Every finding on record at South Creek Post Acute

.Based on interviews and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR, a federally mandated program requiring all individuals to be screened for mental illness or intellectual disabilities before being admitted to a nursing facility or for changes in condition that warrant services) assessments were accurately completed for 1 of 4 sample residents (Resident1) reviewed for PASRR. This failure placed residents at risk of not receiving timely and necessary services to meet their mental health care needs, and the potential for a decreased quality of life.Record review of the facility policy titled, PASRR Process, dated 03/2019, showed If there is a significant change of condition that could affect their diagnosed need for a PASSR II, staff should refer for a NEW PASRR Level II. a. The Level II evaluator will determine if the residents' current care needs are able to be met at the NF. b. If the resident remains appropriate for the Nursing Facility (NF), there may be new recommendations to be placed on the care plan.Resident 1 was admitted to the facility on [DATE] for rehabilitation and long-term care services. Review of the admission Minimum Data Set, (MDS, an assessment tool), dated 05/23/2026, showed Resident 1 was severely cognitively impaired.Record review of Resident 1's Medication Administration Record (MAR) dated June 2026, showed Resident 1 was started on an antipsychotic medication to treat a severe psychotic disturbance on 06/24/2026.In an interview on 08/26/2026 at 12:34 PM, Staff C, Social Services Director, said a new PASRR should be completed when a resident had a change in condition, or start of a new psychotropic medication. Staff C was unable to find an updated PASRR, indicating Resident 1 required a mental health evaluation.In an interview on 08/26/2026 at 12:46 PM, Staff A, Administrator, said the PASRR reassessment for Resident 1 was missed by social services. Staff A said there should have been an updated PASSR completed when Resident 1 started an antipsychotic medication.WAC 388-97 -1915 (1)(2)(a-c)

.Based on observation, interviews, and record review, the facility failed to identify, report and thoroughly investigate a potential concern of abuse/neglect for 1 of 4 sample residents (Resident 1) reviewed for abuse and neglect. The failure to identify and thoroughly investigate allegations of potential abuse and neglect placed facility residents at risk for abuse, neglect, and a decreased quality of life.Record review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022, showed Investigation Allegations, k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly. Resident 1 was admitted to the facility on [DATE] for rehabilitation and long-term care services. Review of the admission Minimum Data Set, (MDS, an assessment tool), dated 05/23/2026, showed Resident 1 was severely cognitively impaired. Review of a nursing progress note dated 08/13/2026 at 7:02 PM showed Resident 1 had a suicidal attempt, and staff intervened to remove her call light cord. Review of Resident 1's care plan dated May 2026, did not show interventions for suicidal thoughts/attempts for Resident 1 following the suicidal attempt on 08/13/2026. Review of the facility's State Reporting Log, dated August 2026, did not show an entry regarding Resident 1's alleged suicide attempt. In an interview on 08/26/2026 at 12:46 PM, Staff A, Administrator, said the incident regarding a suicide attempt should have been logged and investigated. In an interview on 08/26/2026 at 12:55 PM, Staff B, Director of Nursing and Registered Nurse (RN), said she did not log the incident of Resident 1's suicide attempt because there was no harm to Resident 1. Staff B said she was unable to rule out abuse or neglect because no investigation had been completed. Reference WAC 388-97-0640 (6)(a)(b)

.Based on interviews and record review, the facility failed to ensure 1of 4 sample residents (Resident 1) reviewed for abuse and neglect were free from physical abuse. These failures subjected Resident 1 to physical abuse and the potential for physical injury, psychological harm, and a decreased quality of life. Record review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, showed Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.Resident 1 was admitted to the facility on [DATE] for rehabilitation and long-term care services. Review of the admission Minimum Data Set, (MDS, an assessment tool), dated 05/23/2026, showed Resident 1 was severely cognitively impaired.Review of a nursing progress note, dated 08/17/2026 at 4:00 PM, showed Resident 1 was sitting in the dayroom yelling 'help me' while receiving care from a Nursing Assistant Certified (NAC). Resident 2 came over to Resident 1 with a closed fist and hit Resident 1 on the knee.Review of a nursing progress note, dated 08/18/2026 at 10:30AM, showed Resident 1 was yelling 'help me'. Staff entered Resident 1's room to find Resident 2 had grabbed Resident 1 by the foot and pinched her nails into the base of her big toe and sole leaving 2 fingernail indentions on Resident 1' s foot.In a joint interview on 08/26/2026 at 12:55 PM, with Staff A, Administrator and Staff B, Director of Nursing and Registered Nurse (RN), Staff A said she was aware of the requirement to keep residents safe from physical abuse from other Residents. Staff A and Staff B said they were aware that Resident 1 had been physically assaulted by Resident 2 on two separate occasions one day apart.Reference WAC 388-97-0640(1)

Based on interview and record review, the facility failed to answer a call light in a timely manner for 1 of 3 sampled residents (Resident 1) reviewed for call light response time. This failure placed residents at risk of unmet care needs and a diminished quality of life. Findings included. Resident 1 admitted to the facility on [DATE]. The discharge minimum data set, an assessment tool, dated 04/15/2026, documented the resident was cognitively intact. Record review of Resident 1's facility investigation, dated 04/10/2026, documented, The resident reported that his call light was not answered for approximately 1.5 to 2 hours. The resident expressed concern regarding the delay in response to his request for assistance. The resident statement documented, Pushed my call light during breakfast to get assistance for toileting and it took 1.5 to 2 hours to come assist me. Record review of facility's call light report, dated 04/10/2026, documented Resident 1's call light was activated on 04/10/2026 at 6:22 AM. The report documented the call light was answered 2 hours and 23 minutes later. In an interview on 04/30/2026 at 12:33 PM, Staff D, Certified Nursing Assistant, said facility staff just had a meeting about call light wait times, and Staff D was told by management the facility expectation for answering call lights was about 15 minutes. In an interview on 04/30/2026 at 1:03 PM, Staff A, Administrator, said Resident 1's long call light time prompted the facility to review the whole call light system. Staff A said there had been recent meetings to educate staff on call light expectations, and that staff should ideally be answering call lights within 20 minutes of activation. Reference WAC 388-97 -1060(1).

