of bed several times on her own. On 8/23/13 a problem was initiated on her care plan indicating she was at risk for falls with a goal to minimize risk to the resident while maintaining maximum independence. The interventions included assess for assistive devices, assess risk factors, Occupational (OT) and Physical Therapy (PT) eval and treatment, and see in room care plan. On 9/2/13 the resident attempted to sit on the edge of her bed and self-transfer. According to the incident report she slid to the floor and landed on the floor mat. It is unclear from the records when the floor mat was placed next to the resident's bed. Interventions initiated included low bed, near nurse station, one side of bed along wall, mat on floor. The directive to keep the resident near the nursing station was not found on the in room care directive and was not added to the care plan. On 9/4/13 an order was received to discontinue the alarms. No indication could be found in the chart indicating the reason for the discontinuation. On 9/5/13 the resident attempted to transfer herself from bed to her wheelchair. The incident report was initiated but never completed for this fall. No assessment or recommendations were done. On 9/10/13 the resident was found lying on the mat on the floor next to her bed. The incident report was initiated but never completed for this fall. No assessment or recommendations were done. On 9/15/13 the resident was found on the floor mat with pillows under her head. The recommendation was WCTM (Will continue to monitor). No new interventions or recommendations were made. No assessment regarding the effectiveness of the current interventions could be found. On 9/18/13 at 7:00 am the resident attempted to self-transfer out of bed. She sustained a skin tear to her right forearm. The recommendation was for a bolster mattress (a rimmed mattress to prevent a person from rolling out of bed). On 9/18/13 at 3:39 pm the resident was found on the floor lying next to her bed with a skin tear to her left arm. Recommendation was to place a "rimmed mattress" on the bed. It is unclear in the record if the bolster mattress had been placed on the bed after it was recommended with the first fall earlier in the day on 9/18/13. On 9/20/13 the resident fell out of her wheelchair when she was attempting to pick up a jacket she had thrown on the floor. This fall resulted in a skin tear to her right elbow. No assessment or recommendations were made. On 9/23/13 the resident fell out of her chair when she attempted to reach for a ensure on the dining room table. The daughter had been with the resident and left the dining area to speak with the nurse. Recommendation was to educate the daughter about the importance of leaving the resident in a high visibility area. The intervention for leaving the resident in a high visibility area had not been placed on the care plan as of this date. On 9/27/13 the resident was found on the floor in her room next to her bed. Recommendation was to continue with raised lip mattress and frequent staff checks while resident in bed. No new interventions or recommendations were made. No assessment regarding the effectiveness of the current interventions could be found. On 9/29/13 the resident fell when attempting to transfer herself into the wheelchair from the bed. The recommendation was to Continue with the POC (plan of care). No assessment regarding the effectiveness of the current interventions could be found. On 10/1/13 the resident fell out of bed. She complained of right shoulder pain and was given Tylenol. Tab alarms were placed on the resident by the floor LN. No assessment regarding the effectiveness of the current interventions could be found. On 10/2/13 a Computed Tomography (CT) scan (a scan that uses X-rays to make detailed pictures of structures inside of the body) of the resident sacral area revealed the resident had new fractures of the sacrum. The CT scan was obtained after the resident had fallen 9 times. On 10/7/13, after a referral to the orthopedic doctor, the doctor called the facility and indicated he did not feel there was anything he could do for the resident. He also indicated resident 214 should be referred to an endocrinologist. Per RCM A, as of 10/29/13 this recommendation had been acted upon. On 10/10/13 an intervention was added to the care plan to seat resident where constant or near constant observation is possible. No further interventions were added to the residents care plan to mitigate the risk of falls although the resident had fallen 13 times as of 10/10/13. A Review of the in room care directive (an information sheet with interventions for direct care staff to use when assisting the resident) dated 10/24/13 showed no information regarding the residents communication difficulties or the interventions to use to allow resident the ability to make her needs known. No intervention was noted regarding keeping the resident near the Nursing station or within line of site of staff. Observations of resident throughout the survey revealed the following: 10/21/2013 9:43 AM Resident was sitting in the hall near the nursing station. Her wheelchair was slightly in of another resident's chair. Resident 214 kept trying to stand. Resident 214 had an alarm on the chair to alert staff if he/she was trying to get out of the chair independently. Each time she scooted forward to stand the alarm went off. 10/22/2013 5:03PM Resident sitting in the hall by the Nursing station. Often trying to get out of her chair and setting off the chair alarm. Staff not responding. 10/23/13 4:00 pm Resident returned to the facility from a physician's appointment and dropped off by the nursing station at 4:00 pm by activity staff. The resident was observed grabbing her peri area, pulling up her skirt and trying to shove a wad of paper towels into her peri area and waving her hands to summon assistance from staff standing by. The resident kept repeating "I need to go to the bathroom" Surveyor approached after approximately 5 minutes as she continued to try get attention unsuccessfully. She told the surveyor "I am urinating." 10/25/ 12:53 pm Resident trying to get out of wheelchair over and over. Very anxious. No staff responded for approximately 3 minutes although the chair alarm was going off each time she tried to stand. 10/25 2:10 pm Resident sitting in hall across from Nursing Station. She keeps trying to stand up. Staff sitting at the nursing station were trying to give report but resident kept trying to get out of chair and setting off the chair alarm. Softly saying "help, help." The resident began stating "I'm urinating, I'm urinating, help, help." A activity staff member comes and asks if she wants to play games. Resident states "no, no I'm urinating, I'm urinating, bathroom" grabbing at her peri area. 10/27 Between 9:43 and 10:00 am the resident requested to lay down three times.10/27/13 10:00 am The DNS wheeled the resident down hall stating "let's go watch some of your favorite black and white movies on the TV in the lounge." Resident not laid down as she had been requesting. 10/28/13 10:05 am Sitting in front of NS by self. Asked staff to take her for walk. Staff stating "hold on (resident 214) I need to finish with this other resident first then I will come with you." On 10/29/13 a review of the record and interview with RCM A revealed the resident fell again on the afternoon 10/28/13. In the fall she suffered a laceration above her right eye. At that time a 1:1 was initiated for the resident. A staff person was to be with her at all times. During an interview with the family member on 10/28/13 she indicated she had requested the pressure alarms be placed back on the resident's bed and Wheelchair "at least three times in the week before (resident 214) fell and fractured her sacrum. I think at least one fracture could have been avoided." The family member further indicated "I was disappointed when I didn't see them responding when things would happen and I knew it wasn't normal for my mom. I feel like I have to be on top of things. I wanted and requested the CT scan after she fell ." In an interview with the RCM A on 10/29/13 a timeline was presented to the surveyor and reviewed. On the timeline the RCM indicated "alarms were placed on bed and wheelchair 8/17/13. The only place this is indicated is the incident report, it is not indicated anywhere else in the record. I do not know why the alarms were discontinued on the 4th. I looked and can't find any indication of a reason. The first time I know the alarms were back in place was on 9/24 when the family member requested them and I filled out the consent. On 10/10 we also placed on the Care plan to place her where she can be constantly monitored. I believe the reason we didn't get the order from the MD for the alarms and floor mats is because it fell through the cracks. We didn't know we needed to have the MD order for those." In an interview with the DNS on 10/29/13, she indicated "We have tried chair alarms, bed alarms, and the mattress on the floor. We had a regular mattress but there was a concern about infection control so we removed it and placed a perimeter mattress on the floor instead. (Resident 214) is very impulsive. I think sometimes she thinks she can do things she was able to do in her 20's. We tried the alarms but those don't really work for her because they don't remind her to sit back down." On 10/29/13 discussed with DNS the incident reports and the lack of assessment and analysis on 4 reports and discussed the analysis on the other reports that keep suggesting the same interventions or just say WCTM or follow current POC. Asked DNS if there is anything else they may have that gives more info about each incident or analysis of each incident. She indicated everything they had given to the survey team was all they had available. She further indicated she recognized the breakdown in investigation and analysis of incidents. Resident 263 Resident 263 was admitted to the facility 9/28/13 with [DIAGNOSES REDACTED]. Resident 263 resided in the facility for 6 days before she was transferred to the hospital after a fall with a hip fracture. Review of the record showed resident 263 was assessed on 9/28/13 as a high risk for falls due to her CVA and left sided weakness and MS. The occupational therapy notes for 9/28/13 indicated the resident was a one person assist with transfers. A preliminary Care plan was initiated on 9/28/13 with a problem related to the resident' high risk for falls. The goal was "Rs (resident) to have no falls/injury." The only intervention on the preliminary plan was "see in room care plan." The