Every finding on record at Sharon Care Center

Based on interviews and record reviews, the facility failed to provide toileting assistance to 2 of 5 sampled residents (Resident 1 and Resident 2) reviewed for Activities of Daily Living (ADL) care. This failure placed residents at risk of skin infections, low dignity, and a diminished quality of life. Findings included.1) Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/07/2025, documented the resident required assistance with toileting and was moderately cognitively impaired. Record Review of Resident 1's facility investigation, dated 10/15/2025, documented, On the morning of 10/15/2025, two CNA's [Certified Nursing Assistants] entered resident room to adjust her bedding in order to pull her up. Upon rolling resident, dried BM [Bowel Movement] was found on the sheets, on her buttocks and brief was stuck to her. The assumption was that she was not checked and changed during the night. In an interview on 11/18/2025 at 10:17 AM, Staff D, CNA, said Resident 1 was dependent on staff for toileting assistance. Staff D said Resident 1 was on a check and change schedule, meaning staff were to check Resident 1's brief every two hours and change if necessary. Staff D said on 10/15/2025 she came in to work at 6:00 AM and relieved Staff C, CNA, who worked the night shift. Staff D said she went into Resident 1's room and found her positioned low in her bed. Staff D requested another CNA to assist her pulling up the resident. Staff D said when she pulled the sheets down she noticed dry BM around Resident 1's bottom area. Staff D said she changed Resident 1's brief and had to scrub the dried BM off Resident 1. Staff D said after changing Resident 1's brief she reported the issue to her nurse. In an interview on 11/18/2025 at 10:39 AM, Staff B, Director of Nursing/Registered Nurse, said the expectation for residents on a check and change schedule was for staff to check the resident every two hours and change their brief if necessary. 2) Resident 2 admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was frequently incontinent of bladder, required assistance with toileting, and was moderately cognitively impaired. Record review of Resident 2's ADL care plan, dated 02/06/2023, documented, maximum to totally dependent on staff for B/B [bowel and bladder] incontinent care. Record review of Resident 2's facility investigation, dated 10/15/2025, documented, On the morning of 10/15/2025 around 8:30 AM it was reported that [Resident 2] had a grievance for something that happened on the night of 10/10/2025. [Resident 2] stated that CNA did not change her brief during the night. [Resident 2] said that this caregiver would come to her room but did not wake her up for a brief change, and the morning caregivers had to make a complete bed change because [Resident 2] was found with a saturated brief, incontinent pad, and top blanket. Upon interview, [Resident 2] acknowledged she was not changed throughout the night. Day shift staff confirmed the condition and documented the resident's statement. In an interview on 11/12/2025 at 10:19 AM, Resident 2 said she required two-person assistance with toileting, and it was hard to get two staff members to assist her. When asked about the 10/10/2025 incident, Resident 2 said she did have trouble getting toileting assistance and did wake up very wet with urine. In an interview on 11/18/2025 at 10:06 AM, Staff E, Residential Care Manager/Registered Nurse, said Resident 2 required maximum assistance with toileting. Staff E said staff were expected to check and change Resident 2 every two hours. Staff E said a staff member reported to her concerned that Resident 2 was very wet from urine. Staff E said she started an investigation and questioned Resident 2 about the issue, who told her Staff C sometimes did not change her during the night. In an interview on 11/18/2025 at 10:27 AM, Staff F, CNA, said Resident 2 was to be checked and changed during the night every two hours. Staff F said aides can reference a resident's care plan if they were unaware of a residents level of assistance. Staff F said her and another CNA had gone into Resident 2's room to pull her up for breakfast. Staff F said she noticed the incontinence pad under the resident was soaked with urine. Staff F said Resident 2 told her no one had been in her room to change her last night. Staff F said she changed the resident, changed her incontinence pad, and reported the issue to her nurse. In an interview on 11/18/2025 at 10:39 AM, Staff B said during the facility investigation, Resident 2 told him she was checked but not changed. Staff B said Residents should be checked and changed every two hours. Reference WAC 388-97 -1060(1)-(3).

Based on observation and interview, the facility failed to ensure food items were labeled and dated when opened in 1 of 3 kitchen refrigerators, and in 1 of 2 nourishment refrigerators (East Hall) reviewed for food storage. The facility also failed to keep an accurate temperature log for 1 of 2 nourishment refrigerators (East Hall). These failures placed residents at risk for food borne illness, and a diminished quality of life.Findings included . During an observation on 09/08/2025 at 9:12 AM, the kitchen refrigerator on the left, was observed with the following expired, opened items: 1. Plastic Tupperware container of Parmesan Cheese- labeled with use by date of 09/02/20252. Plastic Tupperware container of Jam - labeled with ineligible use by date During an observation on 09/09/2025 at 9:23 AM, the nourishment refrigerator on East Hall, was observed with the following expired, opened items: 1. Fruit cup- labeled with use by date of 09/03/2025 2. Six undated fruit cups During an observation on 09/09/2025 at 9:25 AM, the nourishment refrigerator on East Hall was observed with the latest temperature taken on 09/04/2025. Review of the temperature log did not show documentation for the following dates:09/05/2025, 09/06/2025, 09/07/2025, 09/08/2025, and 09/10/2025. In an interview on 09/08/2025 at 9:19 AM, Staff L, Dietary Manager, said the kitchen staff were responsible for restocking, cleaning, and monitoring temperatures in the nourishment refrigerators. Staff L said the items going into the food storage areas should be labeled right away, should be kept until the use by date, and then disposed of by the third day. Staff L stated, We keep it in the fridge for three days. Staff L proceeded to throw away the expired items. In an interview on 09/10/2025 at 11:38 AM, Staff B, Director of Nursing/Registered Nurse, said he expected food items in the refrigerators to be labeled accurately and discarded by the use by date. Reference WAC 388-97-1100 (3) & 2980

Based on interview and record review, the facility failed to complete pain assessments every shift for 1 of 5 residents (Resident 6) reviewed for pain. This failure placed residents at risk for unmet care needs and a diminished quality of life.Resident 6 was admitted to the facility on [DATE], with multiple diagnoses to include vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), fibromyalgia (chronic condition characterized by widespread muscle pain) and chronic pain syndrome. The Quarterly Minimum Data Set (an assessment tool), dated 05/02/2025, documented Resident 6 was severely cognitively impaired.Record review of Resident 6's Nightingale Pain Assessment: Verbal & Non-verbal, dated 08/25/2025, documented Resident 6 occasionally experienced pain and staff assessment for pain should have been conducted.Record review of Resident 6's Nightingale Pain Assessment: Verbal & Non-verbal dated 07/18/2025, documented Resident 6 was unable to verbalize if she had pain and documented indicators for pain which included non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements or postures related to right heel deep tissue injury.Record review of Resident 6's care plan, initiated on 03/28/2023, documented Resident 6 had chronic pain related to fibromyalgia and interventions included to monitor, record and report complaints of pain.Record review of Resident 6's Hospice IDG [interdisciplinary group] Comprehensive Assessment and Plan of Care Update Report, dated 08/19/2025, documented G: PAIN WILL REMAIN AT OR BELOW GOAL OF 4/10 THROUGH 9/1/25. I: SN -ASSESS PT'S [patients] PAIN USING APPROPRIATE SCALE.Record review of Resident 6's nursing progress note, dated 06/27/2025 at 6:29 AM, documented, Notified by CNA [certified nurses assistant] that res [resident] has a skin issue oh R [right] heel. Upon assessment noted res R heel was black 4.7 cm [centimeters] x 5.2cm. no discharge noted. No open areas noted. Third L [left] toe 0.5 cm spot on knuckle. Res reports it is painful.09/08/2025 at 10:09 AM, Resident 6 was observed lying in bed. When asked if Resident 6 was in pain, Resident 6 said she had pain all over and the pain medication she had received earlier in the morning did not help.In an interview on 09/10/2025 at 1:00 PM, Staff C, Resident Care Manager/Registered Nurse, when asked how Resident 6's pain was assessed Staff C stated, She is supposed to be assessed for pain every shift. When asked to review Resident 6's medication administration record for pain documentation Staff C stated, Pain assessment is normally a separate order, and it should be added.In an interview on 09/11/2025 at 1:19 PM, Staff D, Nursing Assistant, was asked if Resident 6 complained or was observed to be in pain. Staff C stated, she hollers out during care. Staff C said Resident 6 sometimes verbalizes generalized discomfort when receiving care.Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 59) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life. Findings included .Review of the facility's policy titled, Psychotropic Medications [drugs that affect a person's thoughts, emotions, and behaviors], updated 01/01/2023, showed, .If a resident is on antipsychotic medications when they are admitted to the facility, an AIMS test will be performed upon admit, every 6 months, and PRN [as needed].Resident 59 was admitted to the facility on [DATE] with multiple diagnosis to include dementia with agitation and delirium (a condition that causes cognitive decline with a severe state of confusion known as delirium, often manifesting as agitation, hallucinations, and/or delusions).Record review of Resident 59's BIMS (Brief Interview for Mental Status, a screening tool used to evaluate a resident's cognitive function and identify the presence and severity of cognitive impairment), dated 08/27/2025, showed Resident 59 was severely cognitively impaired.Record review of Resident 59's physician orders, dated 08/26/2025, showed Resident 59 was prescribed Olanzapine (an antipsychotic medication) 2.5 mg (milligrams) at bedtime. The August 2025 and September 2025 Electronic Medication Administration Record showed Resident 59 was receiving Olanzapine 2.5 mg at bedtime. Review of Resident 59's Electronic Health Record did not show documentation of an AIMS test completed for the administration of Olanzapine. In an interview on 09/10/2025 at 2:50 PM, Staff C, Resident Care Manager/Registered Nurse (RN), said an AIMS test should be completed for residents receiving antipsychotic medications upon admission and when a new antipsychotic medication was started. Staff C said she could not find an AIMS test completed on Resident 59, stating, It got missed upon admission, it should have been done. In an interview on 09/10/2025 at 3:09 PM Staff B, Director of Nursing/RN, said he expected an AIMS test to be completed on residents taking an antipsychotic medication upon admission and upon starting a new antipsychotic medication. Reference WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to ensure the resident admission Minimum Data Set (MDS, an assessment tool) was completed within the required timeframe for 1 of 10 sampled residents (Resident 59) reviewed for resident admission assessments. Failure to complete the admission MDS within the required timeframe placed residents at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide to facilitate accurate and effective resident assessment practices in long-term care facilities), Version 1.19.1, effective October 1, 2024, showed the admission MDS assessment must be completed no later than the 14th calendar day of the resident's admission (admission date plus 13 calendar days). Resident 59 was admitted to the facility on [DATE]. Record review of Resident 59's Electronic Health Record, on 09/10/2025 at 2:09 PM, showed Resident 59's admission MDS was still In Progress, 16 calendar days after admission. In a joint interview on 09/10/2025 at 2:22 PM, with Staff B, Director of Nursing/Registered Nurse (RN), and Staff E, MDS Nurse/RN, Staff B said Staff E scheduled the MDS assessments. Staff E said she would schedule the admission MDS when a new resident was admitted . Staff E said the MDS ARD (assessment reference date) was usually scheduled for seven days after admission, sometimes sooner. Staff E said the MDS needed to be completed one week after the ARD. Staff E said she did not have Resident 59's MDS done yet because she went on vacation and it should have been completed 2 days ago. In an interview on 09/10/2025 at 2:29 PM, Staff B said he expected the admission MDS was completed by the 14th day of admission. Reference WAC 388-97-1000 (1)(b)(c)

Based on interview and record review the facility failed to ensure the Pre-admission and Resident Review (PASRR) assessment was reviewed, completed and submitted for 2 of 5 residents (Resident 16 and Resident 4) reviewed for PASRR. This failure had the potential to place residents at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included… 1. Resident 16 was admitted to the facility on [DATE] with multiple diagnoses to include anxiety (a common emotional state characterized by feelings of unease) and depression (a common mental health condition characterized by persistent of low mood or sadness). The quarterly Minimum Data Set (MDS, an assessment tool), dated 06/17/2025, indicated Resident 16 was moderately cognitively impaired. Review of Resident 16's PASRR, dated 07/23/2024, indicated Resident 16 had a Mood Disorder (a mental health condition that primarily affects a person's emotional state); however, “No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur.” No other PASRR was completed or transmitted. During an interview on 09/10/2025 at 1:08 PM, Staff H, Social Service Director, said the exemption meant a resident did not need a PASRR evaluation unless the resident was in the facility beyond 30 days and had not discharged . While reviewing Resident 16’s PASRR, Staff H said that one was missed, it should have been reviewed. 2. Resident 4 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 4 was alert and oriented and admitted with diagnoses including major depressive disorder (a persistent mood disorder that affects how you feel, think, and handle daily activities. It is not just temporary sadness but serious mental illness that requires treatment.) Record review of Resident 4's PASRR Level 1 assessment, dated 08/04/2025, documented Resident 4 had a Serious Mental Health Indicator of a Mood Disorder: Depression. The assessment documented that Resident 4 qualified for an Exempted Hospital Discharge because the individual was likely to require fewer than 30 days of nursing facility services. The assessment also documented that a PASRR Level 2 for resident 4 must be completed if the scheduled discharge (of less than 30 days) does not occur. Record review of Resident 4’s Electronic Health Records (EHR) showed no documentation of a new PASRR Level one or Level 2 was completed. In an interview on 09/10/2025 at 1:08 PM Staff H, said she was responsible for making the referrals to the PASRR Coordinator. When asked what an Exempted Hospital Discharge meant on the PASRR Level 1 evaluation, Staff H said it meant the resident didn’t need a PASRR unless they were at the facility longer than 30 days. Staff H said she had not sent in a new the referral to the PASRR Coordinator for Resident 4 requesting a PASRR Level 2 evaluation, and that she hadn’t realized Resident 4 had been at the facility longer than 30 days. Reference WAC 388-97-1915 (1)(2)(c

Based on interview and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 3 sampled residents (Resident 3) reviewed for accidents related to falls. This failure placed residents at risk for subsequent falls, injuries, unmet care needs, and a diminished quality of life.Findings included.Resident 3 was admitted to the facility on [DATE] with multiple diagnosis to include repeated falls. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 06/16/2025, documented Resident 3 was cognitively intact.Record review of the facility's Resident Incident Log, dated August 2025, showed Resident 3 had a fall on 08/12/2025 and 08/24/2025. Record review of Resident 3's fall investigation, dated 08/12/2025, Notes documented, .The Care Plan has been updated: Cue and encourage him to use call light and wait for help.Record review of CONCLUSION FALLS: [Resident 3] 08/12/2025 0530 AM, undated, documented, .The Care Plan has been updated: Cue and encourage him to use call light and wait for help.Record review of Resident 3's fall investigation, dated 08/24/2025, showed Notes dated 08/28/2025, documented, .Care Plan has been updated: Cue and encourage to use call light and wait for help.Record review of CONCLUSION FALLS: [Resident 3] 08/24/2025 @ [at] 11:25 AM, undated, documented, .Care Plan has been updated: Cue and encourage to use call light and wait for help.Record review of Resident 3's At risk for falls related to history of falls care plan, revised 08/14/2025, showed Resident 3 had a fall on 08/12/2025. The fall care plan further showed an intervention, date initiated 08/14/2025, Cue and encourage him to use call light and wait for help.Record review of Resident 3's fall care plan, revised 08/14/2025, did not document a fall and/or a new revision or intervention for a fall on 08/24/2025.In an interview on 09/11/2025 at 11:57 AM, Staff G, Resident Care Manager/Licensed Practical Nurse, said after a resident had a fall, the nurse would do an incident report at the time of the fall. Staff G said she would follow up after the fall and form a conclusion, write a summary of the fall, and update the care plan with a new intervention. When asked about a new fall intervention in the care plan for Resident 3 after the fall on 08/24/2025, Staff G said normally she would have changed the care plan with a new intervention, stating, I must have missed it. In an interview on 09/11/2025 at 12:17 PM, Staff B, Director of Nursing/Registered Nurse, said he expected the care plan was updated to include a new intervention after a resident had a fall. Reference WAC 388-97-1020 (2)(a)(d)