Based on interview and record review, the facility failed to develop and implement a care plan for a resident assessed to be a high elopement risk for 1 of 3 sampled residents (Resident 2) reviewed for care plans. This failure placed residents at risk of elopement, unmet care needs, and a diminished quality of life. Findings included.Resident 2 admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 03/19/2026, documented the resident was cognitively intact. Record review of Resident 2's elopement risk evaluation, dated 03/13/2026, documented the resident was at high risk of elopement. Record review of Resident 2's physician notes, dated 03/15/2026, documented, [Resident 2] was considered an elopement risk. Record review of Resident 2's facility investigation, dated 04/20/2026, documented the resident eloped from the facility and traveled to a relative's house. Record review of Resident 2's comprehensive care plan documented an elopement care plan was initiated on 04/21/2026, 39 days after the resident was assessed to be a high elopement risk and 1 day after the resident eloped from the facility. In an interview on 04/30/2026 at 12:44 PM, Staff C, Residential Care Manager/Registered Nurse, said residents were assessed for elopement risk upon admission and if there was a change in behavior such as exit seeking. Staff C said usually an elopement care plan was triggered by a positive elopement risk assessment. Staff C said Resident 2 was assessed to be a high elopement risk on 03/13/2026. Staff C said it did not look like an elopement care plan was initiated after the assessment on 03/13/2026. In an interview on 04/30/2026 at 1:18 PM, Staff A, Administrator, said she would expect an elopement care plan to be initiated when a resident was assessed to be a high elopement risk. Reference WAC 388-97 -1020(1)(2)(a)(b).

Based on interview and record review, the facility failed to report an allegation of abuse and/or neglect to the State Survey Agency within required timeframes. This allegation involved 1 of 1 sample resident (Resident 1) reviewed for reporting requirements. This failure placed residents at risk for unassessed and unaddressed potential abuse and neglect. Findings included . The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, stated if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy defined immediately as within two hours of an allegation involving abuse or resulting in serious bodily injury. The policy further required that all allegations are thoroughly investigated and documented. Resident 1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a chronic lung condition that affects breathing) and opioid dependence. On 01/27/2026 at 2:10 PM, Staff A, Administrator, was notified of an allegation involving Resident 1. The allegation included reported marks observed on Resident 1's wrists related to restraints and that Resident 1 had been found unresponsive due to being overmedicated. On 02/13/2026 at 2:00 PM, Staff B, Director of Nursing, stated she had not been informed of the allegation between 01/27/2026 and 02/13/2026. Staff B stated she had not initiated a facility investigation related to the allegation and was unable to locate documentation of any investigation involving Resident 1 specific to the reported restraint-related marks and unresponsiveness. Facility documentation showed the allegation was reported to the state hotline on 02/13/2026. The facility investigation document was dated 02/13/2026. On 02/20/2026 at 01:20 PM, Staff A confirmed she received the allegation on 01/27/2026 and believed a prior investigation had addressed similar concerns; therefore, the allegation was not reported to the state hotline at the time it was recieved. Reference WAC 388-97-0640(5)(b)

Based on interview and record review, the facility failed to initiate and complete a thorough investigation of an allegation of abuse and/or neglect within required timeframes. This allegation involved 1 of 1 sample resident (Resident 1) reviewed for investigative requirements. This failure placed residents at risk for unassessed and unaddressed allegations of abuse and potential ongoing harm. Findings included . The facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, stated all allegations are thoroughly investigated. The policy further stated the administrator initiates investigations upon receipt of an allegation and ensures investigations are documented. Resident 1 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a chronic lung condition that affects breathing) and opioid dependence. On 01/27/2026 at 2:10 PM, Staff A, Administrator, was notified of an allegation involving Resident 1. The allegation included reported marks observed on Resident 1's wrists related to restraints and that Resident 1 had been found unresponsive due to being overmedicated. On 02/13/2026 at 2:00 PM, Staff B, Director of Nursing, stated she had not been informed of the allegation between 01/27/2026 and 02/13/2026. Staff B stated she had not initiated a facility investigation related to the allegation and was unable to locate documentation of any investigation involving Resident 1 specific to the reported restraint-related marks and unresponsiveness. Facility documentation showed the investigation was initiated and documented on 02/13/2026. On 02/20/2026 at 1:10 PM, Staff B stated the facility did not initiate or complete the investigation within five working days of receipt of the allegation on 01/27/2026 because she was not aware of the allegation. Staff B stated she reported the allegation to the state and completed the facility investigation on 02/13/2026. During interview, Staff A stated she believed a prior investigation had addressed similar concerns and did not initiate a new investigation on 01/27/2026. Reference WAC 388-97-0640(6)