in room care directive indicated the resident was 1 person assist for ambulation and transfers. However no specific interventions were noted to mitigate the resident's risk for falls. On 9/29/13 resident 263 fell in the bathroom while attempting to transfer self. Recommendations at the time of the incident report included "Staff to reinforce need for resident to wait for staff assistance with transfers and toileting," and "find out resident's usual routine and attempt to follow it." A review of the in room care directive showed neither of these interventions was added to the care directive. A review of the resident records showed no indication anyone had attempted to gather information about the resident's usual routine. According to the incident report, the family indicated the resident had a tendency to be impulsive with self-transfers. This information was not placed on the Care plan or the in room care directive for staff to be aware. On 10/3/13, resident 263 fell twice in her room within an hour period. A review of the incident report showed, after the first fall on 10/3/13 a pressure alarm was added to the wheelchair and a recommendation was made to ensure resident 263 was not left alone in her room. According to the witness statement, the instructions given after the first fall indicated the resident was not to be left alone. Neither of these interventions were added to the in room care directive. During an interview on 10/31/13 with RCM A, he indicated he had placed the resident near the nursing station after the first fall on 10/3/13. While he was on the phone a family member of another resident took resident 263 into her room and left her there. It was just after this the resident fell a second time. On the afternoon of 10/3/13 at 5:18 pm, an order was received to obtain an x-ray of resident's right hip as she was complaining of increased pain on her left side after the falls. On 10/4/13 an xray was obtained and showed a left hip fracture. The resident was discharged to the hospital at 5:07 pm that evening. Resident 182 Resident #182 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's preliminary care plan, dated 8/1/13, indicated the resident received daily scheduled medications of two antipsychotics, an antianxiety, an antidepressant, an anti-seizure and a narcotic for pain. This care plan identified the resident with impaired activities of daily living (ADL) and at low risk for falls/injury. The preliminary care plan did not identify interventions or goals in place for seizure precautions or to prevent incidences of falls/injury for a resident with significant, multiple risk factors to include falls, diagnoses, medications and extensive requirement for assistance. The resident's Minimum Data Set (MDS) an assessemnt tool, dated, 8/8/13, indicated the resident was moderately impaired with daily decision-making skills and required extensive assistance with ADLs. The resident's record dated 8/1/13 to 8/11/13 documented the resident had intermittent episodes of confusion, multiple complaints of pain, and vertigo complaints on 8/5/13 and 8/6/13. There was no additional documentation the facility re-assessed, re-evaluated the resident or identified interventions to develop or revise the plan of care. Record review revealed the resident had an un-witnessed, injury fall while standing at her sink brushing her hair the morning of 8/12/13. The resident sustanined bruising with swelling to the face and left shoulder pain. The facility transferred the resident to the emergency room . Resident #182 was re-admitted to the facility on [DATE] with a left shoulder fracture. Although, the facility's investigation indicated the resident's substanstial injury was reasonably related to her seizure disorder, the preliminary care plan did not identify interventions for seizure precautions or for the prevention of falls/injury for a multi-risk resident. The re-admission preliminary care plan dated 8/13/13 identified the resident with impaired ADL mobility, receiving psychiatric medications, and high risk for falls. The Resident's Care Area Assessment (CAA) dated 8/20/13 for falls indicated the resident was at high risk due to impaired balance, multiple medications, seizure disorder, and confusion with impulsivity, poor safety awareness and impaired memory. Resident #182's falls care plan dated 8/22/13, documented interventions not to leave the resident alone in the bathroom, assess for assistive devices, occupational and physical therapies, and see in-room plan of care. The in-room care directive was dated 8/13/13 and "redid closet sheet @ (at) 9/2/13" without specifics as to what was "redid..." The care direective documented mobility as independent with walker and wheelchair for ambulation. The safety device for the resident was a bed alarm and not to be left alone in the bathroom, which contradicted the resident's independent status. There was no documentation of what specific measures were implemented for seizure precautions or to prevent additional falls/injury. According to the resident's clinical record, Resident #182 continued to have two non-injury falls on 8/27 and 8/29. The staff documented the resident was confused and forget to use the call light. In both incidences, the resident attempted to get to the bathroom. There was no documentation what the facility did to mitigate falls or evaluate the effectiveness of the current interventions. Resident 222 Resident #222 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's preliminary care plan, dated 8/20/13, indicated the resident had confusion and forgetfulness with impaired ADL ability requiring two-person maximum assist, was receiving an anti-anxiety medication as needed and a regularly scheduled blood thinner. This care plan identified the resident at high risk for falls/injury. Resident #222 had eight falls within 14 days to include four on one day. The resident's in-room care directive, dated, 8/20/13, documented rimmed mattress, pressure alarm on wheelchair and bed. The facility's documentation revealed the resident had a non-injury fall on 8/21/13 rolling out of bed at 8:45 p.m. There was no documentation the facility re-evaluated the effectiveness of the rimmed mattress or the functionality of the bed alarm. The resident had four falls on 8/22/13, with three of the falls, the resident complained of hitting her head. At 3:15 a.m., the staff found the resident lying on the floor next to her bed with complaints of hitting her head. The witness report documented the resident "moving around a lot in bed ...pillows were put on her left side to prevent her from falling off of bed again." At 7:00 a.m., the staff found the resident on the floor in her room with complaints of hitting her head. The facility's incident investigation documented the resident was agitated, restless and confused. No new interventions were put into place to prevent further falls for Resident #204 with a TBI receiving a blood thinner medication. There was no documentation the facility re-evaluated the effectiveness of the rimmed mattress or the functionality of the bed alarm for these two falls. At 8:16 a.m., the staff found the resident beside her wheelchair with complaints of hitting her head. The description on the facility's incident investigation indicated, "The family took resident outside for a walk and was not injured in the fall." There was no documentation the facility communicated with the family regarding precautions to be aware of with the resident to prevent falls. At 5:00 p.m., the staff found the resident with her back on the mat next to her bed. There was no documentation of evaluating the effectiveness of the current interventions or implementing new interventions to prevent further falls. Progress note dated 8/23/13 documented resident had a bruise to her right buttock measuring 12.5 centimeters by 12.5 centimeters (4.9 inches by 4.9 inches) as resident has a history of falls on 8/22. After five falls, an individualized falls care plan dated 8/23/13 indicated the resident was at risk for falls due to impaired safety awareness, balance, trunk control, and proprioception (sense of one's body, limb movement, and positioning. Interventions included do not leave alone in the bathroom, low bed with one side along the wall, mattress next to bed as extension of the bed, sensor alarms on bed/wheelchair, physical/occupational therapies and tilt wheelchair to provide resident assist with trunk balance allowing her to be safely up in wheelchair. The next day, 8/24/13 at 4:43 p.m. another fall occurred. The facility's incident investigation indicated, "resident stood up from W/C (wheelchair), NIF (non-injury fall), NWF (non-witnessed fall). The witness report documented, "after this we put a pressure alarm in her chair." The care directive dated 8/20/13 identified an alarm should be placed in the resident's wheelchair. The resident's MDS dated , 8/27/13, indicated the resident was moderately impaired with daily decision-making skills and required extensive assistance with ADLs to include transfering, walking, and toileting. The MDS identified the resident had two or more falls since admission. Resident #222's CAA for ADLs and falls dated 8/27/13. The CAAs documented the resident had multiple falls since admit and was recovering from a TBI. The resident had cognitive deficits, was impulsive, does not like to wait, and displayed poor safety awareness. On 8/30/13 at 9:00 a.m., the staff found the resident on the floor, near her bed with no injuries. There was no documentation the facility re-evaluated the effectiveness of the current interventions or implemented new interventions to mitigate further falls. On 9/2/13 at 6:00 p.m., the staff found the resident on the floor, near her bed "with fecal matter around herself" hurting her wrist. On 10/29/13 at 11:42 a.m., the DNS reviewed the resident's chart and stated the resident was impulsive as she had a brain injury due to a motor vehicle accident. The DNS said the resident was "very challenging in the beginning with poor safety awareness." The DNS reviewed the resident's multiple falls on 8/22/13 to address what the facility did to mitigate future falls. She said a low bed against the wall was probably implemented within the first 24 hours due to the resident's condition. The perimeter mattress came next along the way with the mat, and then alarms fairly close in the beginning. The DNS said the Resident Care Managers should update the care plans and care directives to indicate the resident's fall risk level and when interventions change. The DNS stated, "...we did not do things we should have done."