Based on interview and record review, the facility failed to obtain daily weights per physician's orders for 1 of 5 residents (Resident 5) reviewed for quality of care. The facility also failed to check for PICC (peripherally inserted central catheter line used for long-term intravenous (IV) access to administer medications) line blood return for 1 of 1 resident (Resident 23) reviewed for medication administration. This failure placed residents at risk of unmet care needs, potential complications and a diminished quality of life.Weights Resident 5 was admitted to the facility on [DATE] with multiple diagnoses to include congestive heart failure. The admission /Medicare - 5 Day Minimum Data Set (an assessment tool), dated 06/20/2025, documented Resident 5 was severely cognitively impaired.Record review of Resident 5's physician's order, dated 06/14/2025, documented, Daily Weights for one week and the weights once per week unless ordered otherwise by provider every day shift for Weight until 06/19/2025 18:00 AND every day shift every 7 day(s) for Weight.Record review of Resident 5's electronic health record (EHR) did not show documentation of weights on: 06/15/2025, 06/16/2025, 06/17/2025, 06/18/2025 and 06/19/2025.Record review of Resident 5's physician's order, dated 06/23/2025, documented, Daily Weights for one week and the weights once per week unless ordered otherwise by provider.Record review of Resident 5's EHR did not show documentation of weights on: 06/24/2025, 06/25/2025, 06/26/2025, 06/28/2025, 06/29/2025 and 07/01/2025.In an interview on 09/10/2025 at 1:25 PM, when asked to review Resident 5's weights based on physician's orders, Staff C, Resident Care Manager/Registered Nurse (RN), said some weights were missed. Medication AdministrationResident 23 was admitted to the facility on [DATE] with multiple diagnoses including Endocarditis (an inflammation of the inner lining of the heart caused by a bacterial or fungal infection).Record review of Resident 23's physician's order, dated 08/24/2025, documented PICC: Flush with 5ml [milliliters] Before & After each medication during your shift. Check for blood return prior to flush. If no blood return, notify MD [doctor] EBP [enhanced barrier precautions] for IV Line every shift EBP for IV terapy [sic]. During a medication administration observation on 09/10/2025 at 1:45 PM, Staff F, RN, was observed to flush Resident 23's right arm PICC line and start IV antibiotic administration. Staff F did not check the PICC line for blood return as per physician's order. When asked if it was a requirement that Resident 23's PICC line be checked for blood return, Staff F said blood return was checked the previous day during blood draws (procedure where a small amount of blood was removed from the body for laboratory testing).Reference WAC 388-97-1060 (1)

Based on observation and interview, the facility failed to ensure a safe, sanitary, and comfortable environment was maintained for 2 of 7 rooms (rooms [ROOM NUMBERS]) reviewed for environment, when sharps containers (a puncture-resistant, leak-proof container designed to safely collect and dispose of sharp medical instruments that can puncture or cut skin, like needles, syringes, and lancets) were observed above the full line. This failure placed residents, visitors, and staff at risk for injury, potential exposure to diseases, and a diminished quality of life. Findings Included . In an observation on 09/08/2025 at 11:07 AM, the red sharps container mounted on the wall inside of room [ROOM NUMBER], date written on container 09/16/24, showed sharps instruments inside of the container above the fill line that said, do not fill above this line. The top lid, where the sharps instruments were placed in the container for disposal, was observed to not open all the way as sharps instruments in the full container would catch on the lid and pop up and out to the opening of the lid. In an observation on 09/08/2025 at 11:21 AM, the red sharps container mounted on the wall inside of room [ROOM NUMBER] near the sink, undated, showed sharps instruments inside of the container above the fill line that said, do not fill above this line. Syringes were observed inside the sharps container obstructing the top lid, where the sharps instruments were placed in the container for disposal, from opening and closing all the way. In an interview on 09/08/2025 at 2:23 PM, Staff J, Registered Nurse (RN), said either environmental services and/or nursing staff would empty full sharps containers, just whoever noticed it needed to be done. Staff J said he considered it needed to be done when the sharps instruments inside the container were at the fill line. In a joint observation and interview on 09/08/2025 at 2:34 PM with Staff J, the sharps container in room [ROOM NUMBER] was observed over the fill line. Staff J locked the sharps container lid stating, It's high enough that it should be emptied, it is at the fill line for sure. In a continued joint observation with Staff J, the sharps container in room [ROOM NUMBER] was observed over the fill line. Staff J said it should be locked too and locked the lid on the sharps container. In an interview on 09/08/2025 at 2:36, Staff K, Environmental Services Supervisor, said if she saw a sharps container at the full line she would empty it. Staff K said it was not mandated to any specific department for checking the sharps containers. Staff K said they did not have a process for checking the sharps containers, stating, I suppose we should make it a certain department. In an interview on 09/09/2025 at 11:20 AM, Staff B, Director of Nursing and RN, said he expected staff would change the sharps containers when they reached the full line. Reference WAC 388-97-3220 (1)

Based on observation, interview, and record review, the facility failed to ensure the survey result binder included the health recertification and complaint survey results for 2 of 3 years (2024 and 2025) reviewed for availability of survey reports. This failure prevented residents, resident representatives, family members, and visitors from exercising their right to review past survey results.Findings included . In an observation on 09/10/2025 at 10:30 AM, the facility's survey binder was observed in a wall mounted receptacle across from the nurse's station near the skilled nursing entrance of the facility. Record review of the survey binder labelled, [NAME] Care Center Survey Binder 3 most current years of survey reports. showed the binder contained a Federal Fire and Life Safety re-certification survey, dated 09/10/2024, and the re-inspection, dated 10/31/2024, as the most recent survey completed. Further review of the binder did not show health re-certification survey results for 2024 and/or health complaint investigation surveys for 2024 or 2025. In an interview on 09/10/2025 at 11:09 AM, Staff B, Director of Nursing/Registered Nurse, said that Staff A, Administrator, would post new survey results in the binder after each survey. Staff B said there was only one survey binder. In an interview on 09/10/2025 at 11:11 AM, Staff A said he put the survey results in the binder as soon as they came out and were approved. Staff A said the survey results were never available last year and he couldn't find them online anymore. Staff A said he was able to print the complaint investigation surveys but he did not put them in the binder, stating, I usually only put the annuals in, not the complaints. Reference WAC 388-97-0480 (1)(a)(b)(c)(4)

Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 4 of 9 sampled residents (1, 24, 26 & 30) reviewed for ADs. This failure place residents at risk for losing their right to have healthcare preferences and decisions honored and a diminished quality of life. Findings included . The facility's policy entitled, Advanced Directives, dated 08/01/2018, indicated, I. Upon admission, we will determine whether a resident has an advance directive, if they do not have and advance directive we will determine whether the residents or resident representative wishes to formulate and advanced directive. II. Information will be provided to the residents or resident representative about the right to refuse medical and surgical treatment and formulate an advanced directive. Including the facility policy on advance directive and applicable state law regarding advanced directives. 1) Resident 1 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 07/01/2024, showed Resident 1 was severely cognitively impaired. Resident 1's electronic health record (EHR) did not show an AD or documentation an AD was reviewed since admission. 2) Resident 24 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed Resident 24 was moderately cognitively impaired. Resident 24's EHR did not show an AD or documentation an AD was reviewed since admission. 3) Resident 26 was admitted to the facility on [DATE]. The 5-day MDS, dated [DATE], showed Resident 26 was alert and oriented. Resident 26's EHR did not show an AD or documentation an AD was reviewed since admission. 4) Resident 30 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], showed the Resident 30 was alert and oriented. Resident 30's EHR did not show an AD or documentation an AD was reviewed since admission. On 09/11/2024 at 12:23 PM, Staff K, Social Services Director, said Advance Directives were addressed in the initial admission care conference, and if residents decline, I typically make a note in the care conference. I Follow up. I reach out. If they don't have it, I give them a form to fill out. Staff K said there had been gaps in documentation. Staff K stated, I could probably be better with follow up. It should be documented. At 1:07 PM, Staff A, Administrator, said ADs should be reviewed and addressed at the initial care conference. Staff A stated, Yes. We know there were issues. Reference WAC 388-97-0280 (3)(c)(i)

Based on observation, interview, and record review, the facility failed to obtain a physician's order for 2 of 4 sampled residents (3 & 288) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented .Nursing Staff will also obtain a physician order for the device/enabler. 1) Resident 3 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment, dated 08/05/2024, documented Resident 3 was moderately cognitively impaired. On 09/09/2024 at 10:50 AM, Resident 3 was observed lying in bed on their left side with quarter length bed rails on left and right sides of the bed. At 3:17 PM, Resident 3 was observed lying in bed on their back with quarter length bed rails on left and right sides of the bed. Review of Resident 3's Electronic Health Record (EHR) did not show a physician's order related to bed rails. On 09/10/2024 at 1:32 PM, Resident 3 was observed lying in bed on their back with quarter length bed rails on left and right sides of the bed. On 09/11/2024 at 8:51 AM, Resident 3 was observed sitting up in bed eating breakfast with quarter length bed rails on left and right sides of the bed. At 10:34 AM, Resident 3 was observed in bed on their back with quarter length bed rails on left and right sides of the bed. At 3:02 PM, Staff C, Resident Care Manager (RCM) and Registered Nurse (RN), said enablers such as positioning/mobility bars or quarter rails require a doctor's order. Staff C said she could not find an order for Resident 3's quarter bed rails and indicated there should have been one. At 3:18 PM, Staff B, Director of Nursing Services (DNS) and RN, said it was his expectation residents had physician orders for use of enablers such as quarter bed rails or mobility bars. 50416 2) Resident 288 was admitted to the facility on [DATE]. The admission MDS assessment, dated 09/04/2024, documented Resident 288 was alert and oriented. On 09/09/2024 at 10:03 AM, Resident 288 was observed sitting in her wheelchair next to her bed. Resident's 288 bed was observed to have quarter length bed rails to the left and right sides of the bed. Review of Resident 288's EHR did not show a physician's order related to the use of bed rails. On 09/10/24 at 3:10 PM, Resident 288 was observed sitting in her wheelchair next to her bed. Resident's 288 bed was observed to have quarter length bed rails to the left and right sides of her bed. On 09/13/24 at 8:57 AM, Resident 288 was observed lying in bed watching her television. Resident 288's bed had quarter length bed rails to the left and right side of her bed. Reference WAC 388-97-0620 (1)(a)(b)

Based on interview and record review, the facility failed to ensure a copy of the Notice Before Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 for 1 sampled resident (26) reviewed for transfer notice requirements. This failure placed residents at risk of loss of added protection from being inappropriately transferred or discharged from the facility. Findings included . Resident 26 was admitted to the facility on [DATE] with diagnoses including congestive heart failure exacerbation and physical deconditioning. The admission Minimum Data Set assessment, dated 07/24/2024, documented Resident 26 was alert and oriented. Record review of resident's electronic health records documented Resident 26 was transferred to and admitted to a local hospital on 08/26/2024. On 09/11/2024 at 2:01 PM, when asked if a Notice of Transfer for Resident 26 was sent to the Office of the State Long-Term Care Ombudsman, Staff A, Administrator, said he would check whether the notice was sent. On 09/13/2024 at 12:28 PM, Staff A stated .I just found out about when to send a copy of the Notice of Transfer . to the Office of the State Long-Term Care Ombudsman. Staff A said he sent out the Notice of Transfer for the months of June, July and August on 09/11/2024. Reference WAC 388-97-0120 (5)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's oral/dental status for 1 of 1 sampled resident (21) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 21 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 07/30/2024, documented Resident 21 was severely cognitively impaired, did not have tooth fragments or broken natural teeth, had no mouth pain, and was able to be examined. Record review of the Dietitian Consulting Services - Nutrition Assessment, dated 07/29/2024, documented, natural teeth in poor shape. Record review of a Nutrition/Dietary progress note, dated 07/30/2024, documented, .teeth in poor shape. On 09/09/2024 at 10:19 AM, Resident 21's mouth was observed to have missing upper teeth, and lower teeth had sharp edges and dark tan in color. Resident 21 said he had mouth pain. On 09/10/2024 at 1:17 PM, Resident 21's upper teeth were observed mostly missing on upper gums with pointed short tooth fragments present. Resident 21's lower teeth were observed to be dark tan in color with multiple sharp jagged points. Resident 21 said his tooth pain was on his bottom teeth. Resident 21 said staff had not talked to him about dental concerns or asked about dental pain. On 09/12/2024 at 2:44 PM, after observing Resident 21's teeth, Staff C, Resident Care Manager and Registered Nurse (RN), talked to Resident 21 and stated, It looks like you're missing teeth. Do your teeth hurt? Resident 21 stated, It hurts all the time. Staff C stated, Yes. [Resident 21] does have some missing or broken teeth. Whatever was left on the bottom are broken teeth. [Resident 21] obviously needs dental care. At 3:05 PM, Staff E, MDS Nurse and RN, said she gathered information for the MDS by looking at the resident's medical records, asked staff, and would talk to the resident about pain. When asked about the oral/dental status of the MDS assessment, Staff E stated, If I don't go and see the resident myself ., she would look at the admission assessment, care conference assessment, or skilled care review. When asked about looking at Resident 21 to assess his oral/dental status or gathering information in the medical record, Staff E stated, That's a good question . I don't remember. At 3:26 PM, after observing Resident 21's teeth, Staff B, Director of Nursing Services and RN, said Resident 21 had broken natural teeth. Staff B indicated the MDS oral/dental status was inaccurate and stated, We need to do a correction on this. Staff B indicated there should be a visual assessment completed for the oral/dental status on the MDS. At 3:50 PM, Staff E said she had looked where she got the information for the oral/dental status on Resident 21's MDS, and stated, I probably did not look at [Resident 21's teeth] myself. Reference WAC 388-97-1000 (1)(b), (2)(k)

Based on observation, interview and record review, the facility failed to ensure a comprehensive care plan was developed for 1 of 4 sampled residents (6) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . Record review of the facility's undated policy entitled, Devices/Enablers Policy and Procedure, documented Use of the device/enabler will be appropriately care planned and added to the resident's Kardex. Resident 6 was admitted to the facility on [DATE]. The admission Minimum Data Set assessment, dated 06/12/2024, documented Resident 6 was severely cognitively impaired. On 09/09/2024 at 10:39 AM, Resident 6's bed was observed with the left side against the wall and a mat on the floor the full length of the bed along the right side. At 11:38 AM, Resident 6 was observed sitting up in a wheelchair in her room with the left side of the bed against the wall. Review of Resident 6's Electronic Health Record comprehensive care plan, did not address the left side of bed against the wall and a mat on the floor along the right side of the bed. On 09/10/2024 at 1:11 PM, Resident 6's bed was observed with the left side against the wall and a mat leaning up against a wall away from the bed. On 09/11/2024 at 10:36 AM, Resident 6's was observed lying on the bed on her left side with the left side of the bed against the wall and a mat on the floor the full length of the bed along the right side. At 1:45 PM, Resident 6 was observed sitting up in a wheelchair in her room with the left side of the bed against the wall. At 2:30 PM, when asked how they knew the care needs of a resident, Staff D, Certified Nursing Assistant, stated, We look at the [resident's] care plan. At 3:02 PM, Staff C, Resident Care Manager and Registered Nurse (RN), said residents with their bed placed against the wall and a mat on the floor should have it care planned. Staff C said she could not find a care plan for Resident 6's bed against the wall and mats on the floor. Staff C stated, It should be in the care plan. At 3:18 PM, Staff B, Director of Nursing Services and RN, said it was his expectation care plans were in place for residents with their bed against the wall and mats on the floor. Reference WAC 388-97-1020 (1), (2)(a)(c)

Based on observation, interview and record review, the facility failed to ensure activities of (ADLs) care was provided for dependent residents including nail care for 1 of 2 sampled residents (5) reviewed for ADLs. This failure placed residents at risk of not receiving the care and assistance needed for which they were unable to perform themselves. Findings included . The facility's policy entitled, Nail Care, dated 01/01/2024, indicated I. Nail care which we considered a part of personal hygiene/grooming and is provided by the certified nursing assistant if the resident is not diabetic, and the nails are not severe or complicated. II. If the resident is diabetic the nail care will be done by the licensed nurse due to being higher risk. III. The resident nails are checked for cleanliness and length as a standard of care in grooming/hygiene for the certified nursing assistant and cleaned as needed and nail care is offered. Resident 5 was admitted on [DATE]. The annual Minimum Data Set assessment, dated 08/14/2024, indicated Resident 5 was severely cognitively impaired and needed substantial/maximal assistance with personal hygiene. The ADLs care plan, initiated 08/09/2024, documented check nail length and trim and clean on bath day and as necessary. The Tub/Shower task, dated 09/10/2024, documented Resident 5's last bath or shower was on 08/31/2024. On 09/09/2024 at 12:06 PM, Resident 5 said he would like to have assistance getting his nails trimmed. On 09/10/2024 at 2:14 PM, Resident 5's fingernails were about a 1/3 inch long. Resident 5 said he mentioned to the bath aid he would like his nails done but was told they were not able to do them. Resident 5 said the nails have not been done for about a month. At 2:50 PM, Staff I, Nursing Assistant (NA), said they checked resident nails when they did baths or showers. Staff I said resident nail care was done by the the NA unless the resident was diabetic, for which they would report to the nurse. At 2:59 PM, Staff B, Director of Nursing Services and Registered Nurse, said shower aid would do finger nail care at the time of the resident's baths but the nurse would do the nail care if the resident was diabetic. After observing Resident 5's fingernails, Staff B said it looked like they had not been trimmed for about two weeks. Reference WAC 388-97-1060 (3)(j)(vii)