Based on observation, interview, and record review, the facility failed to discard expired food items for 1 of 1 meal preparation (lunch) observed and failed to ensure resident refrigerator temperatures were checked and/or logged daily for 1 of 3 resident snack refrigerators (North Refrigerator) reviewed for food services. These failures placed residents at risk of consuming expired food goods, food-borne illness, and a diminished quality of life.Findings included. Expired Food In an observation on 02/09/2026 at 11:43 AM, during lunch preparation service, two 8-ounce cartons of Sysco [brand] Thickened Dairy Drink were observed on a food tray, sitting on top of the steam table food counter, along with a stack of napkins for the residents' lunch trays. The expiration date observed on the Thickened Dairy Drink showed, 05NOV2025 [November 05, 2025] best if used by. In an interview and observation on 02/09/2026 at 12:34 PM, Staff D, Dietary Director, said she would check expiration dates when she completed food orders and put away food items on Mondays and Fridays. When asked about the two Thickened Dairy Drinks sitting at the beginning of the tray line during lunch preparation service, she said the drinks were ready to be served to residents. Staff D then picked up the two Thickened Dairy Drinks and stated, They are expired, huh. Staff D said they were missed and should have been thrown away. Refrigerator Temperatures In an observation and record review on 02/09/2026 at 1:04 PM, review of the February 2026 log, titled, North Refrigerator Temp Log, no temperatures were documented for 02/07/2026, 02/08/2026, or 02/09/2026. Food items in the North Refrigerator resident snack fridge were observed to include dairy, juice, and protein drinks, sandwiches, and other food items. In an interview on 02/09/2026 at 1:11 PM, Staff E, Licensed Practical Nurse (LPN), said all the nurses were responsible to check the temperatures in the resident snack refrigerator daily. In an interview on 02/09/2026 at 1:13 PM, Staff F, Resident Care Manager/LPN, said the nurses checked the refrigerator temperatures daily, stating, I thought it was night shift. When asked about the North Refrigerator Temp Log, Staff F said the temperature had not been checked since 02/06/2026 and it should have been. In an interview on 02/09/2026 at 1:59 PM, Staff B, Director of Nursing/Registered Nurse, said the dietary department was supposed to check the temperatures in the resident snack refrigerators, not the nursing staff. In an interview on 02/09/2026 at 2:29 PM, Staff D said the dietary department had recently taken over checking the unit refrigerator temperatures daily. When asked about the North Refrigerator resident snack fridge log, last dated for 02/06/2026, Staff D said they checked refrigerator temperatures in the evening and they missed them. In an interview on 02/09/2026 at 2:53 PM, Staff A, Administrator, said she expected expired drinks were thrown out and refrigerator temperatures were checked daily. Reference WAC 388-97-2980 (1)

Based on interview and record review, the facility failed to ensure facility staff received dementia training for 5 of 28 sampled staff (Staff H, I, J, K & L) reviewed for staff in-service trainings. This failure placed residents at risk of receiving care from untrained staff.Findings included .Staff H, Certified Nursing Assistant (CNA), was hired on 08/01/2024. The Relias (electronic learning center for staff training) transcript, the Training Sign In Sheets and Continuing Education Certificates for Staff H, did not show documentation of dementia training since date of hire.Staff I, CNA, was hired on 03/18/2025. The Relias transcript, the Training Sign In Sheets and Continuing Education Certificates for Staff I did not show documentation of dementia training since date of hire.Staff J, Licensed Practical Nurse (LPN), was hired on 01/31/2025. The Relias transcript, the Training Sign In Sheets and Continuing Education Certificates for Staff J did not show documentation of dementia training since date of hire.Staff K, Licensed Practical Nurse (LPN), was hired on 12/16/2025. The Relias transcript, the Training Sign In Sheets and Continuing Education Certificates for Staff K did not show documentation of dementia training.Staff L, Dietary Aide, was hired on 07/18/2025. The Relias transcript, the Training Sign In Sheets and Continuing Education Certificates for Staff L did not show documentation of dementia training since date of hire.In an interview on 02/11/2026 at 12:36 PM, Staff N, Staff Development Coordinator, said she was responsible for tracking staff competencies oversight. Staff N said not all initial and annual Dementia Trainings were completed due to a Relias issue, causing the program not to show the required training. In an interview on 02/11/12026 at 12:51 PM, Staff A, Administrator said some staff have completed their training, but some have not due to Relias tracking system fault. Staff A stated, it did not show up on their Relias portal. We have a new tracking system going forward.Reference WAC 388-97-1680 (2)(b)

Based on interview and record review, the facility failed to convey the trust account funds for 1 of 4 residents (Resident 115) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds. Findings included.Resident 115 was admitted to the facility on [DATE]. Resident 115 expired on [DATE].Record review of the facility's trust funds statement titled, Resident Statement Landscape, from [DATE] to [DATE], indicated Resident 115 had a balance of $7.94. As of [DATE], 216 days after Resident 115 expired, Resident 115's account had not been closed. In an interview on [DATE] at 1:17PM, Staff M, Business Office Manager, said trust accounts were supposed to be conveyed no longer than 30 days after discharge or death. Staff M said as of [DATE] Resident 115's account had not been closed. In an interview on [DATE] at 3:30 PM, Staff A, Administrator, said Resident 115's final funds should have been disbursed within 30 days of discharge, but they were not. Reference WAC 388-97-0340 (5)

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident 20) were free from physical restraints. This failure placed residents at risk of injury and a decreased quality of life. Findings included.Resident 20 was admitted to the facility on [DATE]. The Admission's Minimum Data Set, an assessment tool, dated 02/03/2026, indicated Resident 20 was alert and oriented.During an interview and observation on 02/06/2026 at 9:18AM, Resident 20 was observed to have bilateral bedrails. When asked about the bedrails Resident 20 said they were for mobility. Record review of Resident 20's electronic health records (EHR) did not show an assessment, consent or an order for bedrails.During an interview on 02/10/2026 at 3:00 PM, Staff F, Resident Care Manager/Licensed Practical Nurse said before a resident got bedrails they would do an evaluation, get consent and get an order. When asked if Resident 20 had an evaluation, consent and an order Staff F said she could not find any of them in the EHR.During an interview on 02/11/2026 at 11:14 AM, Staff B, Director of Nursing/Registered Nurse, said a safety device assessment, order and consent were needed before bedrails were installed. Staff B said Resident 20 did not have an assessment, order or consent for the bedrails.Reference WAC 388-97-0620 (1)(B)