Based on observation, interview, and record review, the facility failed to administer services effectively and efficiently in order to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. Failure to recognize and develop immediate corrective action related to known fluctuating water temperatures, unsecured oxygen tanks, repeated occurrences of falls for 2 of 2 current residents (#s 65 and 214) and 4 of 4 discharged residents (#s 182, 222, 224 and 263) resulted in an immediate jeopardy on 10/21/13, 10/22/13 and a safety plan for Resident #214. Failure to address the potential risk of environmental hazards over a prolonged time placed residents at risk for serious injury. Findings include: 1) Administration failed to evaluate and respond in a timely manner to known environmental hazards placing residents at risk for injury related to fluctuating water temperatures, unsecured oxygen tanks and resident falls (#'s 214, 263, 182, 222). a) On 10/21/13, the facility's water temperatures were observed to fluctuate between 90 degrees Fahrenheit (F) and 138 degrees F in residents' rooms. Interviews with dietary staff, nursing assistants, the bath aide, and the beautician indicated the Administrator (ADM) and the Maintenance Department (MD) knew about the fluctuating water temperatures over a period of months. b) On 10/21/13 at 9:30 a.m., the facility staff was observed securing a portable oxygen tank in a pillowcase with one knot to the back of Resident #253's wheelchair. At 9:56 a.m., two oxygen tanks were observed unsecured in the outside storage room. Record review revealed seven in-service training sign-in sheets addressing the safety of oxygen tank use and storage dated back to 10/11/12. c) Falls: - Resident #214 was admitted on [DATE] an had 14 falls between 8/13/13 to 10/28/13 resulting in the resident receiving skin tears and after the ninth fall the family requested a CT scan which revealed a fractured sacrum (bone located at the base of the spinal column). - Resident #263 was admitted to the facility 9/28/13 Six days later, Resident #263 fell twice in her room within an hour sustaining a [MEDICAL CONDITION]. - Resident #182 was admitted to the facility on [DATE] with a history of falls with fracture. Record review revealed the resident had an un-witnessed, injury fall while standing at her sink brushing her hair the morning of 8/12/13. The resident was diagnosed with [REDACTED]. After readmission the resident had two non-injury falls on 8/27 and 8/29. There was no documentation of what specific measures were implemented for [MEDICAL CONDITION] precautions or to prevent additional falls/injury. - Resident #222 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #222 had eight falls within 14 days to include four on one day and four with complaints of head injury. Refer to F323 This is a repeat citation from 2011 and 2010. 2) Administration failed to ensure thorough investigations to rule out abuse and/or neglect for Resident #s 65, 214, 263, 224 & 204 reviewed for incidents and investigations. Refer to F225. 3) Administration failed to ensure residents received an accurate assessment with an individualized plan of care to prevent the development of avoidable pressure ulcers, avoidable weight loss, falls/injury related to [MEDICAL CONDITION] activity and receive the required care and services for hospice and dental. This caused harm to Resident #s 133, 82 and 182. Refer to F278 4) Administration failed to ensure nursing service implemented Resident #133's plan of care for the treatment of [REDACTED]. This caused harm to Resident #133. Refer to F314 for details. 5) Administration failed to ensure an effective system in place to prevent avoidable weight loss. This caused harm to Resident #s 91 & 134. Refer to F325 6) Administration failed to ensure an effective collaborative system with appropriate care and services in place for residents receiving [MEDICAL TREATMENT], residents at risk for constipation and pain. Refer to F309 7) Administration failed to ensure an effective infection control system in place to offer and administer required PPD screening for residents and staff, pneumococcal immunizations for residents and prevent the spread of infectious diseases. Refer to F441, F334, WAC 388-97-1380, and WAC 388-97-1400. This is a repeat citation from 2012, 2011 and 2010. 8) Administration failed to ensure a system in place to ensure residents were free of unnecessary medications related to adequate indications for use and consistent monitoring of psychoactive, pain and blood pressure medications. Refer to F 329 9) Administration failed to ensure available nursing staff were resourced effectively for residents to prevent avoidable falls/injuries, pressure ulcers, weight loss and receive medications. Refer to F353 10) Administration failed to ensure food was stored prepared and served under sanitary conditions. Repeat citation from 2011 and 2010. Refer to F371 11) Administration failed to implement an ongoing, comprehensive Quality Assessment and Assurance Program addressing care systems and management practices enhancing residents' quality of life and resident choice. Refer to F520

Based on observation, interview and record review, the facility failed to have sufficient qualified staffing to provide and supervise care for residents with complex health care conditions for 7 of 13 sampled residents (#65,91,134,214,204,219,263) The facility did not have sufficient staff that was skilled and/or trained in providing timely and needed care to residents. The care provided was not supervised in a manner to provide consistency in therapeutic approaches to avoid actual harm. Staff did not adequately assess, evaluate, report or document information needed to formulate effective and timely interventions. The harm resulted from a failure to provide care and services to maintain resident's highest practicable well being in the areas of; responding to avoidable hazardous accidents, maintenance of nutrition (weight) unless unavoidable, ensuring dignity of all residents, and development of pressure ulcers. Findings include: 1) 42 CFR 483.13(c)(3) F-225 Resident Behavior and Facility Practice, The facility failed to thoroughly investigate and immediately report alleged incidences of abuse and/or neglect and prevent further similar incidents for 4 of 7 (#s65,204,214 &263) residents reviewed for accidents and incidents. 2) Refer to 42CFR 483.15(a), F-241 Quality of Life, The facility failed to promote dignity during meal time and failed to maintain resident dignity by serving last and labeling residents in the dining room who required assistance to eat. 3) 42 CFR 483.25(h)(1) F-323, Quality of Care, The facility failed to ensure the resident environment was free from accident hazards. This failure to identify environmental hazards placed all residents in the facility at risk for the likelihood of avoidable harm. 4) 42 CFR 483.25(i)(1), F-325 Quality of Care Maintain Nutrition Unless Unavoidable. The facility failed to maintain acceptable standards of nutritional status for 3 resident's (#s 91,134, & 219) and failed to recognize and aggressively intervene to address weight loss for all residents. During interviews with residents and/or resident representatives (#s 65, 77, 224, 246,253,260 &261) complained of problems with receiving care or assistance from staff due to lack of sufficient staffing. All 5 of these residents/representatives gave examples of prolonged waits for assistance when they requested help from staff either verbally or by activating their call light. On 10/31/13, at 1:00p.m., Meeting with the Administrator (ADM) and Consulting Administrator (CADM.) The CADM stated, the staffing in the building was based off of facility census. The ADM or CDAM could not describe how the care needs of the residents was determined to ensure appropriate staff was in place.The facility admitted ,[DATE] residents per day. The population of the building was mostly transitional, short term, and rehab. The facility failed to take into account the acute needs of the resident population to ensure their needs were met.

Based on interview and record review it was determined the facility failed to conduct a Quality Assessment and Assurance Program (QA&A) that identified deficiencies.The facility failed to follow their own policies and procedures to report and thoroughly investigate accidents; failed to maintain adequate staffing levels to meet the needs of residents; failed to identify and effectively address weight loss issues concerns for facility residents; failed to identify and respond to in-house development of pressure ulcers and failed to ensure a sanitary environment in the facilities kitchen. Failure to identify and correct identified concerns resulted in harm for Residents (#91, 133, 134, 214, & 219). These failures placed all residents at risk for decreased psychosocial well-being and/or quality of life. Findings include: Throughout the survey the following deficiencies were identified: Refer to F-225 for failure to implement facility policies to investigate and report allegations of abuse neglect or mistreatment. Refer to F-323 for failure to ensure all residents were free from accident hazards. Refer to F-325 for failure to maintain nutritional standards for residents unless unavoidable. Refer to F-353 to have sufficient numbers of qualified staff to provide and supervise care for residents. Refer to F-371 for failure to store, prepare and serve food in a sanitary manner. On 10/20/13 at 6:00 p.m., the Administrator (ADM) was interviewed regarding the QA &A process. The Administrator stated the committee met quarterly and addressed facility quality care issues monthly as needed. The ADM stated the committee included the Director of Nursing (DNS) Social Work Director (SSD) and the Dietary Manager (DM.) The ADM stated the Medical Director nor any other physician had attended QA meetings over the past year. On 10/31/13 at 1:00p.m. F-225: The ADM reported during the survey time frame issues related to investigations had been identified and the facility was working on a plan "going forward." F-323: Regarding potential accidents hazards in the facility during the survey an Immediate Jeopardy (IJ) was called on 10/21/13 due to unsecured oxygen tanks in use by residents and in storage. The ADM reported everyone was responsible on daily basis to ensure a safe environment for all residents. F-325: The ADM stated, "The computerized system to tracks all weight loss and a report is pulled for QA." F 353: The ADM reported, "The facility ran call light audits response as needed when residents voiced concerns. Responses from resident interviews were discussed in QA&A." F-371: The ADM reported, "The facility had identified issues of cleanliness and sanitation in the kitchen and received a report from the Registered Dietician (RD) on 10/16/13." The ADM stated,"In the QA meetings discussion of facility processes are discussed. Information about deficiencies is collected in different way, for example, resident council minutes, random questioning throughout the building ... we look for trends and review them ...We pull things forward to QA like abuse protocol, or infection control ...monthly or quarterly it just depends." < Management Staff Interviews> On 10/30/13 at 4:00p.m., the Social Service Director (SSD) was asked how the facility identified quality deficiencies, and how concerns were brought to the QA committee? The SSD stated, "We look at resident and family concerns. Whatever concerns we discuss are resident focused, and we figure out what we need to do, and investigate more. QA meetings are sporadic we used to have them one time per month; I don't remember the last time we had one." On 10/31/13 at 10:30a.m., the Director of Nursing Services (DNS) stated, "If quality deficiencies are identified, I get calls at home...If it is less urgent the RCM brings it to the standup meeting and we discuss it as a team...We have a QA meeting, I think it's quarterly. When asked who attended the QA meeting the DNS stated, "department heads, but, not at the same time, they come in and out." When asked what concerns had been discussed recently (over the past year generally) by the QA committee, the DNS could not recall anything specifically. The Dietary Manager (DM) at 2:30p.m., was not able to provide any information regarding topics discussed at the QA meetings over the past year. 10/31/13at 4:00p.m., Residential Care Manager (RCM) A, when asked how he notified management of a quality concerns stated, "I just go into the office and talk to them (the ADM and DNS). I cannot think of a specific incident I have brought to them." When asked, how are resident concerns identified and brought to management? RCM A stated, "Really, our processes should be there to notify management and we are working at getting that into place." The facility did not have an effective system to identify quality of care concerns to address in the QA committee and did not have an effective plan in place to ensure plans for improvement were implemented once concerns were brought forward. The facility did not have a medical doctor on the QA committee for over a year and did not recognize this as a potential deficit in ensuring quality of care for all residents in the facility. .