Based on interview and record review, the facility failed to explain the arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement in a manner of which the resident and/or representative understood for 1 of 3 sampled residents (25) reviewed for arbitration agreement. This failure placed residents at risk of losing legal protections, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life. Findings included . Review of the facility's Optional Voluntary Arbitration Agreement documented, 5. Right to Rescind this Agreement. You may rescind this Agreement to arbitrate within thirty (30) days after signing it by giving written notice of your withdrawal to the Facility . Resident 25 was admitted to the facility on [DATE] and readmitted on [DATE]. The Admission/Medicare - 5 day Minimum Data Set assessment, dated 08/13/2024, documented Resident 25 was alert and oriented. Review of Resident 25's Nursing Note, dated 08/17/2024, documented, .resident believed she was in a hotel and wanted to speak with the manager about her bill . Review of Resident 25's Nursing Note, dated 08/18/2024, documented, .some confusion prior to sleep. Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 08/28/2024, documented, .res [resident] is alert and oriented [A&O] x2 [when someone knows who they are and where they are, but not what time it is], reoriented to time of day . Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 08/30/2024, documented, .A&O x2, some confusion . Review of Resident 25's Daily Skilled Nursing Charting progress note, dated 09/01/2024, documented, .Res alert with some confusion/forgetfulness . Record review of Resident 25's Optional Voluntary Arbitration Agreement, dated 08/29/2024, showed the arbitration agreement was signed by Resident 25 and Staff J, Admissions Coordinator. On 09/13/2024 at 11:25 AM, when asked if Resident 25 recalled signing a binding arbitration agreement, or if staff reviewed a binding arbitration agreement with her, Resident 25 stated, I was under pain with a broken hip. I can't remember any paperwork. Maybe my sister signed it. When asked if Resident 25 knew what a binding arbitration agreement meant, Resident 25 shook her head no and said she was kinda unsure. At 11:41 AM, Staff J said to determine if a resident was capable to sign an arbitration agreement, she would ask them cognitive questions such as, what was the day, month, and the resident's name. Staff J said she would also ask the social services department if a resident could sign their own paperwork. When asked what was explained to residents and/or their representative regarding their right to rescind an arbitration agreement, Staff J said she would tell them if they changed their mind, the facility could change it at any time. Staff J stated, I can't imagine there ever being a time they can't change their mind. After looking at the facility's arbitration agreement, Staff J said she was not aware they had only 30 days to change their mind. When asked if it was explained to a resident and/or their representative they had 30 days to change their mind, Staff J stated, No. I didn't tell them they have only 30 days to change their mind . It bothers me that I didn't know that. At 11:59 AM, Staff A, Administrator, said he did not know for how long after signing an arbitration agreement it could be rescinded, and stated, They have as much time as they like. I don't know. No WAC Reference

Based on observation, interview and record review, the facility failed to ensure infection prevention practices are being maintained including proper use of personal protective equipment (PPE) and hand hygiene for 2 of 8 sampled residents (26 & 30) reviewed for infection prevention and control. These failures placed residents at risk of communicable infections and a decreased quality of life. Findings included . Record review of the facility's Employee Training on Infection Prevention and Control policy, dated 11/01/2018, documented staff trainings and education regarding infection prevention and control included hand hygiene and use of PPE. 1) On 09/10/2024 at 1:58 PM, Staff F, Certified Nurse Assistant (CNA), was observed providing care for Resident 26. Staff F took off her gloves, opened Resident 26's door and proceed to retrieve gloves from the isolation cart located outside the room. Staff F then returned into the room, put on the new pair of gloves and continued to provide resident care. When asked about the process for doffing PPE between care, Staff F said she should have washed her hands in between changing gloves. 2) On 09/10/2024 at 3:37 PM, Resident 30's room was observed with an enhanced barrier precautions sign on the door and an isolation cart outside the room. At 3:38 PM, Staff G, CNA, and Staff H, CNA, went into Resident 30's room to provide incontinence care for Resident 30. Staff G and Staff H did not put on isolation gowns. At 3:58 PM, Staff G was observed taking trash out of the Resident 30's room with the same gloves used to provide incontinence care for Resident 30. Staff G then went to the dirty utility room door, entered the code on the door using the contaminated gloves, opened the door and threw the trash away. Staff G then took her gloves off, returned to Resident 30's room and sanitized her hands. While in Resident 30's room, Staff G put on gloves and collected dirty linen, bagged the linen in a plastic bag, left the room with the gloves on both her hands. Staff G then went to the dirty utility room door, entered the code on the door using the contaminated gloves and discarded the dirty linen. At 4:03 PM, when asked if Resident 30 was on isolation precautions, Staff G stated, Right now I am not sure. When asked how she would know what kind of isolation precautions a resident was on, Staff G stated, We are informed by the charge nurse or the sign outside of the door. When asked about the use of contaminated gloves outside of Resident 30's room, Staff G stated Yes, I had gloves on. On 09/11/2024 at 11:46 AM, Staff B, Director of Nursing Services and Registered Nurse, said infection control trainings were provided on hire date and during staff meetings. Staff B said it was the expectation staff would use the isolation precaution signs outside of resident's doors to identify the appropriate PPE to use during care. Staff B said it was the expectation staff removed contaminated gloves and perform hand hygiene before leaving the resident's room. Reference WAC 388-97-1320 (1)(c)(2)(b)

Based on interview and record review, the facility failed to ensure mail delivery was provided on Saturdays for residents receiving mail via the US Postal Service for 4 of 5 sampled residents (7, 12, 19 & 246) reviewed for communication with privacy. This failure placed residents at risk of not receiving their mail in a timely manner and a diminished quality of life. Findings included . The Nursing Facility Admission Agreement, dated 09/2013, documented, Each resident has a right to . send and promptly receive mail . On 07/19/2023 at 10:55 AM, during a Resident Council group interview, Resident 7 said there was activity staff that worked on Saturdays, but no mail was delivered on Saturday. The residents got Saturday's mail delivered on Monday. Resident 12, Resident 19 and Resident 246 also said there was no mail delivery on Saturdays. At 12:01 PM, Staff H, Activity Director, said mail delivered on Saturdays by the post office was taken by the post office to the assisted living side of the facility and put in a locked area until Monday. At 12:59 PM, Staff A, Administrator, said the post office delivered mail to the mailboxes on the assisted living side of the facility on Saturdays; but for the skilled nursing residents, it went to a secured area. Staff A said the receptionist picked up Saturday's mail on Monday and it was delivered to nursing home residents on Mondays. Staff A stated, I will have to figure out a process for them to get their mail on Saturdays . I will have to change that. Reference WAC 388-97-0500 (1)

Based on observation, interview and record review, the facility failed to ensure foods were prepared, stored, and served in a sanitary manner when the facility failed to ensure the kitchen was free from dust and debris, clean dishes and utensils were stored in a clean manner, and opened foods were not labeled and/or dated as required for all 42 facility residents who received meals from the facility kitchen. These failures placed all residents at risk for food-borne illness and a diminished quality of life. Findings included . On 07/17/2023 at 9:06 AM, during the initial kitchen tour, crumbs, grease, and debris were observed throughout the kitchen. In the dry food storage, a bag of stored food was on the floor. In the freezer, several eggrolls are noted on the floor. The hood had visible grease build-up and dust. A rack with clean dishes was in a high traffic area and had washcloths mixed in with the glasses. Several spices were noted without an open date. On 07/19/2023 at 2:10 PM, the kitchen was observed with Staff N, Dietary Manager. Four dented food cans were identified. Staff N, Dietary Manager, said these cans should be removed from use. Clean cups were stored on a stained and pitted cookie sheet. Staff N said the cups should not be stored on the cookie sheet. Several clean dishes were stored on a three-shelf rack near a high-traffic area. A heavily soiled step ladder was stored between the wall and rack, close to the clean dishes. A cloth was observed in one bin, mixed among the cups. Staff N said the cloth was supposed to be a cover to protect the clean cups. Staff N said staff were worried about the dishes getting contaminated. Staff N said they should find another way to store the dishes. Crumbs and debris were observed throughout the kitchen and appliances/equipment. A heavy layer of grease was observed under the steam table bottom shelf. Items were stored on the shelf. The hood was observed with visible grease, dust, and a cobweb on the sprinkler. A shelf next to the stove and directly across from the steam table, housed tools used to clean the stove top. A piece of cloth or paper next to the tools was stained yellow and black. Several employee water bottles were stored there. Staff N said they would have to look for another place to store the staff water bottles. The top of the stove was covered with grease and dust where oven mitts were stored. Staff O, Dietary Cook, was observed to use these oven mitts during observation of the tray line. Several opened spices were observed without open dates. Staff N said the staff should note the open date. Several clean knives were observed on a magnet hanging next to the three-compartment sink. The knives were not protected from possible splash when the sink was in use. The knives were nearly touching the sanitizer, covered in heavy dust, by the sink. Staff N said the knives could become contaminated and they will look for another solution. At 2:39 PM, Staff N said there had been a lot of turn-over and she had been required to cook. Staff N said she updated their cleaning schedule and will review it to ensure they were capturing the concerns identified. Reference WAC 388-97-2980

Based on interview and record review, the facility failed to ensure resident-centered care and treatment was provided according to professional standards of practice and resident assessment when insulin was administered for one of three sampled residents (1) reviewed for quality of care. This failure placed residents at risk of adverse reactions to medication, unstable blood glucose levels, and a diminished quality of life. This caused harm to Resident #1 when staff checked the blood glucose before administering insulin, but failed to assess the safety of the insulin administration at the current blood glucose level resulting in the resident's emergent transport to the hospital for treatment. Findings included . A facility policy entitled Nursing Care of the Resident with Diabetes Mellitus, revised ,d+[DATE], documented for Glucose Monitoring normal ranges are defined as ,d+[DATE] mg/dL (milligrams per deciliter) before meals and <180 mg/dL after meals . for Management of [CONDITION(S)] . 2. For asymptomatic and responsive residents with [CONDITION(S)] (<70 mg/dL or less than the physician-ordered parameter): a. give the resident an oral form of rapidly absorbed glucose (4 oz juice or ,d+[DATE] ounces of soda); b. recheck blood glucose in 15 minutes; (1) if blood sugar is >130 mg/dL (rebound hyperglycemia) administer diabetic medications; (2) if blood sugar is <70 mg/dL repeat oral glucose and recheck blood glucose in 15 minutes; or (3) if no improvement, notify physician for further order. 3. For symptomatic (lethargic, drowsy) but responsive (conscious) resident with [CONDITION(S)] (<70 mg/dL or less than the physician-ordered parameter): a. if he/she is able to swallow: (1) immediately give the resident an oral form of rapidly absorbed glucose (4 oz juice or ,d+[DATE] ounces of soda); (2) recheck blood glucose in 15 minutes and (3) repeat juice if indicated and recheck blood glucose in 15 minutes. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Special Instructions: inject 5 units under the skin 3 times daily with meals . [8:00 AM, 12:00 PM, 5:00 PM]. This order did not include special instructions with blood glucose parameters for holding insulin. The [DATE] MAR, documented two orders for [MEDICATION(S)] (as noted below). One to be administered at bedtime and one to be administered before meals. Each order, dated [DATE] - [DATE], showed the following: Insulin [MEDICATION(S)] solution: 100 unit/mL; Amount to Administer: Per Sliding Scale: If Blood Sugar (BS) is less than 70, call MD (physician). If BS is 150 to 200, give 2 units (of insulin). If BS is 201 to 250, give 4 units. If BS is 251 to 300, give 6 units. If BS is 301 to 350, give 8 units. If BS is 351 to 400, give 10 units. If BS is greater than 400, give 12 units. If BS is greater than 400, call MD. The [DATE] MAR, documented to administer [MEDICATION(S)] U-100 Insulin (insulin glargine) solution; 100 unit/ml [milliliter]; Amount Administer: 20 units . every 12 hours [8:00 AM and 8:00 PM]. No special instructions noted. The facility's investigation, dated [DATE], documented under Evaluation Notes, .[Resident] then had a low blood sugar in the morning [sometime before 8:00 AM]. MD [medical doctor] was notified and she was given juice per our policy. Her blood sugar increased to 76. She didn't eat breakfast and after that she was due for her scheduled [MEDICATION(S)] and 5 units of fast acting insulin. The nurse gave this. Shortly after he called a code . The [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Progress note, dated [DATE] at 10:41 AM, documented, Res [resident] noted by staff to be sitting up in w/c [wheelchair] but unresponsive and notified this LN [licensed nurse]. Upon assessment res noted to be sitting upright in w/c breathing normally but not responding to staff. Res was assisted to bed with hoyer and would open her eyes and moan but not be meaningfully responsive. ARNP (Advance Registered Nurse Practitioner) in facility notified with instruction to call 911 . Progress note, dated [DATE] at 11:00 AM, noted, .resident was lying in bed unresponsive with agonal [struggling/gasping] breathing and foam around the mouth. This LN immediately went to get in-house NP [Nurse Practitioner] to assess . This LN instructed staff to grab crash cart and for nurse to call 911. Resident placed on oxygen and board placed under resident in anticipation of starting CPR, AMR [emergency response transportation] arrived and resident transported to hospital. The local hospital Discharge Summary, dated [DATE], documented Resident #1 was admitted to [the local hospital] on [DATE] for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 9:35 AM, Staff B, Registered Nurse (RN), said he believed Resident #1's blood glucose was around 72. Staff B said Resident #1 had a schedule for 5 units with no parameter to hold the insulin. Staff B said breakfast trays were in the hallway and he knew Resident #1's eating routine so he did not ask her if she was eating breakfast. At 2:48 PM, Staff A, Director of Nursing Services and RN, said there was a gray area between 70 and 130 for blood glucose. Staff A said there were no parameters to give medication to the Resident #1 in the gray area. Staff B said Resident #1 should not have been given her insulin at that time. Reference WAC [DATE] (1)