Based on interview and record review, the facility failed to initiate bowel interventions for 1 of 5 residents (Resident 8) reviewed for constipation. This failure to initiate interventions placed residents at risk of discomfort, experiencing health complications and a diminished quality of life.Finding included. Review of the facility's policy titled, Bowel Protocol, dated 02/09/2026, showed, it is the policy of this facility to monitor and provide interventions to ensure routine bowl [sp] elimination by residents of this facility. Physician orders will be obtained for implementation of facility bowel care protocol unless an alternate bowel care regimen is ordered by the physician.At the beginning of each shift (based on an eight-hour shift), the Licensed Nurse will pull the Resident Bowel Management Report and identify resident that have not had a BM (bowel movement) for 3 days (please run the report for the last 7 days and check the box 'Include residents regardless of Bowel Alert Status'. The Licensed Nurse will review the residents' MAR to determine if the PRN (as needed) Bowel Protocol had been initiated by the previous shift. Bowel movements are charted every shift by CNA (certified nursing assistant) . Residents who have not had a bowel movement in three days will be given Milk of Magnesia [laxative].Resident 8 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 01/17/2026, indicated Resident 8 was alert and oriented.Record review of Resident 8's electronic health record (EHR) Bowel task sheet documented Resident 8 had a BM on 01/27/2026 at 1:49 PM. The next documented BM was on 01/31/2026 at 9:07 PM, over 103 hours since the last BM.Record review of Resident 8's Medication Administration Record (MAR), dated January 30 and January 31, 2026, did not show an intervention was given.In an interview on 02/11/2026 at 9:53 AM, Staff P, Registered Nurse (RN), said the bowel protocol was initiated after 72 hours of no BM. Staff P said if the resident refused an intervention, it would be documented in the EHR.In an interview on 02/11/2026 at 10:29 AM, Staff F, Resident Care Manager/Licensed Practical Nurse, said the Bowel Protocol should be started three days after no BMs. In an interview on 02/11/2026 11:14 AM Staff B, Director of Nursing/RN said the bowel protocol was initiated after 72 hours of no BM. Staff B said nursing should have been documenting if the resident refused an intervention.Reference WAC 388-97-1060(1)(3)(c)

Based on observation, interview, and record review, the facility failed to secure medications in 2 of 2 residents' rooms (Resident 50 & 67) reviewed for medication access and storage. This failure placed residents, staff, and visitors at risk for accessing unauthorized medication, negative outcomes, and a diminished quality of life. Findings included. Record review of the facility's policy titled, Self Administration of Medication, dated 09/01/2024, revised 02/09/2026, documented, .Medication at bedside is stored in closed, locked cupboards or drawers. This includes over-the-counter medications. 2. the RCM evaluates the resident's ability to self-administer medications using the Self Administration Evaluation form. No medications are stored at bedside nor self-administered until evaluation is complete. 3. A physician order is obtained indicating the specific medications that the resident is able to self-administer. Resident 50 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 01/11/2026, showed Resident 50 was alert and oriented. In an observation on 02/05/2026 at 10:52 AM, one bottle of medication was observed on Resident 50's nightstand labelled Children's Chewable Complete Multivitamin. Two more bottles of medication were further observed on Resident 50's bedside table, one with the label Pure For Men Stay Ready capsules, and one with a pharmacy prescription label, dated 06/13/2025, Chlorhexidine Gluconate 0.12% swish and spit 15 milliliters by mouth twice daily after oral care. Review of Resident 50's Electronic Health Record (EHR) did not show a self-administration of medication evaluation and/or a physician's order to self-administer medications and/or keep medications at bedside. In an interview and observation on 02/05/2026 at 11:08 AM, Staff C, Resident Care Manager/Registered Nurse (RN), said residents that could self-administer medication needed an evaluation completed and a physician's order. Staff C went to Resident 50's room and picked up the three bottles of medications off the nightstand and bedside table. Staff C said Resident 50 should not have had the medication out and the medications should have been stored away. In an interview on 02/09/2026 at 1:44 PM, Staff C said there was not an evaluation completed or physician's order for Resident 50 to self-administer medication or have medications at the bedside and there should have been. In an interview on 02/09/2026 at 2:01 PM, Staff B, Director of Nursing/RN, said it was her expectation medications kept at the bedside should be kept secured and had a physician's order and self-medication evaluation completed for the resident. Resident 67 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], showed Resident 67 was alert and oriented. In an observation on 02/05/2026 at 12:19 PM, Resident 67 was observed to have two bottles of medication on her bedside table. The medication bottles were labeled Vitamin C 1000mg (milligrams) and CoQ-10 (vitamin/antioxidant). A bottle of nasal spray labeled Fluticasone Propionate was observed in her nightstand drawer. Review of Resident 67's EHR did not show a medication self-administration evaluation and/or a physician's order to self-administer medications and/or keep medications at bedside. In an interview on 02/05/2026 at 12:19 PM, Resident 67 said she took the observed medications occasionally. She said she took the CoQ-10 medication for pain and the Flonase nasal spray for her allergies. In an interview on 02/05/2026 at 12:24 PM, Staff G, Licensed Practical Nurse, said residents who chose to keep medication at their bedside would have to be assessed for medication self-administration and have a physician order to do so. Staff G reviewed Resident 67's EHR but was unable to find an evaluation, care plan or physicians order for medication self-administration. In an observation and interview on 02/05/2026 at 12:28 PM, Staff G, observed the medications at Resident 67's bedside and said the medications should have been stored in the medication cart. Staff G explained to Resident 67 that the medications had to be placed in the medication cart pending a physician order. Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure nursing hours were accurately posted and updated daily for 4 of 31 days (01/08/2026, 01/11/2026, 01/13/2026 & 01/15/2026) reviewed for nurse staff postings and failed to provide accurate identifiers on daily postings, to include the facility name, census and date. These failures placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information.Findings included . Record Review of the nursing home daily staff postings showed they had not been updated for 4 shifts, dated 01/08/2026, 01/11/2026, 01/13/2026 & 01/15/2026 to accurately reflect the number of nurses and/or nursing assistants working per shift. Record review of the posting for 01/08/2026 showed 16 nursing assistants (CNAs) for the day shift (06:00 AM - 02:00 PM). The actual day shift schedule showed 13 CNAs worked. Record review of the posting for 01/11/2026 showed 15.5 CNAs for the day shift. The actual evening shift schedule showed 12.5 CNAs worked. Record review of the posting for 01/13/2026 showed 13.5 CNAs for the evening shift (02:00 PM- 10:00 PM). The actual evening shift schedule showed 11 CNAs worked. Record review of the posting for 01/15/2026 showed 13.5 CNAs for the day shift. The actual evening shift schedule showed 11 CNAs worked.The posting showed 8 Nurses for the day shift. The actual day shift schedule showed 7 Nurses worked. In an interview on 02/11/2026 at 12:36 PM, Staff Q, Business Office Assistant, said she was the one responsible for updating the staff postings. Staff Q stated, I make the adjustments. Those days were missed. In an interview on 02/11/2026 at 12:51 PM, Staff A, Administrator, indicated the posting errors could not be clarified. No Associated WAC Reference