Based on observation, interview and record review it was determined the facility failed to ensure 3 of 6 Sample Residents (#s 91, 134 & 219) reviewed for nutrition and/or weight loss maintained or attained acceptable nutritional status and/or did not experience significant unintentional body weight loss of the 51 residents who were included in the Stage 2 review. Failure to provide a nutritionally adequate diet for Resident #s 91, 134 & 219 resulted in harm. Findings Include: Resident #134 Resident was admitted to facility on 7/24/13 with multiple medical issues to include left [MEDICAL CONDITION] with surgical repair, diabetes and dementia. The resident's admission Minimum Data Set (MDS), an assessment tool, dated 7/31/13, noted mild cognitive impairment, no behaviors or resistance to care, and required set-up for meals but ate independently. The Care Area Assessment (CAA) for nutrition dated 8/4/13 indicated the risk factors for nutritional status were diabetic medications, recent [MEDICAL CONDITION], and dementia. The CAA indicated care planning would be initiated "to monitor risk factors for developing poor nutrition." On 10/20/13 at dinner, Resident #134 was sitting at a table with three other residents. The meal began at 5:05p.m. and her tablemates were served at 5:31p.m. She asked, "Where is my food, all I wanted was a salad." At 5:55p.m., the resident's meal tray arrived after her tablemates had finished. The resident said, "I did not order this" and she did not eat. The meal did not include a salad. At 6:00p.m., NA T was asked about Resident #134, she said, "She is at the wrong table, she should be at the cueing table. She needs help, she need to be cued. The group she is sitting with seem to be a little more social and they encourage her to eat. It would be better for us and more fair for her, she is confused, looking around wondering where her food is." On 10/27/13 at breakfast, the resident sat alone at a table and did not eat anything off her plate. At lunch, the resident was served after her tablemates finished. She did not eat and no staff encouraged her to eat. At dinner, the resident ate 1 bite of a bread stick and 1 bite of the entree. No staff encouraged her or offered a substitute. The Resident's documented admission weight of 132 pounds (lbs) was on the Registered Dietician (RD) admission assessment, the Nutritional Risk Review, and the 14 day MDS. On 10/22/13, the resident's weight was 105lbs, a 27lb or 20.5% weight loss in 13 weeks. A discrepancy of 9lbs was noted as the weight record and further RD assessments had a weight of 123lbs on admission. With that number considered, the weight loss would have been 19lbs or 14.6% in 13 weeks. On 8/7/13, the RD completed the resident's admission assessment for nutrition, no supplements were ordered. The documented admit weight was 132lbs. The resident was identified as "at risk for inadequate nutrition RT (related to) dementia." The intervention was to add HiPro Milk with meals. The RD notes dated 8/23/13 state the resident's weight was 118lbs. "Supplements added last week, will continue with POC (plan of care) and monitor closely until weight stabilizes. Will consider fortifying additional foods and/or adding 2oz (ounces) 2 cal med pass (supplement drink)." On 8/28/13, the RD progress note indicated the weight as 113lbs, "down 5# (pounds) (4.2%) x 6 days." "May need appetite stimulant." On 9/6/13, the RD progress note indicated the resident weighed 111lbs down 2lbs from last weight. The RD indicated intake was down to less than 25% at all meals. "[MEDICATION NAME] (an antidepressant) started recently..." The RD recommendation on this date was 2oz 2 cal med pass which was started on 9/8/13. On 10/3/13 a nutritional risk review was completed by the resident care manager (RCM) C. The reason documented for this review was "weight loss of 8lbs since admit", although weights recorded on this form indicated a 23lb loss. The plan indicated, "asked the ARNP (advanced registered nurse practioner) to increase her [MEDICATION NAME] to 15mg (milligrams) from 7.5 to see if this helps with appetite." On 10/16/13, the RD progress note indicated, "Current weight 104#, now down 19# (15.4%) since admission and down 5# in past 2 weeks. Resident with an average intake of about 25% at most meals. Difficult to provide nourish if food is rejected. May need additional assistance or texture modification? May need increase in [MEDICATION NAME]? Will D/C (discontinue) CCHO diet at this time because foods are fortified and supplements are given. Will also increase medpass to 3oz TID (three times daily) for continued supervised supplementation." On 10/28/13 at 2:22p.m., the Director of Nursing Services (DNS) was asked the process to identify weight loss. She stated, "residents are discussed during the NAR meeting. I write out the forms to communicate weight loss to the doctor. The RD comes in 1-2 days per week, if concerned we will have her see them. The RD does not participate in the NAR meetings, but reads the reports." When asked what interventions were expected with weight loss, the DNS said " labs, talking to the resident about likes .....dining services interview." The DNS was unable to locate a dining service interview to address the resident's likes/dislikes. "Should be done on every resident, must have been missed." The only lab the DNS located for this resident was a [MEDICAL CONDITION] function test from 8/19/13. The DNS reviewed the recommendations for increased [MEDICATION NAME] and med pass or for texture modification, verified these were not followed up on or initiated. On 10/28/13 at 4:03p.m., when asked about Resident #134's weight loss the RD stated, "I don't know what I'm going to do with her. She refuses to eat and we cannot force her to eat." The RD was informed of the multiple observations of the resident being served after the table mates had completed their meal. She shook her head side to side and stated, "I was not aware of this" and acknowledged it could play a role in the resident's intake. When asked what "na" meant for usual weight on the admission assessment, she said, "not available." "We might not be able to figure that out since not in the record, if we have concern I will send the dietary manager in (to find out)." Asked if this was done for Resident #134, she said, "I know she is probably below her usual weight without having that information." On 10/30/13 at 10:05a.m., Resident #134 said, "I weigh about 120lbs, always. I've lost weight." When asked what her favorite foods were, Resident #134 added, "I do like ice cream. I don't have a favorite food. I love all food." RESIDENT #91 Resident #91 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on a regular diet. Resident #91's MDS dated [DATE], indicated the resident was not oriented to time or place, but, was able to make simple decisions about his preferences and needs. The resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Resident #91's weight on admission to the facility 8/19/13 was 220 lbs. On 9/4/13, his weight was 208. On 9/12/13, his weight was 207. On 10/15/13 ,his weight was 198 (which is 22 lbs. less than at admission or a 10.0% loss) Review of the medical record revealed Resident #91 was staffed by the Nutrition at Risk Committee on 10/3/13. An intervention added by the Registered Dietician (RD) to mitigate weight loss was "Large protein portions for all meals." Observations at meal times 10/20/13-10/28/13 revealed Resident #91was ate 100% of his meals at breakfast, lucnch and dinner. On 10/26/13 at 8:30a.m., Resident #91's order was taken for breakfast, he stated, he would like to have 2 sausage links and a piece of toast and coffee. After he completed his meal Resident #91 continued to feel for food on the plate in front of him. He poked at the empty plate with his fork several times. When he did find any food with his fork, he placed his fork down at the side of his plate and ran his fingers in a circular motion around the plate, licking bread crumbs from his toast off his fingers. No additional food was observed being offered to resident. A review of the meal monitor filled out for Resident #91 by the Nursing Assistants (NAs) indicated he was eating most all of every meal. Options on the meal monitor to indicate what Resident #91 ate were; 1) less than 25%, 2) 26-50%, 3) 51-75% and 4) 76-100%. Of 171 entries made since the time of admission to the facility it was documented Resident #91 ate 76-100% of his meals over 85% of the time. On 10/26/2013 at 10:32a.m., Resident #91 stated,"...I eat what is put in front of me." When asked what his usual weight was Resident #91 stated, "215-220 pounds." On 10/27/13 at 12:30p.m., observation of Resident #91 at lunch revealed he at 100% of his food. The protein on his plate was one chicken leg. At 6:40p.m., observation of Resident #91 at dinner revealed Resident #91 ate 100% his food. Nursing Assistant (NA) G stated, "No that is not a large portion, he got the general portion like everyone else receives." Resident #91 was not offered more food. At 7:05 the Dietary Manager (DM) stated, some meals like the casserole are hard to give large protein portions of, for example, the casserole served at dinner. The DM continued, "For lunch he would have gotten 3 chicken legs." On 10/28/13 at 11:00a.m., Residential Care Manager (RCM) C stated, "I understand he has had weight loss, we are trying to get him to eat more, and he is eating what he wants to eat ... I believe we have added fortified large protein portions." When asked who was monitoring to ensure Resident #91 received large protein portions RCM C stated, "The NA's are monitoring what he eats..." When asked for documentation of any interventions that had been tried to decrease the weight loss of Resident #91 RCM C stated, "I did not document anything." At 4:03p.m., the RD stated, she had completed Resident #91's initial nutrition assessment on 8/28/13. On 9/6/13. The RD stated she did not actually know what Resident #91's usual weight was. On 10/3/13 resident #91 was staffed by the Nutrition at Risk committee. It was identified he had a 22 pound weight loss since admission to the facility on [DATE]. It was identified he was eating well, 76-100% of all his meals. A plan was put in place to talk to the family about his usual weight and dietary preferences. On 10/10/13 further documentation by the RD and the NAR committee, documented, "May benefit from a snack of a meat sandwich ... " The RD stated, "None of these interventions had been implemented..." Although the resident experienced a 22 pound weight loss, the facility failed to put interventions in place in order to prevent further weight loss. RESIDENT 219 Record review revealed Resident #219 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on a regular diet. Resident #219's the MDS dated , 9/5/13, indicated she required extensive assistance with eating to include; cues, supervision, oversight and encouragement. The resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Resident #219's weight on admission to the facility 8/29/13 was documented to be 146 pounds. On 9/24/13 Resident #219's weight was 136 pounds. On 10/29/13 Resident #219's weight was 132 pounds. On 10/30/13 at 11:00a.m., Resident #219 stated, "I have lost weight my normal weight is 145 pounds... My husband is telling me I am too skinny and need to eat ... Currently I am having trouble eating, things just don't sound good to me." On 10/30/13 and 10/31/13 during at lunch, Resident #219 was offered no cues, encouragement or assistance with eating. Resident #219 ate less than 25% of her meals. 10/31/13 at breakfast and lunch, Resident #219 was observed to eat less than 25% of her meal. No alternatives were offered, no assistance with meals was observed. At 12:30p.m., Residential Care Manager (RCM) A stated, "We have NAR (nutrition at risk) meetings that are supposed to happen every week. The last one we had was a couple of weeks ago." Review of the documentation from resident 219's NAR staffing revealed, On 9/10/13 a note from the Registered Dietician, "... Appetite continues to be very poor, rejects facility food..." On 9/19/13, "...Appetite is poor with average of 25% intake of meals and is refusing supplements. Dietary Manager (DM) to follow up with food preferences. On 10/30/13 at 1:30 the RD stated, "When she (Resident #219) first came in she did not eat anything, she admitted on [DATE]. She hit my radar fast because she was not eating. A Nutrition assessment completed on 9/6/13 ... I saw her again on 9/10/13. I have not seen her since. The RD stated "I do not attend NAR meetings it is the facility policy, that is not the best use of my time, they prefer I follow up on my assessments and documentation." .