Based on interview and record review, the facility failed to prevent the development of pressure ulcer/pressure injury for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk of impaired skin and a diminished quality of life. This caused harm to Resident #1 when she developed a Stage 3 pressure ulcer after admission. Findings included. The facility's policy on Wound Management, undated and received on 01/24/20, documented, (The facility) endeavors to ensure that residents who enter the facility without a pressure ulcer do not develop pressure ulcers unless their clinical condition demonstrates the pressure ulcer was unavoidable. Resident #1 was admitted to the facility on [DATE] for rehabilitation after surgery for [REDACTED].#1 was cognitively intact, required extensive assistance with activities of daily living including bed mobility, and had no unhealed pressure ulcer(s) on admission. The MDS documented the resident used a pressure relieving device on mattress and chair. Resident #1's Clinical Admission Assessment, dated 10/22/19 at 1:21 PM, documented Resident #1 did not have any pressure ulcers. An Integumentary/Feet diagram, dated 10/22/19, documented Resident #1's coccyx (tailbone area) was red and blanchable (viable tissue that pales when it is pressed). A Braden Scale for Prediction of Pressure Sore Risk, dated 10/22/19 at 1:27 PM, documented Resident #1 was at risk for the development of pressure injury or pressure sore. Under interventions, surgical wound care was the intervention marked. The resident's Care Plan, dated 10/22/19, identified Resident #1 was at risk for pressure ulcer due to the [MEDICAL CONDITION], as well as her medical history. The care plan goal documented, All skin irregularities will be treated according to wound care and/or (physician) orders and will heal or be healing without complications. Intact skin will be monitored weekly according to skin policy. Care-planned interventions included pressure-reducing cushion to wheelchair and mattress to bed; report any signs of skin breakdown (sore, tender, red or broken areas) to Licensed Nurse; skin check upon admission and weekly per facility policy; and turn or remind resident to turn frequently while in bed. A nursing note, dated 10/22/19, documented the resident was positioned for comfort with pillows. Nursing notes, dated 10/23/19 through 10/30/19, showed no additional documentation of repositioning of the resident or refusals of repositioning. A nursing note, dated 10/30/19 at 11:34 AM, documented an open area was noted to the top Resident #1's sacrum (tailbone area)/left gluteal cleft, 1.[AGE] x 2 cm (centimeter) in size, with no drainage noted. Nursing noted the resident stated the area hurt a minimum amount, cleaned the area and applied barrier cream, sent a referral for a wound care consultation and notified the physician, requested an air mattress, and updated the resident's care plan. A nursing note, dated 10/30/19 at 9:19 PM, documented Resident #1 was sent to the hospital for evaluation of a possible infection of her surgical wound. A hospital wound note, dated 10/30/19 at 5:04 PM, documented Resident #1 had a pressure injury on her buttock, present on admission, appeared to be a stage 3 with purulent (thick) drainage. The perineal wound had blanchable redness 7 cm x 7.5 cm, with inner open area measuring 3.5 cm x 1.5 cm. The resident's hospital chart included a photograph of the wound, dated 10/30/19 at 7:48 PM, which showed a narrow, shallow area of opened skin to the left of the resident's tailbone. A hospital nursing form, dated 11/06/19 at 4:05 PM, documented the presence of a pressure ulcer on Resident #1's tailbone area when she discharged back to the facility. On readmission to the facility, an Integumentary/Feet diagram, dated 11/06/19, documented Resident #1 had an open area on her coccyx 3 cm x 3 cm, which was overwritten as 2 cm x 2 cm. A nursing note, dated 11/08/19 at 2:02 PM by a facility wound treatment nurse, documented Resident #1's coccyx pressure sore appeared to be a Stage 3 (full thickness skin loss), measured approximately 3 x 3 x 0.2 cm, and noted a moderate amount of serosanguinous (reddish yellow) drainage. On 12/03/19 at 4:20 PM, Resident #1's Family Member (FM) said the facility neglected his mother. The FM said his mother was in the hospital with an unstageable bed sore that was caused by the facility and is now life-threatening. The FM said the paramedic asked him if he knew his mother had a pretty bad bed sore. The FM said the bed sore started in the facility. The FM said the facility did not turn his mother for four days. The FM said he was afraid his mother was going to give up. The FM said the physician said the wound was going to heal, but it would take months. The physician told the FM the wound was almost to the bone, not quite; there was a thin layer of tissue just before the bone. When asked if he talked to anyone at the facility about his mother's wounds, FM said he talked to everybody. The FM said his mother was fighting for her life now. This is a huge set back, huge. On 12/04/19 at 4:20 PM, Resident #1 said she had a bed sore right on her tailbone, right in the center. When asked when the bed sore started, Resident #1 said the ambulance driver noticed it starting on her butt when they came to pick her up from the facility, and told her son about it. The resident said she could not sleep because of it. The resident said the staff were supposed to move me side to side, and the facility staff did not move me. At 4:45 PM, Collateral Contact A, a hospital registered nurse, said she had been Resident #1's nurse when she was in the hospital on her previous visit (10/30/19 to 11/06/19). The nurse said Resident #1 had a Stage 3 then and it was yellow when the resident discharged from the hospital. CC A said now it was black. On 01/24/20 at 3:50 PM, when asked about what skin issues she would report, Staff C, Nursing Assistant (NA), said she would report any kind of pinkness, swelling, and anything new or different. When asked what she would do if a resident reported their bottom was hurting, Staff C said she would recommend the resident change position, help them reposition and report it to the nurse. At 3:55 PM, Staff D, License Practical Nurse, said if she identified or an aide told her about a change in a resident's skin, she would fill out the form on the computer, let the physician know, and use barrier cream if it was in the perineal area. Staff D said the resident would be put on alert for three days, and the treatment nurse would also be notified of the issue. At 4:00 PM, Staff E, Registered Nurse (RN), indicated once Resident #1's wound was identified (eight days after admission), he talked with the resident often about not staying on her back because they did not want the pressure ulcer to get worse. At 4:25 PM, when asked about the development of Resident #1's pressure sore, Staff B, RN and Director of Nursing Services, stated, Yes, it developed here. It started as a Stage 2. Reference WAC 3[AGE]-[AGE]-10[AGE] (3)(b)

Based on interview and record review, the facility failed to ascertain the current status of residents sent to the hospital, including the care and treatment provided by the hospital that improved the resident's condition, prior to initiating a discharge from the facility for 1 of 3 sampled residents (#1) reviewed for readmission/transfer/discharge. This failure placed residents at risk of not having their resident rights honored and a diminished quality of life. This caused harm to Resident #1 when the resident was required to remain at the hospital for an extended period without re-evaluation to determine if the facility had the ability to meet the resident's needs. Findings included Resident #1 admitted to the facility on [DATE] for rehabilitation after a fall and joint replacement surgery, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, a comprehensive assessment tool, dated 01/09/19, documented Resident #1 was rarely and/or never understood, displayed verbal behaviors toward others, had rejected care and required extensive assistance with activities of daily living. Record review of Resident #1's record showed a care plan was initiated for refusal of care, dated 01/08/19. A Behavioral Symptoms care plan, dated 02/04/19, documented resident was beginning to hit and grab at staff. Interventions included use slow, simple, one-step instructions/questions and allow resident time to process information to prevent agitation; assess whether the behavior endangers the resident and/or others, intervene if necessary; maintain a calm environment and calm, slow, understandable approach to the resident; and monitor for hitting/grabbing at staff with interventions to back off for a few minutes, talk with resident and make sure you explain the steps you are taking with the resident. A care plan addition, dated 03/11/19, showed Staff B, the Director of Nursing Services (DNS), documented, [Resident] can be combative and gets agitated very easily. [Resident] needs space at times, this is worse with increased stimulation. A nursing progress note, dated 03/26/19 at 2:14 PM, documented at 8:00 AM therapist reported this resident grabbed her by the throat and choked her with noted red areas on both side of therapist throat. Therapist said she had to pry the resident's hands off her throat. The resident was placed on one to one supervision. Wife was called to update on incident. Physician was called to update at 8:20 AM and gave an order to send the resident to hospital to be evaluated related to harm to others and self. The note showed the resident may return after evaluated by Gero psych. Called Emergency Medical Services (EMS) to transport to hospital. A telephone order, dated 03/26/19 at 8:20 AM, documented, Send [Resident #1] to ER [emergency room ] to be [evaluated related to] choking staff, harm to self and others. May return after [designated mental health professional] and gero-psych evaluation. Hospital provider (who evaluated Resident #1) documentation, dated 03/26/19 at 9:45 AM, noted, 74 [year-old] male BIBA [brought in by ambulance] from [facility] for evaluation of aggressive behavior. Per report, patient was attempting to ambulate to restroom by himself. Two aids came to help him and patient became overwhelmed and aggressive. Patient attempted to grab nursing home staff around her neck. Patient sent to ED requesting psychiatric evaluation . Patient has been calm and cooperative with EMS. Denies any current pain or symptoms. Does not remember what happened or why he is in the ED. Baseline mental status per wife. Patient had initial appointment with neurology scheduled today . The hospital provider documented Resident #1 had a urinanalysis with no evidence of infection. The patient was evaluated by the hospital crisis counselor, who had cleared the resident to return to the facility, and had discussed Resident #1's case with the neurologist, who did not believe the patient required admission for further work-up or needed further mental health evaluation as inpatient. The provider documented, advised to follow-up in clinic for further evaluation. Patient would benefit from continued care at rehab facility. The hospital provider note, dated 03/26/19 at 4:15 PM, documented, the patient was discharged home [the facility] in stable condition. A facility nursing note, dated 03/26/19 at 5:53 PM, documented, .due to a current incident, we were instructed, as well as ER, not to return the patient. The nurse in ER stated she didn't know that there was a DNR status on patient and was on the way back by (EMS). LN [Licensed Nurse] told ER nurse to stop ambulance. ER nurse stated ambulance had already left. When reminding ER nurse they were advised to not return, ER nurse stated she wasn't aware of that and [the resident] was coming by ambulance any minute. LN told ER nurse to prepare a spot for him in the ER . Hospital documentation, dated 03/26/19 at 5:54 PM, documented Resident #1 was returned to the Emergency Department (ED) after being just seen in this ED and sent back to [facility]. The patient was refused at [facility] and sent back to the ED . [The facility] told ED staff that the patient would be accepted back to the facility after a mental health evaluation. The patient has no new behavioral concerns or any new symptoms . A facility nursing note, dated 03/26/19 at 5:55 PM, documented, Tried to get a hold of DNS of resident's return but was not aware the hospital had done an eval there and he was ok to come back. Staff here was told he could not come back until eval was done. Treatment nurse tried to get ahold of Administrator while this LN tried DNS with no success. The hospital stated they tried to contact facility, left 3 messages as far as giving report on resident and he was coming back. Staff on days will have to retrieve these messages tomorrow. The hospital said resident is stable. A facility nursing note, dated 03/26/19 at 6:12 PM, documented, [hospital staff] called and said they were unable to get ahold of DNS, but as far as the orders that were sent with resident have been completed and they are sending him back to facility. This LN texted DNS again of this info. The hospital physician note, dated 03/26/19 at 6:13 PM, documented, Per crisis counselor, our administrator on call has called [facility] and they agree to accept the patient back. The hospital physician note, dated 03/26/19 at 6:52 PM, documented the physician spoke to the admissions coordinator at the facility, who stated the patient was not accepted back to the facility. The admissions coordinator said the resident was too aggressive and the facility could not take him back. The hospital physician note, dated 03/26/19 at 6:55 PM, documented the hospital informed the facility they will file an abandonment complaint. The facility refused to take the patient back. A facility nursing note, dated 03/26/19 at 8:00 PM, documented, [facility admissions coordinator] called this LN and informed me that resident is not to come back to facility at this time as he has not gone thru Gero psych eval and treatment as MD wants. The info the hospital gave this LN was incomplete. Gave this info to [night shift] nurse that he is not to be accepted back at this time. Review of the record showed no documentation the facility made efforts to obtain an accurate status of the resident's condition, find out what treatments, medications, and services the hospital provided to improve the resident's condition, or work with the hospital to determine if the resident's condition and needs were within the facility's scope of care when he was ready for discharge. The resident's chart did not include a Notice of Discharge/Transfer, provision of appeal rights, documentation that the facility attempted to determine if the resident required services of the facility, determine the current status of the resident's condition, find out what treatments, medications or services the hospital provided to improve the resident's condition, and work with the hospital to ensure the resident's condition and needs were within the facility's scope of care. On 04/23/19 at 1:50 PM, Staff C, a Licensed Practical Nurse, said she was the staff who took the telephone order from the provider to send Resident #1 to the hospital for evaluation. When asked why the resident was not allowed to return to the facility after he had been cleared by the hospital, Staff C said, We wanted him to get evaluated by Gero-Psych. We knew it would take some time. When asked whether anyone had contacted Gero-Psych to see if they had room for or could provide an evaluation for Resident #1, Staff C said no, she did not do that and did not know if anyone did. On 04/23/19 at 2:00 PM, Staff D, a Licensed Practical Nurse, said she believed Resident #1 would be welcome once he was stabilized. When asked why the facility would not accept Resident #1 back after he had been cleared for return by the hospital, Staff D stated, It had not been long enough. It had only been about 4 hours. At 3:02 PM, when asked why the resident was not allowed to return to the facility after he had been cleared by the hospital, Staff B, DNS, said she wanted the resident to have a gero-psych eval, so they could make adjustments to his medications. Staff B stated, We would take him back after gero-psych, after he was stable. When asked if she had contacted the gero-psych unit regarding an evaluation or to inquire whether they would be able to accept the resident, Staff B stated, No, I did not. When asked whether the physician or other staff had contacted the gero-psych unit to inquire about services for Resident #1, the DNS said that had not been done. When asked how the facility could insist that the hospital provide an evaluation that the facility could have arranged for, before permitting the resident to return, the DNS did not respond. Hospital records showed Resident #1 was still at the hospital as of 04/23/19, 28 days. Reference WAC 388-97-0120(4)(b)

Based on interview and record review, the facility failed to ensure adequate nutritional interventions were maintained for 1 of 4 current sampled residents (#120) received for nutrition. This failure placed residents at risk for a decline in health status and quality of life. This caused harm to Resident #120. Findings include: Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 8/24/17, indicated the resident was moderately cognitively impaired and required extensive assistance with activities of daily living. The resident weighed 208 pounds upon admission to the facility, had [MEDICAL CONDITION] and was expected to lose weight due to the use of diuretics. The resident weighed 193 pounds on 8/15/17, indicating a 15 pound weight loss in five days. The resident's food intake record showed the resident had poor food intake. The Registered Dietician (RD) evaluation, dated 8/16/17, noted the resident's food intake had been poor since admission and had a 7.2% weight loss since admission. The plan of care, recommended by the RD, included alerting the physician of the weight loss and offering a snack three times a day. On 8/17/17, Resident #120 was reviewed at the weekly weight meeting. There was a recommendation to re-weigh the resident. On 8/19/17, Licensed Nurse (LN) B, a care manager, faxed information to the doctor to report the 7.2% weight loss and to inform the doctor of the RD's 8/16/17 recommendations. On 8/22/17, the doctor's response was noted, to hopefully most of weight loss is from increasing his [MEDICATION NAME] (diuretic medication). Agree with above recommendations. The resident's food intake record continued to show poor food intake and not taken was documented for all snack entries. On 8/25/17, the resident weighed 181 pounds, a 27 pound weight loss over 15 days. On 8/31/17, Resident #120 was reviewed at the weekly weight meeting. A 16.3% weight loss was documented and a recommendation to alert the doctor was noted. There was no documentation in the medical record to show the doctor was contacted about the weight loss at that time. On 9/5/17, the resident weighed 165 pounds, a 43 pound weight loss in 26 days. In a progress note, dated 9/7/17, LN B documented, Resident has had a 20.7% weight loss in one month. Resident with poor appetite, with biliary pancreatitis .Will request change diet to regular, regular texture with high calorie foods . The request for the diet change was faxed to the doctor on 9/11/17. The physician agreed to the diet change on 9/12/17 and stated some of that weight loss was from diuretics. On 9/12/17 the resident weighed 162 pounds, a 46 pound weight loss over a period of 33 days. On 9/12/17 at 1:30 p.m., Resident #120 was observed lying in bed, eyes squinted and appeared to be thin. The resident said he had not been feeling well and no one knows why. On 9/13/17 at 7:30 a.m., the resident was sent to the hospital after the nurse was unable to obtain the resident's oxygen saturation level. On 9/19/17, the DNS provided an inpatient progress note indicating the resident had been admitted to the hospital with [REDACTED]. On 9/20/17 at 9:16 a.m., when asked about snacks on day shift, Nursing Assistant (NA) D said most snacks were given out before bed time. When asked if she knew of any residents who were offered three snacks per day, she said she was not aware of any. When asked about Resident #120, NA D said she was not aware of him receiving or being offered three snacks a day. On 9/20/17 at 9:43 a.m., when asked if Resident #120 had been offered a high protein, high calorie nutritional supplement, the DNS said, No, I don't see where we did that. The DNS said that could have been a potential intervention for him. Although the resident had multiple medical complications [REDACTED].

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#1) reviewed for medication errors. This failure caused increased bleeding and worsening of a medical conditions resulting in Resident #1 requiring additional medical interventions. Findings include: A review of the medical record showed Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. A review of medication orders, dated 5/27/17, noted give 3 mg of [MEDICATION NAME] (also called [MEDICATION NAME]) for [MEDICAL CONDITION]. The FDA approved package insert for [MEDICATION NAME] noted the most common adverse reactions were fatal and nonfatal hemorrhage from any tissue or organ. The dosage and administration of [MEDICATION NAME] must be individualized for each patient according to the patients INR (blood test that measures how long it takes blood to clot) response to the drug. Nursing notes indicated, on 6/06/17, Resident #1's INR was critically elevated at 7.91 (therapeutic range 2-3). Licensed Nurse (LN) A received orders to hold [MEDICATION NAME] and recheck INR on 6/08/17. The Medication Administration Record [REDACTED]. On 6/28/17 at 2:00 p.m., the Director of Nursing Services (DNS) stated LN A had forgot to discontinue the [MEDICATION NAME] in the computer after receiving orders from the doctor to hold it. When LN B came on the evening shift, she gave the medication because it was still in the computer as a medication order. The DNS stated her expectation was that any abnormal labs would also be given in report during the change of shift. Due to this incident, the DNS implemented a policy that all [MEDICATION NAME] orders have a discontinue date, requiring a new order after the results from the INR have been received. A review of the hospital summary, dated 6/17/17, documented on 6/10/17, Resident #1 was admitted to the hospital with [REDACTED].