Based on interview and record review, the facility failed to obtain ordered laboratory services for 1 of 4 sampled residents (Resident 1) reviewed for laboratory services. Resident 1 experienced harm when physician ordered CBC (complete blood count, a lab used in part to determine levels of red blood cells in blood) and BMP labs (basic metabolic panel, a blood test that checks the levels of different substances in your blood including sodium) were not obtained timely for physician evaluation and the resident required transport to the hospital and admission to the intensive care unit where they were diagnosed with profound anemia (low red blood cells) and hyponatremia (low levels of sodium in the blood). Findings included.Record review of the facility policy, titled, Request for Diagnostic Services, dated April 2007, showed, Orders for diagnostic services will be promptly carried out as instructed by the physician's order.Resident 1 admitted to the facility on [DATE]. The 5-day admission Minimum Data Set, an assessment tool, dated 09/11/2025, documented the resident was cognitively intact.Record review of Resident 1's Care Plan, dated 09/08/2025, showed Resident 1 was to have labs (testing) completed per physician's orders and to notify the physician of the results.Record review of Resident 1's physician orders, dated 11/02/2025, documented, CBC and BMP [labs] one time only for nausea for 3 days.Record review of Resident 1's alert note, dated 11/02/2025, documented, RN [Registered Nurse] Weekend Supervisor attempted x1 [one time] to draw labs ordered unsuccessfully AM [morning] shift.Record review of Resident 1's Medication Administration Record (MAR), dated November 2025, did not show documentation that the CBC or BMP labs were collected or completed.Record review of Resident 1's emergency room report, dated 11/05/2025, documented, [Resident 1's] laboratory workup was remarkable for several significant abnormalities including hyponatremia [low sodium in blood], acute renal [kidney] failure, acute anemia [low level of red blood cells], and urinary tract infection as well as elevated lipase [an enzyme that helps digest fats].I did speak with our hospitalist service here. Given he is profoundly anemic [low level of red blood cells] and profoundly hyponatremic [low sodium level in blood] with new acute renal failure with sepsis [blood infection] and AKI [Acute Kidney Injury], they agree that he needs to be at a center where multiple specialties can be consulted. We will reach out to the transfer center to organize transfer to ICU [Intensive Care Unit].In an interview on 12/22/2025 at 9:36 AM, Resident 1 said he was not looked after properly, and he had to go to the hospital ICU because he was so sick. Resident 1 said the facility should have been doing routine blood tests, and that the physician requested the blood tests but the blood tests did not happen.In an interview on 12/23/2025 at 10:21 AM, Staff C, Residential Care Manager/Registered Nurse, said CBC and BMP labs were ordered on 11/02/2025. Staff C reviewed Resident 1's notes and said on 11/02/2025, the weekend supervisor attempted to obtain the labs but was unsuccessful. Staff C said she did not see any documentation of other attempts. Staff C reviewed Resident 1's MAR and said it looked like the labs were not obtained. Staff C said if the lab could not be obtained, the resident's MD (medical doctor) should be made aware.In an interview on 12/23/2025 at 10:50 AM, Staff D, Medical Doctor, said Resident 1's labs were ordered on 11/02/2025. Staff D said he saw the note from the weekend supervisor that documented the blood draw was unsuccessful. Staff D said he wanted Resident 1's blood drawn on 11/03, the day after the unsuccessful blood draw by the weekend supervisor. Staff D said he gave a verbal order for the blood draw on 11/03/2025. Staff D said the order for blood labs was given on a Sunday, and if staff were having issues obtaining the blood the staff should have communicated with the MD on Sunday. Staff D said he did not know why the labs were not obtained. Staff D said the CBC and BMP labs were not obtained, and if the labs were obtained as planned, the resident may have been transferred out of the facility earlier, or given a sodium supplement, depending on the results of the blood labs.In an interview on 12/29/2025 at 10:43 AM, Staff B, Director of Nursing/Registered Nurse, said Resident 1 did have orders for a CBC and BMP that were ordered on 11/02/2025. Staff B said after reviewing Resident 1's electronic medical record that she could not see any results for the labs. Staff B said there was a progress note on 11/02/2025 documenting an unsuccessful blood draw. Staff B said the physician should be notified of the unsuccessful lab draw and orders moved so that the order did not expire in the electronic medical record. After reviewing the MAR, Staff B said the CBC and BMP labs were not obtained on 11/02/2025, 11/03/2025, and 11/04/2025. The resident was then sent to the hospital on [DATE].Reference WAC 388-97 -1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure resident medications ordered by a provider were administered for 1 of 5 sampled residents (Resident 1) reviewed for medication administration. This failure placed residents at risk of delayed healing, unmet care needs, and a diminished quality of life. Findings included. Resident 1 admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 10/22/2025, documented the resident had a wound infection and was cognitively intact. Record review of Resident 1's Antibiotic Medication Care Plan, dated 11/11/2025, documented the intervention, Administer medication as ordered. Record review of Resident 1's Providence Swedish Infectious Disease Clinic Provider Orders, dated 10/15/2025 at 10:05 AM, documented, Meropenem [an antibiotic] 1g [gram] IV [Intravenously] every 8 hours. Record review of Resident 1's Providence Swedish progress note, dated 10/07/2025 and sent to the facility on [DATE], documented, Recommended patient undergo at least 4-week course of Meropenem 1 G IV every 8 hours. Record review of Resident 1's provider note, dated 11/12/2025, documented, ID [Infectious Disease] recommended at least 4 weeks of meropenem 1 g IV every 8 hours. Record review of Resident 1's physician orders failed to document Meropenem was ordered. Record review of Resident 1's October 2025 and November 2025 Medication Administration Record failed to document the administration of Meropenem. In an interview on 11/20/2025 at 2:33 PM, Resident 1 said he was admitted to the facility for about 4 weeks. Resident 1 said he was told by his infectious disease doctor he was getting the wrong antibiotic while at the facility. In an interview on 12/02/2025 at 10:41 AM, Staff C, Residential Care Manager/Registered Nurse, said the process for entering admission medication orders into PCC (Point Click Care, an electronic medical record) was the medical records department would enter the orders into PCC, then two nurses would review the orders in PCC with the printed transfer orders, reconcile the lists, then activate the orders. Staff C reviewed the orders from Providence Swedish Infectious Disease which ordered Meropenem and said the orders came by fax on 10/15/2025, one day before the resident admitted to the facility on [DATE]. Staff C said it was possible the infectious disease medication order was scanned into Resident 1's medical record because the resident had not admitted yet, and then the order was missed when the resident admitted to the facility with transfer orders from the hospital. In an interview on 12/02/2025 at 11:22 AM, Staff D, Medical Doctor, said he remembered reviewing Resident 1's discharge summary that recommended Meropenem. Staff D said he was under the impression Resident 1 was receiving Meropenem as when he went to assess Resident 1 he saw IV medication while in his room. Staff D said he was not aware Resident 1 was not receiving Meropenem until the infectious disease doctor called him and he reviewed Resident 1's medical records and found Resident 1 was receiving Zosyn, another antibiotic. Staff D said if there was confusion with medication orders, the provider should be notified so they can consult with infectious disease providers and clarify the orders. In an interview on 12/02/2025 at 12:01 PM, Staff B, Residential Care Manager/Infection Preventionist/Licensed Practical Nurse, said the process for entering medication orders during admission was the medical record department would enter the orders into PCC, then two nurses would review and verify the orders and activate the orders in PCC. Staff B said somehow the orders from the infectious disease clinic did not get transferred to the hospital transfer orders, and somewhere there was a communication error. Staff B said the infectious disease orders were scanned into Resident 1's medical record on 10/15/2025 at 12:32 PM, approximately 90 minutes after they came by fax into the facility. Staff B said it appeared the infectious disease clinic orders were scanned into the record, but the medication orders were not entered into the record to be reviewed by the nurses and activated. Staff B said all medication orders should be reviewed and processed by the facility nurses. Reference WAC 388-97 -1300(1)(a)(4)(e) .