Based on observation, interview and record review, the facility failed to promote care for residents in a manner that was respectful and dignified during dining for 7 of 30 current sampled residents (#6, 29, 91, 130, 133, 134 & 216). Additionally, the facility failed to ensure dignity was maintained for one resident (#214) who required assistance with personal care. These failures placed residents at risk for not receiving necessary care and services in a manner to maintain or enhance each resident's dignity and self-esteem. Findings include Resident #214 Resident #214 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations of the resident revealed the following: On 10/21/2013 at 9:43 a.m. Resident was sitting in the hall near the nursing station. Resident #214 kept trying to stand setting off her pressure alarm. For approximately two minutes staff did not respond. A nurse standing approximately 30 feet away stated loudly stating "I'm getting it for you." Resident #214 continued to try and stand. The resident behind her started insisting for Resident #214 to sit down, "I'm going to tell on you, sit down"...you better sit down or I'm going to tell on you." Resident #214 turned around and yelled at the resident behind her. Staff did not come towards the two residents. The staff member loudly stated again, "I'm getting it for you." Resident #214 continued to try and get out of the chair. After approximately three minutes, another staff came out from the back room stating loudly from down the hall "she is getting it for you." Resident #214 sat down. At no time did a staff member attempt to address the situation between Resident # 214 and the other resident or come to Resident #214 and reassure her. On 10/23/13 at 4:00 p.m., the esident returned to the facility from a physician's appointment. The resident was at the nurse's station pulling up her skirt, grabbing her crotch, shoving a wad of paper towels between her legs while waving her hands to get assistance from staff. Several staff members were observed nearby. The resident repeatedly stated, "I need to go to the bathroom." The Surveyor approached after approximately 5 minutes as the resident continued to try to get staff's attention unsuccessfully. She told the surveyor "I am urinating" which was told to the staff sitting at the nurse's station. On 10/25/13 at 2:10 p.m. the resident was sitting across from nurse's station repeatedly standing up setting off the pressure alarm; Staff was sitting at the nurse's station. The resident stated "I'm urinating, I'm urinating, help, help." An activity staff member came and asked if she wanted to play games. The resident stated "no, no I'm urinating; I'm urinating, bathroom," as she grabbed her crotch. The activity staff smiled and said "okay, let's go this way." The activity staff took her into her room and walked away. At 2:24 p.m., the resident was outside her room as the activity person told her there would be music in the Dining Room (DR) and walked away. The resident commented to everyone walking by "there is music in the dining room." One staff responded, "The dining room, no, I think it will be a couple more hours before dinner." Another staff responded, "No, I don't think there are movies today." At 2:31 p.m., Resident #214 indicated it was frustrating when people couldn't understand her. Further examples of staff not listening or not responding occurred on 10/27/13. The resident asked Licensed Nurse A to lie down who told the resident twice she would get someone, and soon. Moments later a staff person came telling the resident she would take her to watch movies in the lounge and guided her wheelchair. The resident was not laid down as she requested. A problem initiated on the care plan (instructions for staff) dated 8/23/13 indicated the resident had garbled speech and difficulty making her needs known. The goal was "(Resident 214) will continue to make attempts to communicate with staff using verbal communication." Interventions included: do not make resident feel bad for not being able to communicate appropriately with others, allow her time to respond, encourage resident to repeat herself if she is not understood. A review of the resident's in room care directive (an information sheet with interventions for direct care staff to use when assisting the resident) showed no information regarding the resident's communication difficulties or the interventions to use to allow resident the ability to make her needs known. The facility was not observed to allow the resident to have her expressed needs met in a dignified manner. DINING On 6/20/13 at 5:30 p.m., a sign measuring 8 X 5 inches in a plastic upright holder was in the center of a dining table. In bold letters the sign on the dining room table read, " CUEING AND ASSISTANCE TABLE. " Resident #s 133,134, 216, 130 and 91 were seated at the table. Residents at other tables in the dining room had their meals delivered and had beverages to drink. No assistance or pre meal beverages were observed to be offered to Residents at the "Cue and Assist" table. At 5:50 p.m., Nursing Assistant (NA) T stated, "The cueing table trays come last all at one time, but, all the other trays come randomly. Meals don't come in any order actually, it is confusing, and the sign helps the staff so we know where people should sit." At 6:15 p.m., (NA) R stated, "I think I would feel labeled if there was a sign like that on a table for me." At 6:25p.m., NA S stated, " ...we don't have enough staff in the dining room to assist the residents who need assistance to eat. That is mostly what it is...we don't have the staff so everyone who needs assistance sits together. I think it's very labeling." .

Based on interview, observation and record review, the facility failed to thoroughly investigate incidents to rule out abuse and/or neglect, protect residents and prevent incidents in accordance with state law and 42 CFR 483.13 (c)(3) for 2 of 2 current sampled residents (#65 & 214) and 2 of 5 discharged /former residents (#263 & 204) reviewed for incidents and investigations. The failure placed the residents at risk for abuse and/or neglect due to lack of thorough investigations. This caused harm to Resident's (#214 & 263). Findings include: Resident #214 Resident #214 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the record and the daughter, the resident had a history of [REDACTED]. Between August 13th and October 31st, the resident had 14 falls, including 2 falls on the same day. A review of the resident record and incident reports revealed the following: On 8/17/13 the resident was found sitting on her floor next to her bed. On 8/19/13 the resident was found sitting on the right side of her bed on the floor. On 8/29/13 two witness reports indicated the resident was found with a bruises on her right and left foot. No documentation was found to indicate the facility completed an investigation to rule out abuse and/or neglect. On 9/2/13, The resident attempted to self transfer from her bed and slid to the floor on the floor mat. On 9/5/13 at 5:45 am the resident was found with a scratch to her left hip region. The incident report did not document an analysis to rule out abuse and/or neglect. As of 10/31/13 the incident report indicated the DNS and ADM did not completed the investigation. On 9/5/13 at 9:15 p.m. the resident attempted to transfer from her bed to the wheelchair. On 9/7/13 a witness report indicated the resident was found with her right thumb nail bleeding. No incident report was found to indicate the facility completed an investigation to rule out abuse and/or neglect. On 9/10/13 the resident was found lying on the floor mat next to her bed. On 9/15/13 the resident was found on the floor mat. On 9/18/13 at 7:00 a.m., the resident was found lying on the mat next to her bed. She sustained a skin tear to her right forearm. There was no analysis to rule out abuse and/or neglect. The DNS and ADM completion date was 10/24/13, over a month after the incident. On 9/18/13 at 3:39 p.m., the resident was found a second time on the floor lying next to her bed, this time with a skin tear to her left arm. There was no analysis to rule out abuse and/or neglect. The DNS and ADM completion date was 10/24/13, over a month after the incident. On 9/20/13 the resident fell out of her wheelchair. This fall resulted in a skin tear to her right elbow. There was no analysis to rule out abuse and/or neglect. As of 10/31/13 the incident report indicated the DNS and ADM had not completed the investigation. On 9/23/13 the resident fell out of her chair. On 9/27/13 the resident was found on the floor next to her bed. On 9/29/13 the resident fell when attempting to transfer herself into the wheelchair from the bed. On 10/1/13 the resident was found on the floor in her room. She complained of right shoulder pain. There was no analysis to rule out abuse and/or neglect. The DNS completion date was 10/22/13 and the ADM completion date was 10/23/13, three weeks after the incident. On 10/6/13 the resident attempted to self-transfer and received two scrapes to her left shin. In the incident report, there was no analysis to rule out abuse and/or neglect. The DNS completion date was 10/22/13 and the ADM completion date was 10/23/13, almost three weeks after the incident. On 10/9/13 a witness report indicated the resident was found to be bleeding near her right eye. No incident report was found to indicate the facility completed an investigation to rule out abuse and/or neglect. Record review showed on 10/2/13 a Computed Tomography (CT) scan (a scan that uses X-rays to make detailed pictures of structures inside of the body) of the resident sacral area revealed the resident had new fractures of the sacrum (lower part of the back). The order for the CT scan was obtained after the resident had fallen 9 times. In an interview on 10/29/13 the Resident Care Manager (RCM) A indicated if a resident