Based on observation, interview and record review, it was determined the facility failed to ensure residents were as free from accident hazards as possible and received adequate supervision to prevent accidents for 2 of 4 residents (#74 & 138) reviewed for accidents. The facility caused harm to Resident #74 when they failed to implement new interventions and failed to consider medication side effects for the resident who had repeated falls and sustained substantial bruising to her face. The facility caused harm to Resident #138 when they failed to monitor the newly admitted resident per the facility's protocol and the resident fell and sustained injuries requiring hospital evaluation. These failures placed all residents at risk for falls and injuries. Findings include: <Resident #74> Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's MDS dated [DATE], the resident was cognitively intact, required extensive assistance with ADLs and had fallen and sustained a fracture prior to admission to the facility. Review of the resident's medical record showed the resident fell while in the bathroom unattended on 6/2/16. On 6/21/16, the resident fell again in the bathroom and reported feeling dizzy prior to and after the fall. On 7/9/16, the resident fell out of bed and hit her left eye on the bedside table, sustaining a laceration below her left eye as well as bruising to her face. On 7/11/16, the resident was observed with deep purple bruising to approximately 30% of her face. Review of the resident's care plan for falls showed all interventions were put into place on 4/5/16 upon admission. No new interventions were put into place following the three falls. On 7/13/16 at between 9:00 a.m. and 11:23 a.m., the resident was in her room asleep, with the door closed and in a darkened room. At 11:23 a.m., the resident was observed lying on her left side just a few inches from the edge of the bed. No new interventions were observed in the resident's room following her fall with injuries including a laceration under her eye and substantial facial bruising. At 11:25 a.m., when asked how her 7/9/16 fall occurred, the resident said, I just fell out of bed. At 12:01 p.m., Licensed Nurse (LN) B confirmed the resident had been sleeping on the edge of her bed. When asked how the facility was attempting to keep the resident safe, LN B stated, I don't know about the interventions. I have been gone. At 12:30 p.m., the DNS was asked how the facility was attempting to keep the resident from having further falls. The DNS stated, I will talk with her and see what we can do. She gets out of bed on her own. <Resident #138> Resident #138 was admitted to the facility on [DATE]. The Minimum Data Set (MDS), an assessment tool, dated 6/17/16, documented the resident had two prior falls. Resident #138's Care Plan, dated 6/17/16, documented the resident was at risk for falls due to new stroke, poor vision and weakness. Staff were to check on her every 15 minutes for three days after admission or a fall. On 6/17/16, staff found Resident #138 on the floor in her room and she was admitted to the hospital with [REDACTED]. She was re-admitted to the facility on [DATE]. A witness statement regarding the fall, dated 6/17/16 by NA E, documented she forgot to sign the 15 minute check form for Resident #138. NA E wrote .I was very busy in other rooms. The last thing on my mind was signing the 15 min sheet. We don't have the staffing to check her every 15 min, especially not at 4 pm when all the aides are in rooms getting people ready for dinner. On 7/7/16 at 10:02 a.m., the Director of Nursing Service (DNS) reported Resident #138 was initially admitted on [DATE], then fell approximately 5 hours later and was admitted to the hospital for 3 days. On 7/12/16 at 10:29 a.m., Nursing Assistant (NA) A said when there are 15 minute checks required, staff go in and check off what the residents were doing and where they were. Any licensed nurse or NA could complete a 15 minute check. On 7/12/16 at 2:50 p.m., the DNS stated Resident #138 had not been at the facility long enough on 6/17/16 to set up a check sheet for every 15 minute checks. The DNS created an intervention on 6/22/16 in Resident #138's Care Plan to monitor the resident frequently, including 15 minute checks beginning on 6/21/16. The resident was observed on 7/8/16 at 3:17 p.m. and 7/11/16 at 9:30 a.m. in bed. Her right arm was wrapped from above her elbow to her wrist. She stated the bandage on her arm was from an injury when she fell . A note posted in the facility nursing station found instructions for staff to place all new admits on 15 minute checks for the first 3 days to help reduce falls from new admissions. This typewritten note had a handwritten signature by the DNS. Review of the form used for 15 minute checks showed no documentation of 15 minute checks for Resident #138 on 6/22/16 between the hours of 6:00 a.m. and 10:00 p.m. On 7/12/16 at 10:55 a.m., the DNS stated the NA who came on shift after the blank form noticed there was no documentation, she should have reported it.

Based on interview and record review, it was determined the facility failed to provide nutritional care and services to 2 of 3 residents (#22 and 107) reviewed for nutrition in a timely manner when delays were identified after the registered dietician had made recommendations to improve residents' nutritional status. This failure caused harm to Resident's #22 and #107 when they each experienced significant and unplanned weight loss. This failure placed residents at risk for continued and unplanned weight loss and potential declines in health status. Findings include: <Resident #107> Resident #107 was admitted on [DATE] and according to the resident's MDS dated [DATE], the resident was moderately cognitively impaired, required limited assistance with ADLs and was not on a planned weight loss program. Review of Resident #107's chart on 7/11/16 showed the resident weighed 112 pounds on admission to the facility on [DATE] and weighed 104 pounds on 5/31/16, indicating an eight pound or 7.1 % weight loss over 16 days. Record review showed the Registered Dietician (RD) assessed Resident #107's nutritional status on 5/26/16 and noted the resident had wounds which could contribute to her nutritional needs. The RD documented the plan was to alert the physician to the resident's weight loss, add 60 cc of 2cal (a high calorie/high protein nutritional supplement) between meals and add small portions to meals with meals plus. On 7/11/16 at 1:48 p.m., the DNS referred to a binder where nutritional recommendations were kept and stated she did not see initials from the care manager indicating they had requested order changes from the physician for Resident #107. No documentation was found in the chart to show the facility had communicated with the physician or forwarded the RD recommendations to the physician prior to the resident's discharge on 6/1/16. <Resident #22> Resident #22 was admitted on [DATE] and according to the resident's Minimum Data Set (MDS), an assessment tool, dated 5/16/16, the resident was cognitively intact, required extensive assistance with activities of daily living (ADLs) and was not on a planned weight loss program. Review of the resident's chart on 7/11/16 showed Resident #22 weighed 178 pounds upon admission. On 5/25/16, 15 days after admission, the resident weighed 167 pounds and had experienced an unplanned 11 pound or 6.2 % weight loss. Per record review, the RD reviewed the resident's nutritional status on 5/26/16 and made recommendations to: 1)Alert the physician of the weight loss. 2) Recommend a diet change to NAS (no added salt), regular diet with meals plus ([MEDICATION NAME]/extra calorie foods). 3) Recommend 60 cc of 2Cal two times a day between meals. The resident's chart showed physician communication regarding the RD's recommendation was first initiated on 6/7/16, 12 days after the recommendations were made. On 7/13/16 at 10:29 a.m., Licensed Nurse B was asked when Resident #22 began receiving a nutritional supplement and after looking at the resident's Medication Administration Record, [REDACTED]. At 12:36 p.m., the Director of Nursing Services (DNS) stated, The process of reviewing the recommendations and contacting the physician should be done within a couple of days. The DNS agreed there was a delay in communicating with the physician and indicated the care manager who was responsible for it was new. The DNS stated, I should have followed up. .

Based on observation, interview and record review, it was determined the facility failed to ensure 2 of 5 residents (#61 & 74) reviewed for medication management did not receive unnecessary medications when sedative medications, used to treat anxiety, were administered at a dose that exceeded federal nursing home guidelines for elderly residents and without attempting and documenting non-medication interventions prior to administering those medications. This failure caused harm to Resident #74 when she experienced possible side effects from a medication which included sedation and repeated falls, one with a significant injury. This failure placed residents at risk of experiencing medication side effects, including drowsiness and increased risk of falls and potential decline in overall health status. Findings include: <Resident #74> Resident #74 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool dated 4/11/16, the resident was cognitively intact and required extensive assistance with activities of daily living. During observations of Resident #74 on 7/6/16 at 3:56 p.m., 7/7/16 at 9:39 a.m., and 7/13/16 between 9:00 a.m. and 11:23 a.m., the resident was in her bed in a darkened room, was groggy, or said she was too tired to talk. On 7/13/16 at 11:23 a.m., Resident #74 was difficult to wake. When asked how she fell on [DATE], the resident spoke with her eyes closed and said, I just fell out of bed. The resident was observed with extensive purple bruising on her face from the fall. Review of the resident's chart showed the resident fell in the bathroom on 6/2/16 and on 6/21/16. Per the facility's investigation report, the resident was dizzy before and after the 6/21/16 fall. The resident had a third fall on 7/9/16 which resulted in a laceration above her eye and substantial facial bruising. Review of the resident's June and July MARs showed the resident had been sleeping and not available to take medication or refused medications several days during that time frame. On 7/12/16 at 10:30 a.m., the Director of Nursing Services (DNS) stated nurses should be giving as needed [MEDICATION NAME] after they have already tried non-medication interventions. The DNS said the non-medication interventions should be documented in a progress note or a medication note. Review of Resident #74's MAR indicated [REDACTED]. Review of nurse progress notes and medication notes did not describe the type or level of anxiety or behavioral issues the resident was displaying and did not describe any type of non-medication interventions offered prior to administering [MEDICATION NAME]. On 7/13/16 at 10:37 a.m., Licensed Nurse (LN) B stated, Resident #74 rarely comes out of her room. When asked what symptoms and behaviors the resident displayed prior to receiving [MEDICATION NAME], LN B said, She just asks for it. When asked if the resident's care plan directed non-medication interventions, LN B stated, I am not positive. If they ask for it, we give it. At 3:19 p.m., Nursing Assistant F said, Resident #74 stays in her room a lot. She sleeps a lot. <Resident #61> Resident #61 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's MDS, dated [DATE], the resident was cognitively intact and required supervision of activities of daily living (ADLs). Review of the resident's July Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. According to The Drug Reference Book, older adults may be more sensitive to the side effects of [MEDICATION NAME], especially loss of coordination and drowsiness. These side effects increase the risk of falling. Review of the resident's medical record showed the resident had fallen multiple times in the facility. On 7/13/16, the resident's medical record was reviewed which showed the Consulting Pharmacist's cautioned the facility on 4/12/16 and 6/30/16 regarding Resident #61's excessive [MEDICATION NAME] order. On 7/13/16 at 2:46 p.m., the Director of Nursing Services acknowledged she had received the pharmacist's recommendation regarding the resident's excessive dose and said, I just saw those yesterday so nothing has been done with those.

Based on interview and record review, it was determined the facility failed to identify and/or prevent and treat pressure ulcers for 2 of 3 resident's (#107 & 8) reviewed for pressure ulcers. This failure caused harm to Resident #8 when she developed a new and preventable pressure area. This failure caused harm to Resident #107 when she experienced a delay in treatment and deterioration of her wound. These failures placed all residents at risk for acquiring pressure ulcers and/or experiencing treatment delays. Findings include: <Resident #107> Resident #107 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool dated 5/22/16, the resident was moderately cognitively impaired, required limited assistance with activities of daily living (ADLs) and did not have a pressure ulcer upon admission to the facility. On 7/11/16, the resident's admission note, dated 5/15/16 was reviewed and documented: .skin check, has stage 2 popped blister 5 x 3.5 cm wide superficial area, covered with island dressing, clean pink healthy tissue present .will leave dressing on buttocks and have treatment nurse view tomorrow and treatment plan. Review of the resident's progress notes did not include further assessment of the wound, a description of the wound or treatment planning to care for the wound. The first treatment order was dated 5/20/16, five days after the resident was admitted to the facility. The resident's Treatment Administration Record (TAR) documented the resident's first treatment to the wound was completed on 5/22/16, seven days after admittance to the facility. On 7/11/16 at 2:03 p.m., the Director of Nursing Services (DNS) said she had looked through the resident's chart and was unable to locate the resident's skin assessment sheet that would have described the condition of the resident's skin and size of the wound. The DNS provided a copy of the facility's weekly wound report for the week ending 5/27/16 which documented Resident #107 had a wound with black eschar (dead tissue) in the center of it. The DNS was asked to provide a description of the care and services, including treatments on Resident #107's wound. At 2:50 p.m., the DNS stated she could not find anything before the 5/20/16 treatment order and said there should have been a progress note at the time of the treatment order but stated it had not been done. On 7/12/16 at 1:30 p.m., the wound nurse stated she had just started working at the facility during the time Resident #107 was admitted . The wound nurse said she was unfamiliar with the facility's electronic charting, was unsure how and/or where to document and did not remember a lot about Resident #107's wound care. Although the resident was at the end of her life, the facility failed to promptly assess and implement treatments to prevent worsening of the resident's skin condition. <Resident #8> Resident #8 was admitted on [DATE] post hospitalization for left hip surgery. Resident #8 was admitted with an abduction (prevents forward and backward movement following hip surgery) brace on and a physician order [REDACTED]. The resident's MDS, dated [DATE], documented Resident #8 was cognitively intact, required two person assistance for bed mobility, transfer, dressing, toileting and personal hygiene, and was totally dependent upon staff for bathing. The MDS documented the resident was at risk for developing pressure ulcers and had an unstageable ulcer to her left heel. Record review of June and July TAR showed no documentation of daily or each shift monitoring of the skin under the brace. On 7/12/16 at 2:01 p.m., Nursing Assistant (NA) B reported that on 7/09/16, while getting Resident #8 up for lunch, drainage was noted on the drawsheet. She stated NA D went to inform Licensed Nurse (LN) C of their findings. Record review of nurses notes for 7/09/16 showed no documentation of an assessment or treatment plan for the drainage found by NA B and NA D. NA B further stated that on 7/10/16, while getting Resident #8 up for breakfast, NA A found drainage on sheet. LN H was informed and came to investigate. On 7/10/16 at 9:23 a.m., a progress note for Resident #8 documented a pressure ulcer had been found to the left thigh (directly under the abduction brace) and was measured to be 11 centimeters (cm) x 3 cm with small open areas. The facility failed to assess, evaluate and intervene with a treatment for [REDACTED]. On 7/11/16, after the development of the new ulcer, the pressure ulcer care plan had been updated to include monitoring of skin each shift. The facility caused harm to Resident #8 when they failed to monitor the skin under the brace frequently, failed to aggressively prevent the development of a pressure ulcer and failed to promptly treat the area for a resident who was at high risk for developing pressure ulcers.

Based on observation, interview and record review, it was determined the facility failed to have sufficient numbers of qualified staff to provide and supervise care for residents with complex health care needs and to ensure residents were protected from abuse, assessed for infections and treated with dignity and respect for current residents (#1, #2, #8, #9, #23, #24, #20, #13, #26, #27, #38) and discharged residents (#6, #7, #10, #21, #11, #12, #22). This failure placed all residents at risk of not attaining and/or maintaining the highest practicable physical, mental, and psychosocial well-being in accordance with resident assessments, care plans and professional standards of practice and impacted their well-being and quality of life. Findings include: The information below is more detailed in the individual citations: 1) Refer to 42 CFR 483.13(c) - F 224 Prohibit Mistreatment/neglect/misappropriation for facility neglect of 2 residents (#9, #1) and for a Licensed Nurse (LN) who intentionally neglected to respond to Resident #24's need for emergency assistance. 2) Refer to 42 CFR 483.25 - F 309 Provide Care/services For Highest Well Being for failure provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well being for 1 of 5 residents (#20) when they failed to accurately assess the resident for aspiration and resulted in harm to the resident when care was delayed. This failure caused harm to Resident #20 when the resident's health deteriorated to the point where emergency hospitalization to the Intensive Care Unit (ICU) was required. 3) Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores for facility failure to ensure 10 of 10 current and former/discharged residents (#1, #6, #8, #7, #9, #10, #21, #2, #23 and #24) who were identified at risk for skin breakdown and who developed pressure sores/infections in the facility, were assessed, monitored, evaluated and treated by qualified personnel and in accordance with accepted standards of practice and resulted in harm to these residents. 4) Refer to 42 CFR 483.25(h) F-323 Free of Accident Hazards/Supervision for facility failure to ensure adequate supervision for 5 of 8 sampled residents (#11, #12, #22, #13 and #24) reviewed for accidents when staff members were transferring and/or providing direct resident care and resulted in harm to these residents. 5) Refer to 42 CFR 483.65 F 441 Infection Control for facility failure to maintain an active, ongoing Infection Control Program (ICP) that tracked current organisms and infection history in the facility for several residents reviewed for urinary tract infections [MEDICAL CONDITION], respiratory infections, surgical site infections. Resident #21, #20, #26, #8, #27 and #38 were identified with respiratory infections and Resident #20 had laboratory-confirmed Influenza A. Not knowing the numbers of infections, locations in the facility, the organisms and/or correct treatment placed residents, staff and visitors at risk of exposure to serious infections and prevented the interdisciplinary team from participating in the recognition of infection clusters and trends to prevent/control the spread of infections.