Based on interview and record review, the facility failed to thoroughly investigate a fall for 1 of 3 sampled residents (Resident 1) reviewed for facility investigations. This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included.Resident 1 admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 06/25/2025, documented the resident was cognitively intact. Record review of Resident 1's smoking care plan, dated 07/10/2025, documented the intervention, Supervision provided while resident is smoking. Record review of Resident 1's smoking assessment, dated 07/10/2025, documented, Patient is unable to safely get to smoking area independently and has cognitive impairment. Patient is unable to safely smoke independently. Record review of Resident 1's fall investigation, dated 07/12/2025, documented, NAC [Nursing Assistant Certified] assisted resident outside to watch patient smoke. NAC witnessed resident slide out of wheelchair, and fall hitting her head on the concrete, knocking off her glasses. Resident 1's witness statement was, I fell down. I only hurt my pride. In an interview on 08/25/2025 at 10:19 AM, Collateral Contact 1 said Resident 1 had a fall near the smoking area. Collateral Contact 1 said Resident 1 had been left by a staff member when the fall occurred. In an interview on 09/04/2025 at 11:11 AM, Resident 1 said during the fall incident, the NAC said she needed to use the restroom and left the resident outside. Resident 1 said her lit cigarette fell, and when she leaned forward from her wheelchair to pick it up, she fell from the chair and hit face first. In an interview on 09/04/2025 at 11:36 AM, Staff C, Residential Care Manager/Registered Nurse, said Resident 1 was an assisted smoker, meaning staff needed to stay with the resident when they smoke. Staff C said during the fall near the smoking area, Resident 1 was being assisted to the smoking area. Staff C said the NAC told Resident 1 she needed to use the restroom. Staff C said the NAC came back two minutes later and found Resident 1 on the ground. Staff C said she educated the NAC on the smoking times and to not leave residents alone when assisting with smoking. When asked why the facility fall investigation documented the fall as a witnessed fall, Staff C said Resident 1 had told her the NAC had left at the time of the fall. Staff C said she was mistaken documenting the fall as a witnessed fall and must have been thinking about another fall at the time the report was made. In an interview on 09/09/2025 at 11:11 AM, Staff B, Director of Nursing/Registered Nurse, said Residential Care Managers were responsible for gathering evidence and compiling information for fall investigations. Staff B said the facility investigation concluded the resident fall was witnessed based on the statements obtained from Resident 1 and the staff on shift. When informed of the discrepancies between the facility investigation and the interviews with Resident 1 and Staff C, Staff B said she would agree the witness statement in the facility fall investigation could have been more detailed. Reference WAC 388-97 -0640 (6)(a)(b).