was found with a new fracture and the facility was unsure which fall it may be related to, a new incident report should be started and the state hotline called. In an interview with the DNS on 10/29/13, she indicated if a resident had numerous falls with no documentation of a fracture(s), a new incident report should be filed if a fracture is later discovered and it is unclear when the fracture occurred. She further indicated the state hotline should also be called. A review of the incident report log and the incident reports for Resident #214 showed no report was started when the CT scan revealed sacral fractures and the state hotline was never called regarding the fractures. Resident #263 Resident #263 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #263 resided in the facility for 6 days before she was transferred to the hospital after a fall with a [MEDICAL CONDITION]. A review of the accident/incident reports for Resident #263 revealed: On 9/29/13, Resident #263 fell in the bathroom while attempting to transfer self. There was no analysis to rule out abuse and/or neglect. As of 10/31/13, the incident report indicated the DNS and ADM had not completed the investigation. On 10/2/13 the resident was found to have a skin tear to the top of her left forearm. There was no analysis to rule out abuse and/or neglect. As of 10/31/13 the incident report indicated the DNS and ADM had not completed the investigation. On 10/3/13, Resident 263 fell twice within an hour period. Both times the resident was found alone in her room. According to the witness statement, the instructions given after the first fall indicated the resident was not to be left alone. In the incident report, the alleged abuse and neglect area was documented as "no." There was no analysis to rule out abuse and/or neglect. As of 10/31/13 the incident report indicated the DNS and ADM had not completed the investigation. Resident #204 Resident #204 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #204 had eight falls within 14 days to include four on one day. Four of these eight falls were non-witnessed with injury. 1) The facility's investigative report dated 8/22/13 at 3:15 a.m., documented the licensed nurse found the resident lying on the floor next to her bed. The resident had an injury with complaints of hitting her head. The investigation did not have an analysis to rule out abuse and/or neglect. 2) The facility's investigative report dated 8/22/13 at 7:00 a.m., documented the staff found the resident on the floor with complaints of hitting her head on the floor. The investigation was incomplete with no analysis to rule out abuse and/or neglect. 3) The facility's investigative report dated 8/22/13 at 8:16 p.m., documented the staff found the resident beside her wheelchair with complaints of pain from hitting her head on the floor. "Family took resident outside for a walk ..." The investigation was incomplete with no analysis to rule out abuse and/or neglect. 4) The facility's investigative report dated 9/2/13 at 6:00 p.m., documented the staff found the resident on the floor, near her bed "with fecal matter around herself" with complaints of hurting her wrist. The investigation was incomplete with no analysis to rule out abuse and/or neglect. The completions dates for the ADM and DNS were blank for all of the investigations on 8/22/13 and 9/2/13. On 10/29/13 at 11:29 a.m., the DNS explained the facility's incident process was the licensed nurse initiated the form which automatically distributed to the Resident Care Manager (RCM) and herself (DNS). The DNS stated the RCM should investigate it further. Once the RCM was finished, the incident was discussed with her (DNS) and at the stand up meeting. The DNS stated the process to rule out abuse and neglect was not documented on Resident #204's investigations. The DNS said "we have revamped our process recently the computer system is new to us... we should have completed a good overall picture that abuse did not occur, what happened what could it be related to, look at environmental factors or is it medically related, then summarize what is going on. who what when and how and get to root cause why it occurred." RESIDENT #65 Resident #65 was admitted to the facility from the hospital on [DATE]. Resident #65 [DIAGNOSES REDACTED]. Record review revealed the resident had fallen twice since admission to the facility. On 10/12/13, the facility's fall incident report documented, "(Resident #65) was found on the floor by her bed and sustained a laceration three quarters of an inch long to right hand middle finger." There was no investigation of this injury fall. On 10/31/13 at 1:00 p.m., interview with resident's family member/representative stated he was concerned with the facility's lack of interventions to ensure his mother would be safe. "She fell 15 minutes after I left the building a few days ago and had another fall 2 weeks ago." On 10/29/13 discussed with DNS the incident reports and the lack of assessment and analysis on the reports and discussed the analysis on the other reports that kept suggesting the same interventions or just say "WCTM" or follow current plan of care. The DNS indicated she recognized the breakdown in investigation and analysis of incidents. She indicated she was unsure why the incident reports showed her completion dates for incidents as either incomplete, or done in the last week. Refer to F-323 .

Based on observation, interview and record review, the facility failed to conduct ongoing assessments, evaluate the resident clinical conditions and pressure ulcer risk factors, define, follow and implement interventions consistent with the resident needs and identified goals, recognized standards of practice; to monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate for 2 of 3 current sampled residents (#34 and 133) reviewed for pressure sore development. This failure caused harm to resident #133 when the resident developed three pressure sores after admission. Resident #133 Resident was admitted [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), an assessment tool, dated 3/26/13, indicated the resident had no pressure ulcers and was at risk of pressure ulcer development. The resident required an extensive assist of two persons for repositioning and transfers from bed to wheelchair. Resident was frequently incontinent of bowel and had a Foley catheter for urine collection. Resident did not exhibit rejection of care per admission MDS and most recent MDS dated [DATE]. The Care Area Assessment identified risk factors and indicated to proceed to care planning. A Braden score (an assessment to measure risk of skin breakdown) was completed on readmit from a hospitalization on [DATE]. Resident scored a 14 which equaled moderate risk. The pressure ulcer care plan dated 3/27/13 and in room care directive dated 9/13/13 were not implemented as follows: The care plan indicated interventions in place as of 3/27/13 to include an air mattress on the bed and a Roho (pressure reducing device) cushion in the wheelchair. Observations of the resident's bed from 10/22/13 through 10/27/13 were no air mattress was in place, a regular hospital bed mattress was in place. According to the Occupational Therapist (OT) A, the cushion in the wheelchair was not a Roho, but a trial cushion which was initiated a few weeks ago. The in-room care directive did not address the resident ' s skin condition and it indicated the resident was a "priority lay down after meals - notify nurse if refuse to lay down," and the turn schedule indicated "frequently." There was not instructions for pressure reduction when up in wheelchair. Multiple observations during the survey found the resident in bed on her back or in her wheelchair for hours between meals: On 10/22/13 at 10:43a.m., resident was in her room sitting in the wheelchair in the upright position sitting in front of the TV with eyes closed; at 12:00p.m., in the main dining room in her wheelchair in the upright position; at 1:30p.m., in bed on back with pillow under left hip with eyes closed; at 3:00p.m., same position with eyes closed; and at 5:00p.m., upright in wheelchair to main dining room. On 10/23/13 at 7:00a.m., resident was upright in the wheelchair at a table in the main dining room; at 9:38a.m. resident was in her room sitting upright in the wheelchair in front of the TV with eyes closed; at 11:27a.m., in same position in room; at 12:10p.m., upright in the wheelchair at a table in the main dining room; at 3:55p.m., sitting upright in the wheelchair at nurses' station; and at 6:00p.m., resident upright in the wheelchair at a table in the main dining room. On 10/24/13 at 3:15p.m., the resident was in bed on her back with the head of bed (HOB) elevated about 45 degrees; at 3:56p.m., awake in bed watching TV on back with HOB at about 45 degrees; and at 4:50p.m., upright in the wheelchair in the main dining room. On 10/25/13 at 9:19a.m., the resident was sitting upright in the wheelchair in her room in front of the TV with eyes closed and left arm on pillow; at 10:16a.m., in same position with eyes closed; at 11:05a.m., remained in same position, but awake; at 11:07a.m., nursing assistant certified (NAC) P wheeled the resident to the main dining room for lunch; at 12:43p.m., the resident remained sitting upright in the wheelchair at a table in the main dining room; and at 2:23p.m., the resident was in bed on her back with a pillow under right hip and HOB at about 15 degrees. On 10/26/13 at 4:00a.m., the resident was in bed on back with HOB at about 15 degrees; at 4:26a.m., was in the same position; at 5:06a.m., same position; at 5:43a.m., same position; at 6:45a.m., sitting in the wheelchair at the nurses' station reclined back; at 7:39a.m., in same position with eyes closed; at 7:52a.m., sitting upright in the wheelchair at a table in the main dining room; at 8:42a.m., upright in the wheelchair near the nurses' station