Based on observation, interview and record review, it was determined the facility neglected to perform timely assessments, evaluate, treat and implement ordered interventions for 2 of 10 sampled residents (#9, #1) reviewed for neglect of pressure ulcers. This failure resulted in harm to these residents when new pressure ulcers developed without prompt recognition/intervention and for neglect in implementing the Comprehensive Care Plan (CCP) and reporting of impaired oxygen levels for Resident #9. In addition, a Licensed Nurse (LN) intentionally neglected to respond to Resident #24's need for emergency assistance. Also Residents #1, #2, #3, #4, #8,#9,#11, #12, #13, #20, #26,#27, and #38 and former Residents #'s 6,7,10, 21 and 22 neglected to receive services that affected their health and/or safety. Findings include: 1) Resident #9 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including kidney disease, heart failure, diabetes and stroke. He was alert, oriented and made his own care decisions. He required extensive assistance with mobility and transfers and was at high risk for skin breakdown. The Comprehensive Care Plan (CCP) dated 2/16/16 documented, To wear Podus boots (boot that helps in the healing and/or prevention of heel and toe ulcers) on both feet while in bed. On 3/4/16 at 1:30 p.m., Resident #9 was observed lying in bed without Podus boots applied. On 3/5/16 at 2:10 p.m., Resident #9 was again lying in bed without Podus boots applied. At 3:30 p.m. Resident Care Manager (RCM) A said Resident #9 had an order for [REDACTED]. At 4:00 p.m., Physical Therapist (PT) E stated he had never seen Podus boots applied to the Resident and I have just seen them in the room. At 4:10 p.m., the Director of Nursing Services (DNS) was observed to apply Podus boots to Resident #9. On 3/4/16 at 1:45 p.m., PT E was observed transferring Resident #9 into bed. During the transfer Resident #9 became short of breath with audible wheezing and mildly cyanotic (blue in color) lips. PT E placed an oxygen monitoring device on Resident #9 and obtained a reading of 80% (normal reference range 92-100%). PT E monitored Resident #9's oxygen levels for approximately two minutes and the resident's oxygen level increased to 85%, still below accepted range. PT E stated: The resident's normal level is 90-93%, I will let the nurse know. At 3:00 p.m., when asked about the oxygen levels, LN A stated that PT E had not spoken to her about Resident #9's low oxygen level and shortness of breath during the observed transfer. LN A stated: That is information I should know. 2) Resident #1 was admitted to the facility from home on 1/21/16 following right foot surgery. He had multiple medical conditions including diabetes and diabetic [MEDICAL CONDITION] to both feet. He was alert, oriented and made his own care decisions. On 2/18/16 at 3:30 p.m., during interview with the resident and the DNS, he stated he felt the new pressure ulcer that developed on his left foot on 2/3/16 was from neglectful care. The resident was upset and said: This is nothing but neglect . The resident made comments about the possibility of needing a peg leg and asked: Who doesn't check a diabetic's feet every night .you know I don't have any feeling in my feet .why is everyone interested in my foot now .where were you two weeks ago .? The resident said he admitted to the facility with one bad foot that (as of 2/10/16) is infected right now and added he came in with one bad foot and would be leaving with two (bad feet). Because of the new pressure ulcer, the resident said his stay in the facility was prolonged. Review of the DNS' nursing note dated 2/19/16, revealed no documentation of the resident's statements of neglect. The incident was not logged, reported or investigated as a resident's allegation of neglect until brought to the DNS' attention that the resident alleged the pressure ulcer was from neglect. 3) According to the records, Resident #24 had multiple medical complications [REDACTED]. He was totally dependent on staff for all care. On 3/4/16 at 4:00 p.m., during interview with Nursing Assistant (NA) C, she said she was walking by the resident's room when she found him on the floor. According to the records and interview, the NA asked the charge nurse for help. The charge nurse said: I can't help you, I'm off shift and put her hand in front of my face to stop me from proceeding with talking .I then found 2 other NA's .the resident required a mechanical lift and 6-7 people to lift him back to bed. The NAs found another nurse to assess the resident. The licensed nurse (LN) in charge of the residents for her shift intentionally neglected to respond to an emergency situation to help Resident #24. Refer to F 226 Residents #2, #3 and #4. Refer to F 314 Residents #1, #8, #9, #2, #23, #24 former/discharged residents #6, #7, #10, #21. Refer to F 323 Residents #11, #12, #13, #24 and former/discharged Resident #22. Refer to F 441 Resident #21, #20, #26, #8, #27 #38.

Based on observation, interview and record review, it was determined the facility failed to ensure 6 of 10 current residents (#1, #8, #9, #2, #23, #24) and 4 former/discharged residents (#6, #7, #10, #21) who were identified at risk for skin breakdown, and who developed pressure sores in the facility, were assessed, monitored, evaluated and treated according to accepted standards of practice and were evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the residents in a timely manner. Failure to recognize, assess, monitor, evaluate, prevent and/or promote prompt healing of existing pressure ulcers resulted in harm to these residents. Findings include: Review of the facility's Skin at Risk Program Overview indicated: This facility endeavors to ensure residents who enter the facility without a pressure ulcer do not develop pressure ulcers unless their clinical condition demonstrates the pressure ulcer was unavoidable and residents who enter the facility with a pressure ulcer receive appropriate care and services to promote healing and prevent infection. Further, An appropriate treatment order will be obtained and implemented when a pressure ulcer is identified .Weekly measurements .daily wound monitoring/documentation .Optimal care plans developed and implemented .Documentation includes length, width, depth, undermining, tunneling, pain, amount and type of drainage, condition of wound bed and wound edges . 1) Resident #1 was admitted to the facility on [DATE] from home following surgery on his right foot pressure ulcer. His right foot was bandaged. He had no identified issues with his left foot. He had multiple medical conditions including insulin dependent diabetes and diabetic [MEDICAL CONDITION] (nerve damage to feet and legs, can range from pain and numbness to inability to feel pain) with loss of feeling to his feet. He was alert, oriented and made his own care decisions. The record indicated on 2/3/16 at 8:30 a.m., a therapist found the resident in bed with an open, draining wound to his left heel. According to the physician's surgical progress notes dated 2/3/16, resident quite out of sorts today, not enjoying his time at the facility .angry .wants to change facilities. He now has a pressure ulcer to his left heel. It measures approximately 4 cm in diameter. It is full thickness (Stage III). The resident was to be non-weight bearing on both feet now. The physician's surgical note dated 2/11/16 indicated the left heel, full thickness ulceration .bilateral (both) toe nail overgrowth .now with an infection to right foot. The resident stated he informed facility staff there was a pin hole type puncture that occurred over the past week on his right foot and for the last couple of days his right foot grew increasingly red, hot and swollen. The patient noted to have excessively long length of his toenails on both feet. The physician interventions for the feet included: Daily dressing changes are to be performed on both his left full thickness decubitus ulcer as well as over the surgical sites of the right foot. On 2/18/16 at 10:00 a.m., during interview with the resident regarding the pressure ulcers to his feet, he said: The right one (foot) has an infection now (validated in the record on 2/10/16 and physician surgical notes dated 2/11/16) and the left one is pretty bad, pure neglect. The resident said he came in to the facility with one bad foot and would be leaving with two. He felt his stay had been prolonged now because of the new pressure ulcer which impacted his minimal mobility even further. He said his sock remained on his left foot for two weeks .No one was looking at my foot .I don't have any feeling in my feet, they know that .who doesn't check a diabetic's feet every night? The resident continued: When the therapist took my sock off, there was a big sore .there was blood on the sheet. The resident said there is no routine, they change the dressings any time of day or night .the other night it was changed at midnight .how can you see anything at that time? The resident's family member was present and also identified problems with staff members attending to the resident's feet and questioned how the pressure ulcer occurred on his left foot. On 2/18/16 at 10:00 a.m., Licensed Nurse/Resident Care Manager (LN/RCM) B was asked about the area but was not able to describe it as s/he only worked three days a week. When asked how the wound was managed, s/he said s/he was not sure as each person might do it differently. The LN was asked if the resident was due for a dressing change and s/he said usually later in the day. S/he was asked if it could be observed now as the resident said it had not been changed for two days. During inspection of the foot with the LN and family member, the area was noted to be approximately the size of the palm of a hand covering the entire heel with black (necrotic/dead) tissue. The family member said: Oh, that is much worse than when I saw it two weeks ago in the doctor's office. A nickel-sized scab to the resident's left outer area above the ankle was noted. When asked about the area, the LN said s/he was not aware of it. The resident said: That happened when my leg kept rubbing against a bolt on the wheelchair (footrest attachment) and the therapist changed it. The therapist documented the nurse was informed. No nursing documentation was found to indicate the wound was identified, assessed or managed for healing. The LN changed the dressing and used some saline and gauze to clean the area then applied an antibiotic ointment. S/he placed a small foam pad to the heel and wrapped it with gauze. The resident motioned to all of the supplies the LN had placed on the bedside table and said: No one ever cleaned it like this before .all the cleaning with water .and ointment and then asked how the wound should be managed. Review of the clinical record indicated the resident was at risk for skin breakdown/pressure ulcers and was to have weekly skin checks which were not found documented consistently. When asked about the application of a routine antibiotic ointment to the pressure ulcer, the LN said she would need to check the order. According to the physician's last order, it was to be dry dressing change. The LN validated this later in the day after verifying the order. No other dressings had been identified as applied to the wound or measurements and description of the wound to know if it was getting better or worse since discovery on 2/3/16. On 2/19/16 at 1:00 p.m., the resident said the left heel area had been checked at the surgeon's office the afternoon of 2/18/16. During observation with two LN's, the Director of Nursing Services (DNS), Clinical Care Consultant (CCC) and primary care physician, the left heel was observed debrided (dead tissue removed) and now had a quarter sized area of black in the center and was surrounded by red, pink tissue. No description of the wound was available. An additional area on the resident's left great toe was identified at this time. There was a black seed-sized area on the tip of the toe. The CCC observed and measured the areas prior to a dry dressing application and asked the resident if he could feel her pressing on his foot. He said he had no feeling in his feet. The CCC recommended a blanket cradle to keep the covers off of the resident's feet. The resident informed all of the observers that a staff nurse cut away the left great toenail the other day because it was curling around my toe. The nail treatment/cutting and black area were not found documented in the resident's clinical record. The resident's toenails were very long and thick (½ inch) and all were in need of trimming/cutting. The resident said the surgeon doesn't cut toenails. This was validated in the physician's surgical note dated 2/11/16 when he documented: bilateral (both) toe nail overgrowth .excessively long length. The physician's surgical note dated 3/2/16 indicated there was necrotic (dead) tissue to the left heel and to plan surgical debridement. At this time, the surgeon informed the resident he was at risk of losing both legs. 2) Former Resident #6 was admitted to the facility from the hospital following surgery on 1/31/16 with multiple medical conditions including heart rhythm irregularities/pacemaker, lung disease and diabetes. The resident was alert, oriented and made his own care decisions. The resident was at risk for skin breakdown. According to the record, on 2/9/16 the Nursing Assistant (NA) found an open wound to the left interior buttock that measured 7.0 x 3.0 cm .Cleansed with soap and water and barrier cream applied. Note left in physician's box. The note indicated the area was red when admitted on [DATE] .Continue to apply Barrier cream to area twice a day and as needed .resident repositions self in bed. Review of the resident's most recent Minimum Data Set (MDS), an assessment tool dated 2/14/16, did not indicate or describe the resident's new pressure ulcer found on 2/9/16. 3) Resident #8 was re-admitted to the facility on [DATE] following a 3-day stay at the hospital with multiple medical conditions including recent surgery. She had a history of [REDACTED]. According to the records, on 11/28/15, an order was given to monitor buttocks and apply house barrier cream every shift and as needed. On 12/1/15 at 3:22 a.m., the evening nurse found the resident with a new open wound the size of a nickel to her left buttocks and routine barrier cream applied .note put in physician's box and Resident Care Manager's (RCM's) box. Also documented on 12/1/15 was both heels were found with ulcerations identified on 11/30/15. The left heel wound measured 7.5 x 7.5 centimeters (3 by 3 inches) and was red and mushy with black center; the right heel wound size was 3.5 x 3.0 cm (approximately 2.5 inches) with irregular purple discoloration and 2.5 cm unstageable ulcer. Facility staff indicated these were not noted at lunch time when skin checks were done. The facility determined the areas were unstageable and the resident was incontinent of bowel and bladder; needed maximum assist with mobility; unable to lift buttocks related to weakness; therapy working on bed mobility; area appeared superficial from shearing .monitor until healed. 3a) The record indicated on 12/30/15, the therapist reported Resident #8 was found with a black area 3.5 cm x 2.2 cm behind the right ankle with redness around edges and slightly warm. Skin assessments indicated Unable to stage, necrotic (dead) tissue adhered firmly to wound bed. New orders for treatment of [REDACTED].continue to monitor wounds. 3b) The record indicated on 1/2/16 the resident complained of right leg pain and requested to go to the hospital where she was admitted . According to the hospital records dated 1/3/16 at 9:00 a.m., the resident arrived with complaints of right leg pain, bilateral heel ulcers, large ulcer on her back of her right lower leg, now with redness from the knee down to the foot. She is in pain. She stated she had pain and swelling for the last 3 or 4 days. The hospital records indicated right lower extremity, redness and swelling from just below the knee to the toes, with some deep purple area on the foot, paleness to toes, prolonged capillary refill. On the back of the calf there is about an 8 x 4 cm area that is black, necrotic ulcerated and on the heel there is a half-dollar sized ulcer. Left lower extremity has a half-dollar sized ulcer on her left heel . and left fifth toe with fracture .and compression fracture to lower back. The hospital records indicated: right lower extremity with [MEDICAL CONDITION] (infection) and necrotic (dead) tissue. X-rays to rule out bone involvement .start on IV (intravenous) ABOs. 4) Former Resident #7 was admitted to the facility from the hospital following surgery on 11/29/15. She had multiple medical conditions including [MEDICAL CONDITION], stroke, [MEDICAL CONDITIONS] and poor nutrition. She was at high risk for pressure ulcers. She was dependent on staff for all care. The Comprehensive Care Plan (CCP) dated 11/29/15 indicated the resident was at risk for pressure ulcers due to weakness and stroke with left [MEDICAL CONDITION]. The goal was to keep her skin intact. Interventions were to apply moisture barrier skin cream as appropriate. Skin check upon admission and weekly per facility policy. According to the Minimum Data Set (MDS), an assessment tool, the resident had no pressure areas on 12/25/15 and on 1/6/16 the resident was identified with both heels soft and mushy. Left heel approximately 5.0 x 5.0 cm (dark purple area). Will float heels and monitor every shift until resolved. The facility determined the resident had developed sDTI (suspected Deep Tissue Injury which are localized areas of dead tissue and represent a serious form of pressure ulcer). The area was identified with purple, mushy areas, unable to visualize wound bed .due to decreased mobility and stroke . unable to stage as area covered with eschar (dark scab, dead tissue). 5) Resident #9 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including kidney disease, heart failure, diabetes, stroke and without pressure ulcers. He was alert, oriented and made his own care decisions. He required extensive assistance with mobility, transfers and was at risk for skin breakdown. The CCP for pressure ulcers was initiated on 1/18/16 when the resident was found with an unstageable area on left buttock that measured 3.0 x 2.5 cm; Stage II on right buttock that measured 2.2 x 4 cm and Stage II on his scrotum and tip of penis .foul odor. The resident had a catheter and severe swelling from his knees to waist. The staff faxed the physician about the wounds, applied dressings to the wounds and barrier cream to the scrotum and penis. On 3/4/16 at 1:45 p.m., LN A was observed providing treatment to Resident #9's coccyx pressure ulcer. After explaining the procedure to the resident and obtaining his/her consent, LN A removed the dressing and exposed the pressure ulcer. Resident #9 had a 3 x 3 cm open (Stage II) pressure ulcer to the coccyx with discoloration extending outward approximately 5 cm onto the right and left buttock. There was active bleeding from the ulcer. Additionally, LN A did not identify a new open stage II pressure ulcer on Resident #9's right gluteal fold. The 1 x 0.5 cm pressure ulcer to Resident #9's gluteal fold was open and draining pink-tinged fluid. The ulcer was not covered by any dressing. LN A stated: That just comes and goes. Nursing Assistant D said: That (gluteal fold pressure ulcer) was not there earlier. 6) Former Resident #10 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including lung/[MEDICAL CONDITIONS], stroke, UTI [MEDICAL CONDITION] (not identified on the MDS assessments). The resident was alert and could make her needs known. She required extensive assistance from staff for mobility and transfers. She was at risk for skin breakdown. According to the record on 10/15/15 the resident was found with blisters to both heels (left lateral heel measured 4.0 x 2 cm fluid filled; right lateral heel with 3.0 x 3.0 cm red blister with black area; left great toe with blister and black scab; right great toe with small scab). The facility determined the areas were unable to stage, covered with eschar. At this time, Heel protectors and a blanket cradle were placed on the resident's bed to keep pressure off toes. After the resident unexpectedly passed away on 10/20/15, the facility determined the pressure ulcers were unavoidable due to the resident's condition. 7) Former Resident #21 lived in the facility since April 2011. He had multiple medical conditions including stroke that affected his right side, [MEDICAL CONDITION] and poor circulation to his legs. He required extensive assistance for mobility, transfers and was assessed at risk for skin breakdown. The most recent MDS dated [DATE] indicated the resident had no pressure ulcers. On 1/8/16 the resident was found by the NA with a small open area (Stage II) on his left buttock. Barrier cream to open area twice a day until resolved .faxed doctor .continue to monitor. The facility determined the ulcer occurred because the resident refused to lie down after breakfast per his usual .increases risk for skin breakdown .request physical therapy evaluate the open area to left buttock and wheelchair cushion . 8) Resident #2 was admitted to the facility on [DATE] with multiple medical conditions including [MEDICAL CONDITION] (loss of function to arms and legs), diabetes and diabetic [MEDICAL CONDITION]. He required extensive assistance with mobility, transfers and eating. He was alert, oriented and could make his needs known. He was at risk for skin breakdown. The record indicated on 9/18/15 a new wound was found on the bottom of his right foot, blister the size of a half dollar. The note by the RCM A indicated: Not aware of this until 10/6/15 when the area was mostly healed with a small piece of skin to come off yet but is healed under this flap. According to the CCP, initiated on 10/6/15 for Informed of blister to right outer ball of foot and no shoe/socks only to right foot .foot rest on wheelchair padded. The documentation was confusing as there were notations regarding the area as a bruise and blister/pressure ulcer. On 3/4/16 at 10:30 a.m. the resident was observed in his wheelchair at the front entry. His right foot heel was resting on the front edge of the foot pedal. The resident wore a sock and sheepskin heel protector was inside out, with the soft area on the foot pedal. When the resident was placed in bed at 1:30 p.m., observation of the right heel revealed a 50 cent sized red area where his foot was resting on the pedal. The NA saw the redness and said she would inform the nurse. The NA said they did notice his foot was not on the pedal when they put him back to bed. The resident said he knew how important it was to not have skin breakdown, especially on his feet. 9) Resident #23's most recent MDS dated [DATE] indicated the resident had no skin issues. She had multiple medical conditions including Alzheimer's dementia, [MEDICAL CONDITION], poor circulation to legs and dependent on staff for care. She was assessed at risk for skin breakdown due to always being incontinent of urine and bowel. According to the record dated 2/20/16, the resident was found by the NA with open areas to her left and right buttock folds. Barrier cream was applied. The area was noted where the disposable brief elastic was located and the facility determined could cause incontinence and some maceration (softening/breaking down of skin from moisture) from incontinence. Staff continued to apply barrier cream to the open wounds until 2/24/16 when the physician saw the resident and ordered a foam dressing applied until healed. 10) Resident #24 was admitted to the facility from the hospital on [DATE] following surgery. He had multiple medical conditions including wound infection,[MEDICAL CONDITION], diabetes and stroke. He required extensive assistance of two staff for mobility and transfers. He was at high risk for skin breakdown. According to the CCP, on 1/20/16 the foot doctor debrided the end of the resident's right great toe. No assessments could be found to indicate the problem related to the resident's toe. According to the record, on 2/20/16, the resident was found by the NA with two open areas on his coccyx. The total area measured about 6.0 x 8.5 cm in diameter (approximate 2.5 x 3.5 inches) with some purple areas around the wound. Resident has a urinary catheter but little output in the urinary bag and frequent large incontinence in briefs. Foam dressing applied, note faxed to doctor. The NN dated 2/25/16 indicated Not placing foam dressing to coccyx related to saturating with urine and bowel movement .very odorous . On 3/4/16 at 10:00 a.m., Resident #24 was observed in bed positioned flat on his back with his heels touching the mattress. At 10:30 a.m., Resident #24's spouse indicated she visits the facility daily from early morning until approximately 6:00 p.m. She stated the NAs come in once or twice a day to change him. She stated: He is always on his back. On 3/4/16 from 10:00 a.m. through 5:30 p.m., Resident #24 was observed lying flat on his back without being turned. On 3/4/16 at 11:15 a.m., NA B and NA E were observed providing care for Resident #24. An uncovered open pressure ulcer to his coccyx was observed. The Resident's spouse was present and stated: That has opened up in the past several days. The resident's right upper leg was discolored skin with an open area along his inner thigh with visible tissue showing. The resident had an open wound to his scrotum that was draining stool and urine. The resident had pressure sores to both heels including open pressure sores to both great toes. There was a Band-Aid covering the right great toe. The Resident's spouse stated: That has been that way for several days (Band-Aid needed changed). Upon request of the surveyor, LN A removed the Band-Aid and a mushy, open sore was observed. The NA's covered all ulcers on his bottom with routine barrier cream and replaced the resident's brief without any covering to these pressure sores.