Based on interview and record review, the facility failed to ensure vital signs were obtained upon admission to the facility and before administration of a blood pressure medication for 1 of 4 sampled residents (Resident 1) reviewed for vital signs monitoring. This failure placed residents at risk of unmet care needs and a diminished quality of life.Findings included. Record review of the facility policy, Admitting the Resident: Role of the Nursing Assistant, dated September 2013, documented, The following information should be recorded in the resident's medical record. The resident's vital signs. Resident 1 admitted to the facility on [DATE]. The Medicare 5-day Minimum Data Set, an assessment tool, dated 06/15/2025, documented the resident was cognitively intact. The resident discharged from the facility on 06/15/2025. Record review of Resident 1's physician's order, dated 06/16/2025, documented, [check] Blood Pressure weekly prior to giving antihypertensive [blood pressure] medication. Notify MD [Medical Doctor] for systolic [blood pressure top number] less than 100. Record review of Resident 1's physician's order, dated 06/16/2025, documented, [Check] Blood Pressure daily x2 weeks prior to administering antihypertensive medication. Notify MD if systolic less than100. Record review of Resident 1's physician's order, dated 06/16/2025, documented, Metoprolol Succinate [blood pressure medication] ER [Extended Release] Tablet Extended Release 24Hour 50 MG [milligrams] Give 1 tablet by mouth one time a day for hypertension [high blood pressure]. Record review of Resident 1's electronic medical record failed to document the resident's vital signs, including blood pressure or pulse.Record review of Resident 1's Medication Administration Record, dated June 2025, documented the resident was given Metoprolol on 06/15/2025. In an interview on 07/24/2025 at 12:34 PM, Staff C, Registered Nurse, said vital signs were obtained on newly admitted residents within one to two hours. Staff C said Certified Nursing Assistants (CNAs) or nurses would obtain the vital signs, write them down on a vital signs sheet, and then the nurse would review the vital signs and enter them into the resident's electronic medical record. Staff C said before administration of blood pressure medications, vital signs were assessed first. Staff C said the vital signs should be in the residents' electronic medical records. In an interview on 07/24/2025 at 12:48 PM, Staff D, Licensed Practical Nurse, said newly admitted residents should have vital signs assessed as soon as possible. Staff D said vital signs were documented on a vital signs sheet, then entered into the resident's electronic medical record. Staff D said a resident's vital signs should be obtained before a blood pressure medication was given. In an interview on 07/24/2025 at 1:28 PM, Staff E, Residential Care Manager/Registered Nurse, said nurses and CNAs should orient newly admitted residents right away. Staff E said vital signs were obtained and documented on a sheet of paper, given to the nurse to review, and entered into the resident's electronic medical record. Staff E said before a blood pressure medication was administered, vital signs including blood pressure should be obtained. Staff E confirmed the resident was administered Metoprolol, a blood pressure medication, on 06/15/2025. Staff E reviewed Resident 1's electronic medical record and could not find vital signs for admission to the facility or before administration of a blood pressure medication. In an interview on 07/24/2025 at 2:05 PM, Staff B, Director of Nursing/Registered Nurse, said vital signs should be assessed upon admission to the facility. Staff B said vital signs were documented on a sheet, given to the nurse to review, and entered in to the resident's electronic medical record. Staff B said best practice was for nurses to obtain a resident's vital signs before administration of blood pressure medications such as Metoprolol. Staff B said she was unable to see any vital signs documented in the resident's electronic medical record. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure it was in compliance with state and local laws and regulations when the facility allowed 2 of 2 sampled Nurse Technicians (Staff D and Staff E) to administer scheduled medications and IV (intravenous) medications. This failure placed residents at risk of medication errors, injury, and a diminished quality of life. Findings included . [NAME] Administrative Code 246-840-870 documented, The nursing technician is authorized only to perform specific nursing functions within the limits of their education, up to their skills and knowledge, as verified by their nursing program. The nursing technician . May not administer chemotherapy, blood or blood products, intravenous medications, scheduled drugs, nor carry out procedures on central lines. Staff D, Nurse Technician, was first credentialed as a nurse technician on [DATE]. Staff D's nurse technician credential expired on [DATE]. Staff E, Nurse Technician, was first credentialed as a nurse technician on [DATE]. Staff E's nurse technician credential expired on [DATE]. A review of Staff D's Medication Administration Record (MAR) report (showing what medications Staff D had administered), dated [DATE], documented Staff D administered scheduled opioid (controlled/scheduled) medications 11 times to 11 residents over the month of June. Staff D also administered IV medications three times over the month of [DATE]. A review of Staff E's MAR, dated [DATE], documented Staff E administered scheduled opioid medications 20 times to 17 residents over the month of June. Staff E also administered IV medications one time over the month of [DATE]. On [DATE] at 3:26 PM, Staff D said she was still in nursing school and had just completed her first year of nursing school. Staff D said when she worked in the facility, she was allowed to perform tasks that had been checked off while in nursing school. Staff D said those tasks included assessments, medications, and wound care. Staff D said she could dispense medications while working in the facility, as long as a Registered Nurse was also in the facility. Staff D said while she did receive education from the facility regarding medication administration, she was not educated directly on what classes of medications or routes of administration she was allowed to perform while in the facility. Staff D said she had administered IV medications and scheduled medications while working in the facility. On [DATE] at 3:40 PM, Staff C, Licensed Practical Nurse, said licensed nurses and nurse technicians dispensed medications in the facility. Staff C they had seen nurse technicians dispense controlled medications such as narcotic medications. Staff C said they did not receive any education from the facility regarding the roles of nurse technicians in the facility. On [DATE] at 10:56 AM, Staff B, Director of Nursing/Registered Nurse, said licensed nurses, medication technicians, and nurse technicians administered medications in the facility. Staff B said as far as she was aware, nurse technicians could dispense narcotic/scheduled medications as well as IV medications. Reference WAC 388-97-1620 (2)(b)(i)(ii) .