with eyes closed; and at 10:40a.m., sitting upright in the wheelchair in exercise group. The facility's policy and procedure for skin at risk/skin breakdown stated, "It is the policy of this facility, that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing." Record review revealed Licensed Nurse (LN) E made a progress note in reference to a discovered "skin tear" to resident's right buttock during her shift on 10/24/13. The note did not indicate a new treatment was immediately obtained; rather a communication form was left for the Advanced Registered Nurse Practitioner (ARNP) and the wound nurse. According to the facility policy: "4) Upon discovery of newly identified skin impairment, the LN will: notify the physician and obtain a treatment order if needed." The ARNP was not notified for a treatment order until the afternoon of 10/25/13. The last documented skin assessment on the treatment record (TAR) was 10/22/13 on shift 2 and "no skin impairment present" was indicated. On 10/25/13 at 2:24p.m., the area of skin impairment was viewed while LN D and Resident Care Manager (RCM) C assessed the "skin tear ." LN D stated, "It is pressure." LN D indicated, the area on the right buttock was a Stage II (as defined by facility skin grid sheet: partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) pressure sore measured 2.5 centimeters (cm) by (x) 2cm x 0.1cm depth. LN D added the left buttock had a 2cm x 1.5cm suspected deep tissue injury (SDTI) (as defined by facility skin grid sheet: purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue). LN D stated, "the ARNP ordered a [MEDICATION NAME] dressing to be applied and changed every 3 days." On 10/25/13 at 3:16p.m., OT A said, "the cushion (in resident #133) wheelchair was not a Roho cushion." OT A added, "the current wheelchair cushion (Varilite) was a trial that the vendor claims cannot bottom out in it even if sitting all morning. The cushion formed to her buttocks." When asked how inflation level was monitored, OT A stated "it's currently not monitored." OT A also added, "(the resident) is off of therapy, we are waiting for a new wheelchair, then will change the plan of care." At 3:21p.m., when asked how care needs communicated to NACs, RCM C stated, "the information is on the closet sheet (in-room care directive)." RCM C stated, "priority lay down means skin is at risk and lay down after meals." RCM C acknowledged resident #133 is a priority lay down, but "it depends on her mood, frequently doesn't want to lay down, social person who likes to see what is going on and doesn't like to be confined to her room." RCM C indicated the NAC should pass refusals on to the nurse and it should be documented. Review of the progress notes during the survey time period showed one note of refusal made by RCM C on 10/25/13 at 2:42p.m. RCM C verified no other documentation regarding refusals in other sections of medical record. When asked of interventions that were in place prior to the development of new pressure ulcers, RCM C stated, "frequent reposition (which she defined as at least within 2 hours in bed and wheelchair) and Dermaseptin cream to buttocks." RCM C indicated the new plan included: an air mattress, therapy to evaluate wheelchair cushion, a [MEDICATION NAME] dressing to the areas, continue frequent repositioning and priority lay down. She added, "if she continues to refuse laying down I will have the son sign an informed consent." At 5:28p.m., the RD made a note regarding consult for new pressure ulcer. The RD note indicated labs were not current, increased protein and energy needs for healing. "Will recommend Vitamin C, Multi-vitamin, large protein portions and HiPro TID (three times daily) with meals." No labs were requested or ordered. On 10/27/13 at 10:39a.m., asked RCM C the process for placing air mattresses. She indicated the facility owned air mattresses and maintenance puts them on. RCM C was unaware the air mattress was not in place as ordered, "I told MA on Friday and he forgot." On 10/28/13 at 11:18a.m., observed LN D complete the dressing change to right and left buttocks. LN D stated, "(the resident) developed a new stage II pressure ulcer on the distal coccyx slit in between the other two pressure ulcers." It measured 3cm x 1.5cm x 0.1cm. LN D indicated she would follow the procedure to notify the physician, family, registered dietician (RD) and complete an incident report. LN D added, "the area will be covered by a [MEDICATION NAME] dressing." At 2:22p.m., the director of nursing services (DNS) was asked of the process for follow up on orders related to the development of new pressure ulcers, in specific related to Resident #133, to include an air mattress and RD recommendations for vitamin C and a multivitamin which were obtained on 10/25/13. She stated, "there should be no delay with the mattress as they have in house and the RD recommendations should have been forwarded to the physician when received." The DNS verified the orders/recommendations had not been followed up on. At 3:28p.m., RCM C verified the RD recommendations were on the list, but had not been followed up on. She added the air mattress was put in place on Sunday the 27th after she became aware of the delay in placement. At 3:41p.m., OT B indicated a new wheelchair was on order, "the current wheelchair would allow for pressure reduction by utilizing the tilt feature." She stated, "It (the current cushion) has been in place about 2 weeks." OT B was not aware of the resident's newly developed pressure ulcers. "May not be the right cushion, may need to go back to the Roho." At 4:04p.m., RD explained the process of recommendation follow through was for her to complete dietary slips for changes or additions to the meals and the RCMs complete follow up of recommendations for medication and/or lab needs to the physician. When asked how often she would recommend labs she stated, "Labs are utilized and recommended if the resident has a history of abnormals or if [MEDICATION NAME] is skewed because of fluids will ask for pre [MEDICATION NAME], but not routinely." On 10/30/13 at 11:04a.m., review of the resident's record revealed the last labs obtained were 7/31/13 for a basic metabolic panel. No labs were obtained to identify nutritional needs to promote wound healing. RD assessment dated [DATE] indicated most recent labs (7/31/13) within normal limits with no recommendation for follow up labs. Reviewed the incident reported completed on 10/25/13 for the 2 newly developed pressure ulcers. RCM C documented the pressure ulcers were unavoidable related to "resident frequently refuses priority lay down program which includes incontinent care when she allows." Risk factors identified in this assessment included chronic bowel incontinence and poor skin turgor. According to the incident form, "a determination that a pressure ulcer was unavoidable may be made only if routine preventative care is provided. Check if documentation verifies the following: Good skin care (clean, protect from moisture), maintains adequate nutrition and hydration, if possible, and utilizes pressure reduction support surface(s)." All three areas checked even though the resident was not being laid down as a priority and there was not an air mattress on her bed or the cushion in the wheelchair was different than indicated on the care plan. Resident #34 Resident was admitted [DATE] with multiple medical [DIAGNOSES REDACTED]. An incident report was completed on 10/1/13 in relation to the resident developed a heel ulcer. "Resident was found by her aide with a pressure blister to her right heel. The area is purple and measures 2 x 2.5cm." Report indicated an intervention of "blue boots" (pressure reduction devices for feet) are to be used at all times. According to the report the pressure ulcer was "unavoidable" with a root cause "Resident had a fall with fracture to right hip. She is noncompliant with cares refusing turning, etc. Often refuses to free float heels and refuses abductor wedge." The resident's admission Minimum Data Set (MDS), an assessment tool, dated 10/4/13, indicated the resident had an unstageable deep tissue ulcer and was at risk of pressure ulcer development. The resident required an extensive assist of two persons for repositioning and transfers from bed to wheelchair. Resident was identified as rejecting care and verbal behaviors 1-3 days. The resident's care plans dated 10/9/13 did not address that resident #34 had developed a pressure ulcer, only addressed skin at risk. The in-room care directive dated 9/27/13 with dated changes to sections of transfer, weight bearing, and incontinent products on 10/9 and 10/10/13, did not indicate a heel ulcer under wounds. "PRD (pressure relieving device) boots when in bed and w/c (wheelchair), off for transfers, standing" was in different writing, but no date to indicate when this was added to the directive. The care plan and MDS identified resident refused blue boots related to dementia, but no specific interventions were added to the care plan or in-room directive to address refusals aside from reapproach and educate. Unable to locate documentation of other interventions tried to mitigate the risk of developing pressure ulcers. A RD assessment dated [DATE] did not indicate the resident had developed a pressure ulcer since admission; only skin issue indicated on the document was a surgical incision. No nutritional interventions or labs recommended related to a new in-house pressure ulcer. On 10/30/13 at 3:17p.m., the right heel ulcer was observed with LN D. The area as described by LN D was "deep purple with a black area on the end and drying out with edges lifting, it is doing what it is supposed to do." LN D applied [MEDICATION NAME] and area left open to air. The facility failed to assess reasons for care refusals and implement alternate interventions to mitigate the development of pressure ulcers for Resident #34 and #133. .