Based on observation, interview and record review, it was determined the facility failed to maintain an Infection Control Program (ICP) that included surveillance, investigation, prevention, control and reporting to prevent the spread of infection; prevent and control outbreaks and to keep current, accurate records of the organisms in the facility and the corrective actions once infections were identified. During investigation of facility, hospital and physician clinic records, Resident #21, #20, #26, #8, #27 and #38 were identified with respiratory infections and Resident #20 had laboratory-confirmed Influenza A. This failure resulted in the inability to track current organisms and infection history in the facility for several residents reviewed for urinary tract infections (UTI), respiratory infections, surgical site infections and placed residents, staff and visitors at risk of exposure to serious infections and prevented the interdisciplinary team from participating in the recognition of infection clusters and trends to prevent/control the spread of infections. Findings include: Review of the infection control tracking documents/tracking book provided by the facility on 2/26/16 at 1:20 p.m., revealed no compilation/tracking of infections were available to review since December 2015. When asked about the absence of an active, ongoing ICP since December, 2015, the Director of Nursing Services (DNS), said the nurse on the East and West medication cart nurses can look at the medication information to see if an infection was identified. There was no tracking or analysis of the data to show the identified organisms and how the facility was implementing precautionary measures or how the facility staff members knew what infections might be problematic and the precautions they should take. Without an active ICP since December, the DNS said she would compile data later when she obtained additional information about the infections. There was nothing provided for review for January 2016. Since no surveillance program was in place for the last two months, the DNS was unable to indicate how many residents had infections, the type of organism and what prevention measure had been implemented to ensure prompt identification and/or necessary treatment. To obtain infection control information, review of some residents' records, hospital records and physician clinic records revealed the following but did not include all residents in the facility that may have infections. 1) Former Resident #21 had lived in the facility since 2011. According to hospital records, the resident presented in the emergency room (ER) on 1/18/16 from the facility around 9:00 p.m., critically ill, in respiratory failure with large bilateral pneumonia infiltrates and decreased level of consciousness .oxygen levels 60% .emergent interventions. 2) Resident #20 was admitted [DATE] from the hospital without infections. On 2/3/16 the resident was assessed in the hospital ER for shortness of breath at which time the resident was found to have sepsis (potentially life-threatening condition from infection) from a complicated UTI. A facility nursing note (NN) dated 2/21/16 indicated the resident had a fever, had not felt well for several days, was in respiratory distress with oxygen saturations of 75% (normal range 92-100%) on room air. The hospital report dated 2/21/16 showed Resident #20 had aspiration pneumonia, and Sepsis related to Influenza A infection present on admission .acute respiratory failure .UTI. admitted to Intensive Care Unit (ICU). 3) Resident #26 was admitted [DATE] without infection. On 3/3/16 the resident started running a fever and on 3/4/16 was found with a temperature of 101.1. The facility determined she had an upper respiratory infection. She required breathing treatments, oxygen and ABOs. The resident also was found on 2/22/16 to have a red, swollen left ear with drainage. The resident was started on ABO's for infection of the ear (Cellulitis). 4) According to facility records, on 1/2/16 Resident #8 requested to go to the ER for continued right leg pain. She was evaluated in theER on [DATE] where she complained of right leg pain and a cough for 2-3 weeks. The chest x-ray showed mild respiratory process for possible Bronchitis. She was started on ABOs. She also was found with cellulitis to her right lower extremity with complaints of pain for 3-4 days, redness, swelling from just below the knee to toes, with some deep purple are on the foot, pale toes .ulcerations on legs and buttocks. 5) Resident #27 was admitted [DATE] without infections. On 2/26/16 the resident was started on ABO for respiratory symptoms (Bronchitis). 6) Resident #28 was admitted to the facility on [DATE] with pneumonia and sepsis and ABOs. According to the Center for Disease Control (CDC) .If there is one laboratory-confirmed influenza positive case along with other respiratory infections an influenza outbreak might be occurring. There was no documentation to indicate the facility recognized and implemented precaution measures for other residents, staff or the public. On 3/4/16 at 3:00 p.m., during interview with the DNS, she said she felt there was not an outbreak occurring yet could not say how many residents had respiratory infections in the facility whether admitted with or developed in the facility or the locations of infections or identified organisms. There was no notations to indicate awareness of the confirmed Influenza A or what measures the facility implemented other than Resident #20. The DNS said Resident #20 was already in a private room. 7) Resident #1 was admitted [DATE] without infections. The resident developed an infection to his right surgical foot identified on 2/10/16 validated in the surgeon's note dated 2/11/16. The resident was observed on 2/19/16 during dressing changes to his feet. The resident said the infection to his right foot happened in the facility and he was not happy about it since he was diabetic and had also developed a pressure ulcer to his left heel while in the facility. 8) Former Resident #5 was admitted on [DATE] without infections. On 2/19/16 she was found with redness, swelling and warmth to right surgical hip. No further information was found on the information provided by the facility on 2/26/16. 9) Resident #29 was admitted [DATE] without an infection. On 2/29/16 it was documented the resident had a UTI. On 3/1/16 the resident was started on an ABO. 10) Resident #9 was admitted [DATE] without infection to his left foot. On 2/5/16, after returning from the physician's office, the Resident's spouse told the facility there was an order for [REDACTED]. The NN indicated: orders for ABO related to infection wife stated to left foot. 11) Resident #30 was admitted [DATE] from the hospital with red hot skin around incision .placed on alert. The resident was determined to have an infection to her right surgical hip incision and right lower leg (Cellulitis) and was started on ABO's. 12) Resident #38 was admitted [DATE] without infections. On 3/1/16 the record indicated the resident had a moist cough. On 3/5/16 the resident was sent to the ER for evaluation of new swelling and redness to his right lower extremity and was found to have cellulitis and was started on ABOs. Failure to ensure an active, ongoing ICP was in place to identify residents with new infections, admitted with infections and/or those who acquired infections while in the facility placed all residents, staff and the public at risk of infections and/or repeated infections. Refer to F 314.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to Residents #1, #6, #8, #7, #9, #10, #21, #2, #23, #24, #11, #12, #22 and #13 and impacted their care, safety, dignity, quality of life and/or prolonged their stay. Findings include: The information below is more detailed in the individual citations: 1) Refer to 42 CFR 483.13(c) - F 224 Prohibit Mistreatment/neglect/misappropriation for facility neglect of 2 residents (#9, #1) and for a Licensed Nurse (LN) who intentionally neglected to respond to Resident #24's need for emergency assistance. 2) Refer to: 42 CFR 483.13(c)(2), F226-Abuse Policies and Procedures - for facility failure to operationalize its written policies and procedures to prevent and/or protect 3 of 10 residents (#2, #3, #4) who were reviewed for abuse and neglect prohibition. This failure caused physical and/or emotional harm to these residents and placed all residents in an environment of similar fear and risk. 3) Refer to: 42 CFR 483.25(H) (1) AND (2) F 323 Accidents and Supervision for facility failure to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents and/or injuries to 5 of 8 sampled residents (#11, #12, #22, #13 and #24). This failure placed all residents at risk of harm and/or repeated injuries during staff transfers/care. 4) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient, qualified staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function and impacted their well-being and quality of life and resulted in harm to Residents #1, #6, #8, #7, #9, #10, #21, #20, #2, #23, #24, #11, #12, #22 and #13. 5) Refer to 42CFR 483.75(i) F 501 Responsibilities of the Medical Director for facility failure to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for residents who developed pressure ulcers, infections, exposed to physical and mental abuse and injuries during staff to resident interactions. This failure created an unsafe environment for all residents.

Based on observation, interview and record review, it was determined the facility failed to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for residents in the facility. This failure created an unsafe environment for all residents and caused harm to current and discharged Residents #1, #6, #8, #7, #9, #10, #20, #21, #2, #23, #24, #11, #12, #22 and #13. Findings include: The information below is more detailed in the individual citations: According to the records provided by the Director of Nursing Services (DNS) and during interview on 2/26/16, the Medical Director's (MD) job description was provided. The DNS said the new MD started working with the facility a few months ago. The MD was also the primary physician for 34 of the 42 facility residents. Review of the facility job description and contract for the MD indicated: The Medical Director shall: 1) Assist in the coordination of medical care in such a way as to ensure the adequacy of medical services provided to residents. 2) Advise and make recommendations to the DNS in matters related to the execution of patient care policies. 3) Provide surveillance of the health aspects of the facility staff. The staff shall cooperate and make appropriate reports and records so the MD can accomplish this function. 4) Review incident reports to identify health and safety hazards. 5) Be active as a vital participant in the Quality Assurance Program to help assure effectiveness in identification and correction of deficiencies. There was lack of documentation to show the Medical Director participated in identifying the deficiencies related to failure to prevent abuse and neglect; failure to ensure pressure ulcers did not develop and/or appropriate treatment was provided; failure to ensure staff could perform assigned duties to prevent injuries and failure to ensure an infection control program was in place to protect residents, staff and the public. 1) Refer to 42 CFR 483.13(c) - F 224 Prohibit Mistreatment/neglect/misappropriation for facility neglect of 2 residents (#9, #1) and for a Licensed Nurse (LN) who intentionally neglected to respond to Resident #24's need for emergency assistance. 2) Refer to: 42 CFR 483.13(c)(2), F226-Abuse Policies and Procedures - for facility failure to operationalize its written policies and procedures to prevent and/or protect 3 of 10 residents (#2, #3, #4) who were reviewed for abuse and neglect prohibition. This failure caused physical and/or emotional harm to these residents and placed all residents in an environment of similar fear and risk. 3) Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores for facility failure to ensure 10 of 10 current and former/discharged residents (#1, #6, #8, #7, #9, #10, #21, #2, #23 and #24) who were identified at risk for skin breakdown and who developed pressure sores/infections in the facility, were assessed, monitored, evaluated and treated by qualified personnel and in accordance with accepted standards of practice and resulted in harm to these residents. 4) Refer to 42 CFR 483.25(H) (1) AND (2) F 323 Accidents and Supervision for facility failure to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents and/or injuries to 5 of 8 sampled residents (#11, #12, #22, #13 and #24). This failure placed all residents at risk of harm and/or repeated injuries during staff transfers/care. 5) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient, qualified staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function and impacted their well-being and quality of life and resulted in harm to Residents #1, #6, #8, #7, #9, #10, #21, #20, #2, #23, #24, #11, #12, #22 and #13. 6) Refer to 42 CFR 483.65 F 441 Infection Control for facility failure to maintain an active, ongoing Infection Control Program (ICP) that tracked current organisms and infection history in the facility for several residents reviewed for urinary tract infections [MEDICAL CONDITION], respiratory infections, surgical site infections. Resident #21, #20, #26, #8, #27 and #38 were identified with respiratory infections and Resident #20 had laboratory-confirmed Influenza A. Failure to know the numbers of infections, locations in the facility, the organisms and/or correct treatment placed residents, staff and visitors at risk of exposure to serious infections and prevented the interdisciplinary team from participating in the recognition of infection clusters and trends to prevent/control the spread of infections.

Based on interview and record review, it was determined the facility failed to ensure adequate supervision for 4 of 8 current residents (#11, #12, #13, #24) and 1 former/discharged resident (#22) reviewed for accidents that occurred when staff members were transferring/providing direct resident care. This failure placed all residents at risk of harm and/or repeated injuries during staff care. Findings include: 1) Resident #11 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including a stroke and infection/swelling to her legs. She required the assistance of two for care and a mechanical lift for transfers. According to the records, on 1/6/16 staff transferred the resident with a gait belt from the shower chair to the bed and the resident's right forearm hit the arm rest causing a skin tear with bruising that measured 6.0 cm x 3.0 cm. The Nursing Assistant (NA) was not aware of the care planned directive for use of a mechanical lift for transfers. 2) Resident #12 was admitted to the facility on [DATE] with multiple medical conditions including Alzheimer's dementia. She required assistance for walking. According to the records, on 1/22/16 in the morning, a staff member was walking the resident in the hallway. The resident got too close to the ice chest (in the hallway) and her hand hit the broken corner and she got a skin tear .2 x 2 cm to the top of her right hand .steri-strips applied. The facility determined the resident was blind in her right eye; has glaucoma, walks kinda' fast and tends to go to her right side .try to keep her in the center of the hallway .has fragile skin .teach the resident to slow down and stay in center of hallway . There was no identification of the need to keep the hallways clear of clutter and to have staff be aware of safety hazards to the resident and how to prevent a repeated occurrence. On 3/4/16 at 2:00 p.m., during tour, the ice chest was observed near the entry to the facility on the right side of the hallway and with the broken/chipped corner of the plastic tray with sharp edges felt. 3) Former Resident #22 had lived at the facility since 2000. She had multiple medical conditions including stroke, diabetes and pressure ulcers to her buttocks. The resident was totally dependent on staff for all care and required a mechanical lift for transfers. According to the records, on 10/2/15, the resident was transferred by staff to the shower chair with the mechanical lift at which time the resident incurred a bruise and skin tear to the top of her right hand that measured 1.0 x 1.5 cm and dripping blood .steri-strips applied. The facility inserviced the NAs to be more careful. 4) Resident #13 was admitted to the facility from the hospital on [DATE] with multiple medical conditions including recent surgery, pneumonia, heart failure and weight loss. The resident was dependent on staff for care. On 2/12/16, while being transferred by the NA to the wheelchair, the resident was found to have approximately a 7.0 cm bruise and a 3.0 cm bleeding skin tear to right wrist that required first aid. The facility determined the injury occurred during the transfer and the resident could easily bump arm, causing bruise and skin tear will encourage long sleeves/arm protectors if he agrees. The documentation failed to indicate how staff would safely transfer the resident to prevent repeated injury. On 2/26/16 at 4:00 p.m., during interview with the DNS regarding the injuries to the residents when staff members were in attendance, she needed to review the documentation and would provide more information later. 5) According to the records, Resident #24 was found on the floor on 3/1/16 at 6:00 p.m. and was determined to have hit his head on the floor. The resident had multiple medical conditions and received several medications for pain. He was totally dependent on staff for all care and required assistance with meals. On 3/4/16 at 4:00 p.m., during interview with NA C, it was learned s/he was walking by the resident's room when s/he found him on the floor. According to the records, the NA asked the charge nurse for help. The charge nurse said: I can't help you, I'm off shift and put her hand in front of my face to stop me from proceeding with talking .I then found 2 other NA's .the resident required a mechanical lift and 6-7 people to lift him back to bed. The NA found another nurse to assess the resident. According to NA C, the resident's feet were in the air hanging from his catheter .food tray under his back with broken glasses and plate. When asked why no one was feeding the resident at this time, NA C said his wife usually feeds him but said she did not know why no one was with him. When asked if the bed was in low position, the NA said the bed was up high and put her hand slightly above her waist to show the height of the bed. The record indicated the resident said he fell on his head and the therapist who helped put the resident back in bed said the bed was about 38 inches high and the head of the bed was raised about 45 degrees. On 3/4/16 at 4:30 p.m., the DNS was asked why the nurse who was immediately available but going off shift was unwilling to help in this situation. The DNS said the investigation was not completed and the identified nurse was not yet interviewed. The DNS said she had not been informed of the issue at the time it occurred. The DNS provided a list of issues for which she was to be notified and staff to resident events was one of them.

Based on observation, interview and record review, it was determined the facility failed to operationalize its policy and procedures to prevent and/or protect 3 of 10 residents (#2, #3, #4) who were reviewed for abuse and neglect prohibition. This failure caused physical and/or emotional harm to these residents and placed all residents in an environment of similar fear and risk. Findings include: The facility's Abuse Prohibition Program indicated the Purpose: To prevent abuse and/or neglect to residents, staff and visitors by investigation of employee backgrounds, staff education, staff monitoring and investigations of unusual occurrences and It is the policy of this facility to provide a safe environment for residents, employees and visitors. The facility would complete a report at the time of an occurrence/event and the initial investigation will begin at that time. Action will be taken to prevent the same or like occurrence based on the conclusion of the investigation. The occurrence will be logged, tracked and analyzed to identify trends. The Administrator and Director of Nursing Services (DNS) will be responsible for ensuring the development and implementation of new/modified Policy and Procedures. All staff are responsible to immediately report an occurrence and are Mandatory Reporters. 1) Resident #3 lived in the facility since October 2013. She had multiple medical conditions including arthritis, Alzheimer's dementia and [MEDICAL CONDITION] (causes bones to become weak and brittle; even mild stresses like bending over or coughing can cause a fracture, commonly occur in the hip, wrist or spine). The resident required extensive assistance of 2 people for mobility and transfers using a sit-to-stand mechanical device (requires a sling be placed around the resident's back and under arms to assist with standing). According to the documentation, on 10/19/15 around 7:00 a.m., Nursing Assistant (NA) R reported that NA B was helping to transfer Resident #3 from the bed to her wheelchair with the sit-to-stand device. According to NA R, the resident said she was in pain, twice and flung her arms and in turn, NA B removed the sling roughly, pulled the machine back, causing more pain to the resident and before leaving the room, LN B said to the resident: Don't you talk to me like that ever again, with her finger in the resident's face. The NA R reported the incident to the nurse on duty (Resident Care Manager, RCM A). RCM A asked the resident twice about the incident and the resident could not identify what happened so the resident was placed on alert monitoring. The NA continued to work with residents. Refer to Resident #2 below. 2) Resident #2 was re-admitted to the facility on [DATE] with multiple medical conditions including [MEDICAL CONDITION] (loss of function to arms and legs), diabetes, diabetic [MEDICAL CONDITION] (pain and/or loss of sensation/feeling in legs/feet). He required extensive assistance with mobility, transfers and eating. He was alert, oriented and could make his needs known. According to the records, on 10/19/15 at approximately 8:30 a.m. in the main dining room, NA B was late to help the resident with his breakfast. When she sat down she said: Don't you give me any crap. I'm the only one working. The resident said NA B grabbed 4 straws and threw one at me and said she had to go take care of something .all nasty. She didn't come back for 10 minutes and when she came back, she fed me only one piece of toast and then said she had to leave again. The resident said he heard a loud thump, Like she hit the wall or something and After about an hour and a half, she (NA B) came to apologize. The resident said he did feel threatened by NA B. Another NA, A, was at the table and witnessed the interaction. On 3/4/16 at 2:30 p.m., during interview, the resident said he did not like the way he was treated by the NA. Yes, another NA was at the table and saw everything. I don't know what she did about it, I think she told someone. He said when NA B apologized to him, she said that no one should be treated the way I treated you. On 2/26/16 at 1:30 p.m., during interview with NA A, she said she was at the table and witnessed the interaction between Resident #2 and NA B. When asked if she reported the incident to anyone, NA A said: I reported it to (DNS) and to the Resident Care Manager (RCM) A who was on duty (who had earlier been told about NA B's interaction with Resident #3 by NA R). The NA A said: I don't remember what she (RCM A) told me and she took care of it. I called the state hotline. When told her complaint had not been identified on the hotline, she said: I don't know what number I called. When asked where she would find the number, she said NA R had the number and maybe she called. NA A did not know the hotline number was located on the back the name badge she was wearing until the DNS pointed it out to her. When NA A was asked if she had any training regarding abuse and neglect since starting at the facility, she said: I haven't had any training .I don't recall . I only started in August (2015). The NA said while at the table she heard Resident #2 say to NA B: Oh, you are going to feed me? She said she observed NA B point her finger at the resident and say: Don't start with me. NA A said: NA B sat down and started throwing the resident's raisins in a cup on the table. When NA A took the resident to his room, he said: I didn't do anything to (NA B) and started crying. The NA A said she reported the event to the DNS and the nurse on duty (RCM A) on 10/19/15. The allegation was not investigated until 10/23/15 when the DNS was made aware of the event because the resident told the nurse on duty the day of 10/21/15. According to the documentation dated 10/23/15, when the DNS was informed of the interaction between Resident #2 and NA B, the resident stated he felt threatened by her (NA B) and was visibly upset when discussing the incident. The DNS determined the incident between Resident #2 and NA B resulted in mental anguish that fits the description of mental abuse . 3) Resident #4 was admitted to the facility from the hospital on [DATE]. She had multiple medical conditions including recent hip surgery, facial fractures, acute pain due to trauma, lung disease, [MEDICAL CONDITION] and anxiety. She was alert and oriented and made her own care decisions. According to NA C, on 12/23/15, the resident wanted to eat dinner in her room as the therapist had told her if she did not want to eat in the dining room, she could stay in her room. The NA asked the nurse who said the resident was a 'feeder' and needed to be taken to the dining room. The resident said: I don't know the rules but I thought if you didn't want to come to the meals you didn't have to. They jerked me up by my arms and put me in the chair and took me to the dining room. I needed my bottom teeth. As far as I am concerned this is abuse and I am concerned. The resident's written statement indicated: I have had a hip replacement, two girls came in and pulled me over to get me up, they didn't care I was in pain. They jerked my legs apart, I screamed but they ignored my screams and the more I screamed the more they loved being rough .it's like they wanted to hurt me. I wanted to eat in my room and they said no, you have to eat in the dining room. When I told them I had to go to the bathroom, she said you don't pee anyway. I think this is elder abuse and (I) should not be treated in this manner. The facility responded to the resident's allegations of elder abuse by performing a SLUMS (Saint Louis University Mental Status Examination). The SLUMS required the resident to do math problems related to spending $100 and how much would be left after spending $23 dollars; respond to numbers backwards; mark hours on a clock; and after reading a short story, identify specific issues. The facility determined abuse did not occur and the NAs were to be trained in resident rights and customer service . Refer to F 224.

Based on interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well being for 1 of 5 residents (#20) when they failed to accurately assess the resident for aspiration and resulted in harm to the resident when care was delayed. This failure caused harm to Resident #20 when the resident's health deteriorated to the point where emergency hospitalization was required. Findings include: Resident #20 was admitted [DATE] following treatment in the hospital for UTI [MEDICAL CONDITION] (potentially life-threatening condition from an infection). He requested full code (all heroic measures to be taken to save his life). This information was noted throughout his record. According to the facility and hospital records, on 2/3/16 Resident #20 was fed lunch by the speech therapist (ST). The nursing note (NN) at 5:30 p.m. documented the events of the day and indicated around 1:00 p.m., ST informed me she was testing the resident on thin liquids and he aspirated on some ice cream. The Licensed Nurse (LN) was unable to hear lungs sounds because of the coughing and noises (resident) was making from his mouth. The LN determined the resident would be on alert monitoring for lung sounds and temperature for 3 days for signs and symptoms of aspiration (breathing foreign items into lungs). Around 4:00 p.m., the resident was found by the Nursing Assistant (NA) and Physical Therapist (PT) having trouble breathing, anxious, unable to speak .spouse informed he had aspirated some ice cream after lunch . The LN obtained an oxygen concentrator and started oxygen at 2 L/mn but found the concentrator was not functioning properly. The LN documented she grabbed another concentrator and portable tank, longer tubing and mask to try. No vital signs were recorded until 4:35 p.m. when they were: Blood pressure, 60/40; pulse 133; respirations 34; and temperature 100.1. The LN documented she asked the spouse if she wanted 911 called or the doctor called first. Around 4:40 p.m., the doctor said to call 911. There was no documentation to validate adequate, timely resident assessments and monitoring were being done until the NN at 5:30 p.m. when the resident was found in critical distress with lack of functioning equipment for emergency care. According to hospital records the resident arrived at the hospital emergency room (ER) at 5:30 p.m. in acute, severe respiratory distress and the resident aspirated at lunch today, approximately 5 hours ago .patient does not normally have respiratory issues. The resident's oxygen level on arrival was 23% (normal reference range 92-100%). The resident was admitted to the Intensive Care Unit (ICU) for three days and aggressively treated with multiple intravenous antibiotics for aspiration pneumonia and while at the hospital was found to have a urinary tract infection/sepsis. The hospital records indicated on 2/21/16 at 10:00 p.m., the resident returned with shortness of breath and another aspiration event this evening at the facility. The resident arrived with a 103.1 degrees F fever, pulse of 142 and respirations of 36. The resident was determined to have aspiration pneumonia, acute [MEDICAL CONDITION] related [MEDICAL CONDITION] from confirmed Influenza A, present on admission from the facility. On 2/29/16, the facility records indicated the resident returned to the hospital. Failure to ensure timely assessments and close monitoring of the resident's condition caused delays in care and life-threatening complications. Refer to F 441.

Based on observation, interview and record review, the facility failed to thoroughly investigate, analyze, and implement current interventions and take additional corrective actions to prevent further occurrences of falls for 1 of 3 current sampled residents (#24) reviewed for accidents and incidents. This failure caused harm to Resident #24. Findings include: Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received medications known to cause dizziness and weakness. According to the Minimum Data Set (MDS), an assessment tool, dated 04/30/11, the resident was cognitively impaired with memory problems. He had a history of [REDACTED]. On 5/16/11 at 5:00 p.m., the resident was observed sitting on the edge of his lowered bed, feet on the floor, head drooped, eyes closed. The call light was not within his reach as directed in the resident's care plan. At 6:30 p.m., the resident was observed sitting on the side of his bed, feet on the floor, eyes closed, head drooped. The call light was not within his reach. review of the resident's medical record revealed [REDACTED]. He sustained a back injury on 4/24/11 from a fall and required hospitalization . An investigation report dated 3/14/11 documented Resident #24 fell at 1:30 a.m., while attempting to get up from of his wheel chair. The wheel chair rolled out from under him and he fell in a seated position. The intervention report documented in order to mitigate additional falls staff would be instructed to lock wheel chair brakes only when preparing to transfer residents thus allowed for self-propel movement. The conclusions and follow up for this incident included "staff in-serviced on verifying brakes are locked on wheel chairs when residents are attempting to stand." There was no documentation provided by the facility the in-services had occurred. The Resident's care plan and the nursing care directives (instruction for care) were not updated to include locking his wheel chair brakes and no additional instruction to the staff was provided to ensure resident's safety. An investigative report documented on 4/24/11 at 6:50 a.m., staff heard a loud thud like sound, followed immediately by the resident crying out. Resident was found sitting on his buttocks with his back and shoulders against the wall and door jamb. He continued to cry out " my back, my back." The intervention report for this incident documented the resident was transported and admitted to the hospital. There were no new interventions put in place upon the residents return from the hospital to mitigate additional falls on the care plan or documented on the nursing care directives. An investigative report documented on 05/07/11 at 2:00 a.m., a thump was heard from the resident's room, he was found sitting on the floor in between the bed and the bedside table. His underpants were wet but the floor was dry. The intervention report documented to decrease additional falls the resident was to be checked more frequently though out the evening and night shifts while he was in bed. Additionally, the bed side table was to be moved to prevent further injury if another fall were to occur. There was no documentation to define what was meant by checking resident frequently in the evening and/or at night time. Resident's bedside table was observed on the right side of his bed, there was no documentation it had been moved in order to prevent further injury from falls. The care plan and/or nursing care directives were not updated to ensure the Residents safety. An investigative report documented on 05/09/11 at 6:00 a.m., resident was found on the floor leaning on his left shoulder facing the door to hallway. There was a 1 centimeter sized skin tear on his right elbow. The intervention documented to decrease residents continued falls included "alert and neurological checks for 24 hours." On 5/23/11 at 10:00 a.m., Nursing Assistant (NA) K stated when Resident #24 is up walking around " I will grab his wheel chair and offer it to him, or try to get him to sit in a chair." When asked to see this intervention on the nursing care directives, she stated, "that's not really there, I really don't know if that is written, it's just what I do." At 10:15 a.m., NA J stated she did not know and could not show me anything on the nursing care directive related to interventions to decrease resident #24's falls. NA J. stated he needed stand by assistance with ambulation, the nurse care directive stated he required 1-2 person assistance with walking. At 11:00 a. m., NA L stated "I don't know" when asked about interventions to be used in order to decrease resident falls. At 1:30 p.m., Resident Care Manager (RCM) B stated "he was started on pain medication because he had been complaining of pain."When asked if his care plan, the MDS or nursing care directives had been updated to ensure resident's safety RCM B stated "no, I ' m not sure what you can do. I don't know how you would avoid resident falls. When we see him trying to walk we generally go up and will walk with him that helps, but, is not a part of his care plan." At 2:30 p.m., The Director of Nursing Services (DNS) stated resident's pain was better controlled and that helped mitigate his falls. She could not provide any documentation to show other interventions had been attempted to decrease the likelihood of resident falling on the residents care plan, nursing care directive or the MDS. On 5/26/11 at 11:30 a.m., record reviewed revealed Resident #24 had another fall on 5/24/11.