Based on record review and interviews the facility failed to prevent the development of pressure ulcers for 1 of 3 sampled residents (#1) reviewed who were assessed as being at risk for skin breakdown. Staff failed to perform skin assessments to the resident's left lower leg and foot which resulted in pressure ulcers necessiating an amputation. Findings include: Resident #1: admitted to the facility on [DATE] from a hospital rehabilitation unit with [DIAGNOSES REDACTED]. Review of hospital records revealed the resident had a small, nondisplaced fracture of her left ankle thus was receiving rehabilitation services at the hospital. An orthopedic boot had been placed on the resident's left lower leg and foot by the rehab physician on 10/20/11 to enable the resident to be partial weight bearing for transfers. Review of the resident's medical record and facility investigation report revealed she was admitted with a walking type boot to her left leg. Review of a written statement by the admitting Licensed Nurse (LN) revealed a skin assessment on admission (10/29/11) was not performed to the left lower leg and foot as the boot was not removed based on information from the resident's family member that the boot was not to come off. Additionally, there were no physician's orders regarding the status of the boot. A telephone interview on 11/29/11 at 1:55 p.m. with the above family member noted when asked by the admitting LN regarding whether the boot could be removed or not he stated he did not know. He stated he and the resident relied on staff to to know what to do regarding the boot. Review of the Skin at Risk assessment form dated 10/29/11 noted the resident was at risk for skin breakdown however the plan of care addressing a potential for skin problems was not initiated until 11/9/11 (11 days later). Review of the resident's plan of care noted she was at risk due to decreased bed mobility, bowel and bladder incontinence, obesity, and [DIAGNOSES REDACTED]. Review of the facility investigation report revealed on 11/16/11 the resident's walking boot on her left foot was found with drainage on it and on the bed sheets. The boot was then removed and pressure ulcers measuring 1.2 by 1.8, 0.6 by 0.32, and 3.52 by 3.28 inches were noted on the left foot and 1.8 by 2.16 inches on the left heel. The areas were noted to be "totally necrotic" (dead tissue) with foul odor. The physician was immediately notified and orders received to transfer the resident to the emergency room . Review of hospital records dated 11/16/11 revealed the resident was admitted to the hospital with [REDACTED]. A below knee amputation of the left leg was performed on 11/20/11. During an interview on 11/28/11 at 1:45 p.m. with LN A she stated when she entered the resident's room the morning of 11/16/11 she could smell the foul odor coming from the drainage on the boot. She stated staff had not performed any skin assessments to the resident's left leg and foot due to the walking boot being on. She stated staff had not consulted with a physician to obtain clarification relative to the walking boot being left on or not. An interview on 11/28/11 at 1:50 p.m. with a therapy staff member revealed the walking boot to the resident's left leg was wet with foul smelling drainage on 11/16/11. She stated the walking boot totally enclosed the resident's lower left leg and foot thus skin assessments to the area could not be performed without removing the boot. She stated she was unaware nursing staff was not checking the resident's skin to the left leg and foot. A telephone interview on 11/28/11 at 3:50 p.m. with the above rehab physician revealed the walking boot to the resident's left leg and foot was to have been removed by staff when the resident was in bed or during a shower. Skin assessments were to be performed at that time. He stated the resident's fracture was small and stable thus the walking boot was implemented to allow the resident to be partial weight bearing and to decrease her pain level with activity. The resident did not have any existing pressure ulcers to the left leg and foot upon discharge from the hospital on [DATE]. Despite the resident's [DIAGNOSES REDACTED].

Based on record review and interviews the facility failed to ensure 2 of 22 sampled residents (#'s 166, 9) received toileting assistance in a timely manner. This deficient practice caused actual harm to Resident #166 due to bladder pain. Findings include: Resident #166. Review of the resident's medical record noted documentation on 07/04/11 stating the resident was alert and oriented, and required staff assistance with transfers and toileting. An interview with the resident on 07/12/11 at 9:14 am revealed "have waited more than once 35 minutes to go to the bathroom ... yesterday around noon I had to use the bathroom and had to wait 35 minutes" after putting on her call light. On 07/13/11 at 1:45 p.m. the resident stated she had put her call light on at 6:15 that morning and waited 40 minutes for her light to be answered. The Occupational Therapist (OT) had answered her light. During this time she stated she could hear 4 to 5 female staff members laughing and talking outside her room. She stated she began crying due to the bladder pain she was having. She had been previously diagnosed with [REDACTED]. In addition, she had received a water pill the evening before. She stated she was unable to take herself to the bathroom as her walker and wheelchair were not within her reach as they were across the room. The resident stated she frequently had to wait for her call light to be answered and it usually took over 30 minutes. An interview with the above OT on 07/13/11 at 2:00 p.m. noted she had answered the resident's call light and had assisted her to the bedside commode. She stated the resident had been crying due to the pain she was having with her bladder. Resident #9. During an interview with the resident on 07/12/11 at 9:36 a.m. she stated "they left me sitting on the bedside commode Saturday morning for 35-40 minutes... I had to be ready for my Dial-a-Ride appointment by 9:00 a.m... many times I have diarrhea and can't get to the commode fast enough - very embarrasing". An interview with the resident on 07/14/11 at 9:45 a.m. noted the above incident occurred on 07/09/11 at approximately 7:15 a.m. She stated she had her call light on for 35-40 minutes after the Nursing Assistant (NA) put her on the bedside commode. She stated the NA knew she needed to be ready early that morning as she had a Dial-A-Ride appointment at 9:00 a.m. When the NA answered her call light she stated she had been in room [ROOM NUMBER] caring for another resident. She stated she had been left on the bedside commode before for a long period of time.

Based on record review and interviews the facility failed to provide the necessary care and services to prevent the development of avoidable pressure ulcers for 1 of 3 residents (Resident #1) reviewed with pressure ulcers. Resident #1 developed Stage II pressure ulcers (open areas of the skin tissue caused by unrelieved pressure) to her buttocks and associated pain from being left on a bedpan for a prolonged period of time. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of a skin assessment dated [DATE] revealed the resident was at high risk of pressure ulcers due to very poor nutritional status, limited mobility, was bedfast with problems relating to friction and shearing, and had occasional moist skin. Review of Progress Notes noted a skin assessment dated [DATE] stating the resident was admitted with a Stage I pressure ulcer (persistent area of redness that did not disappear when pressure was relieved) below her coccyx and had several skin areas on her buttocks that did not blanch when pressure was relieved (indicative of insufficient blood flow to the tissues). Review of an assessment between 8/19-25/10 by the Physical Therapist revealed the resident required maximum assistance of two staff members to turn in bed, and was very confused and unable to follow directions. Review of a facility investigation report and Progress Notes dated 8/22/10 noted on 8/22/10 at 12:05 p.m. family members informed staff the resident had been left on a bedpan for over two hours. The skin assessment performed at that time revealed there was an impression of a bedpan to the resident's buttocks. A nonblanchable area measuring one inch was noted on the left buttock. An assessment performed by staff the following day (8/23/10) noted worsening of the skin as evidenced by open blisters to the right and left buttocks and the area below the coccyx had progressed from a Stage I to a Stage II pressure ulcer. Review of a skin assessment dated [DATE] by the Nurse Practitioner (wound consultant) noted wounds were due to a bedpan being left in place with the pressure area outlined on both buttocks in "horse shoe shape". There were several areas of open and closed blisters to the buttocks and two areas that were much darker tissue that "may become much deeper wounds" and was unable to stage them at that time. The remaining areas were noted to be Stage II pressure ulcers. The resident was exhibiting increased pain and anxiety with the wound care. A telephone interview conducted on 9/13/10 at 12:45 p.m. with a family member revealed on 8/22/10 she arrived at the facility at 9:00 a.m. and noted the resident "looked unusually different related to her expression of pain". When she questioned the resident regarding her pain the resident stated "it just hurts" and she was unable to get comfortable. At approximately 11:20 a.m. family members obtained staff assistance to turn the resident in bed at which time they discovered she was sitting on a bedpan. The family member stated there was a "serious, very deep indentation with purple discoloration of her buttocks from the bedpan". Despite the resident's high risk of skin breakdown, actual pressure ulcer on admission, [DIAGNOSES REDACTED].

Based on record review and interviews the facility failed to provide consistent supervision to ensure a safe environment for 1 of 3 residents (Resident #2) reviewed at risk for falls. The extent of supervision was not sufficient to prevent the resident from exiting the facility and falling. The resident sustained [REDACTED]. Findings include: Resident #2: admitted to the facility from the hospital in January 2010 following a fall at home in which she sustained a dislocated shoulder and fractured left ankle. Review of a comprehensive nursing assessment dated [DATE] revealed the resident required staff assistance with transfers and ambulation, and had impaired memory and cognition. Review of Progress Notes between 6/6 - 7/26/10 revealed the resident had fallen to the floor 13 times as she would attempt to transfer without staff assistance either from her bed or wheelchair. Documentation on 6/25/10 stated a wanderguard bracelet (device to alert staff when resident attempted to exit from the facility) was placed on the resident's wrist on 6/24/10 as the resident had wandered out the automatic sliding glass door entrance of the facility in search of her family member who had visited that day. Review of the resident's plan of care noted she was at risk for falls due to incontinence; decreased mobility; poor cognition, safety awareness, and impulse control; and inability to recall fall safety cues from staff. Review of a facility investigation report dated 8/13/10 at 3:20 p.m. noted the resident was being taken in her wheelchair outdoors by Employee #1 for an activity. When she got to the first set of automatic sliding glass doors to exit the facility the wanderguard alarm sounded, thus Employee #1 turned the alarm off. She then left the resident unattended between the two sets of automatic sliding glass doors while she attended to another resident who was inside the facility. During that time the resident exited outside the facility through the second set of doors. Her wheelchair went down the ramp that sloped towards the parking lot. It then tipped over "ejecting" the resident onto the pavement in the parking lot. She sustained multiple bruises to her face with a large hematoma (area of swelling caused by break in a blood vessel) above her left eyebrow. She was then taken to the emergency room . She returned to the facility the following day (8/14/10) with a "goose egg" bump on her left forehead, blackened left eye, and abrasion to the nose. An interview on 9/1/10 at 3:45 p.m. with Employee #1 revealed her back was to the resident when the resident exited the facility and started down the ramp in her wheelchair. She stated she was aware the resident was impulsive, had sustained numerous falls, and would get up unassisted by staff. Despite the awareness of Employee #1 relative to the resident's impulsive behavior, history of falls, and potential for elopement, she turned off her alarm system, then left her unattended in front of the automatic exit door enabling her to leave the facility unsupervised by staff which resulted in substantial facial injuries.