Based on interview and record review, the facility failed to ensure the Dietary Manager (Staff C) had the required qualifications/certification to perform their duties for 1 of 1 facility kitchens. The failure placed residents at risk of receiving a menu prepared by staff without the required competencies and skills to provide the necessary food and nutrition services. Findings included . On 04/15/2025 at 2:07 PM, a public complainant said the facility's dietary manager did not have a dietary management certification. On 04/17/2025 at 11:53 AM, Staff A said when Staff C was out of the facility, oversight of the kitchen was done by the Human Resources Director, who was also pursuing their Dietary Manager certification. Staff A said Staff C started her position as dietary manager on 02/10/2025. Staff A said Staff C was waiting about a month for a proctor for her final test to obtain her dietary manager certification. At 12:33 PM, Staff B, Director of Nursing Services and Registered Nurse, said Staff C did not have a dietary manager certification. Staff B said Staff C was in the process of obtaining the certification and was waiting for a proctor to administer the test. At 1:23 PM, Staff A, Administrator, said the facility's dietician worked on a part-time basis in the facility. Reference WAC 388-97-1160 (1)

Based on interview and record review, the facility failed to ensure staff followed and implemented the abuse and neglect policy and procedures for protecting residents by not identifying and reporting unwanted touching for two of four sampled residents (#1 & 2) reviewed for abuse and neglect. This failure placed residents at risk for abuse and neglect, psychological distress and a diminished quality of life. This caused harm to Resident #1 when she was touched without her consent. Findings included . The facility policy entitled Abuse - Washington, dated 02/19, noted Sexual abuse is defined as sexual contact, including fondling, with a resident caused by an employee, agent or other resident of a long-term care facility by force, threat, duress or coercion, or sexual contact where the resident has no ability to consent . Staff with knowledge of inappropriate sexual comments or contact between staff and resident or resident and resident will report immediately to the facility social services director, DNS (Director of Nursing Services) or administrator. 1) Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, dated dated [DATE], indicated the resident was cognitively intact and able to make needs known. 2) Resident #2 was admitted to the facility on [DATE]. The Minimum Data Set, dated dated [DATE], indicated the resident was cognitively intact and able to make needs known. The Care Plan Intervention, dated 01/11/2021, indicated Resident #2 was not to be left alone in the company of vulnerable residents due to sexually inappropriate comments and behaviors. Resident is not to be in other resident rooms and has been educated on this multiple times. Resident #1's progress notes, dated 01/13/2021, did not show documentation that another resident had been in Resident #1's room or had put their hands on her. The local Police Department Statement, dated 01/15/2021, documented Resident #1 said Resident #2 told Resident #1, he had rubbed Resident #1's back. Resident #1 told Resident #2 he was fighting hard on the creep factor and he needed to knock it off. Resident #1 said she was a victim of a crime, she never gave him consent and she never would. The Police Department Statement, dated 01/15/2021, documented Resident #2 stated, I rolled in the room and tried waking her up and rubbed her neck, whatnot . She was talking in her sleep basically, I guess, just she was awake, but not all the way awake. Resident #2 stated he told Resident #1 the next morning he had rubbed her neck. Resident #2 said Resident #1 went off on me eventually, 'but you know what, you're lucky I didn't wake up because I would have went off on you, scratched out your eyes and everything else.' The Police Department Statement, dated 01/15/2021, documented Staff B, Nursing Assistant (NA), said she was walking past Resident #1's room and heard Resident #2's voice coming from the room. Staff B said she went into the room and observed Resident #2 massaging Resident #1's shoulders while Resident #1 was asleep in her wheelchair. On 01/25/2021 at 9:57 AM, Staff A, DNS, said she found out about the incident when Resident #1's son called her on 01/14/2021 and reported the incident. At 10:34 AM, Staff B said she was aware Resident #2's care plan showed he was not supposed to be in other resident rooms. Staff B said she should have notified the nurse of what occurred. On 02/02/2021 at 12:59 PM, Staff C, NA, said if she caught another resident in the wrong room she would ask the resident to leave, then ask the other resident what happened, and make sure they were alright. Staff C said she would notify the nurse afterwards. At 1:18 PM, Staff D, Licensed Practical Nurse, said if a resident was in another resident's room, she would separate the two residents and make sure they were safe. I would notify the bosses and start the risk assessment. Reference WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to implement the care planned assistive device and a two-person transfer to prevent an avoidable accident from occurring for one of three sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #1 when staff did not use a Hoyer lift (an assistive device) and two-person assistance when transferring the resident, who was injured during the transfer. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], documented the resident was alert and oriented, required a two-person assist with transfers, was not steady and required staff assistance moving from a seated to standing position. An ADL (Activities of Daily Living) Care Plan, dated 06/18/2020 and revised 06/24/2020, documented Resident #1 had an ADL self-care performance deficit. The interventions documented resident does not ambulate/resident is non-weight bearing and transfer - total assist of 2 (staff) with hoyer lift. Resident #1's KARDEX (a care directive for floor staff for each resident), undated, documented Resident #1 was a high fall risk, was a total assist with transfers, and required two-person assistance and a hoyer lift for transfers. A provider note, dated 08/02/2020, documented, History Of Present Illness: Received a call from nurse that patient was supposed to be two-person Hoyer lift however she was transferred with 1 person pivot. Now patient is complaining of mild right foot pain and burning sensation with a slight swelling. Patient will have surgery on Tuesday to check for herself circulation in the right leg and was not supposed to bear any weight on that leg . Plan: 1. Please keep the right foot immobilized and continue to use the Hoyer do not transfer the patient otherwise. An alert note, dated 08/02/2020, documented, At 10:45 AM this LN (licensed nurse) was coming out of another room and NAR (Nursing Assistant Registered) reported that she needed help in room [ROOM NUMBER]. NAR reports that she transferred resident after her shower to bed and during transfer resident reported that she felt a pop just above her right heel and then felt pain to area. Res (resident) was sitting on edge of bed. Res was not wearing shoes and a towel was on the floor. NAR reports that she transferred resident using a gait belt and had resident stand and pivot to bed. Swelling noted to Achilles (backside of ankle) area and res reports a burning pain. Res assisted to laying position and right leg elevated with pillow. Res advised to not use foot or bear any weight. Res reports pain at 5 out of 10 (with 0 being no pain 10 being severe pain) that is localized to area. On call provider called and new order received to obtain X ray to foot and ankle to be done tomorrow. Family member called and notified and resident placed on alert to monitor. An alert note, dated 08/03/2020, documented, Back of right foot/leg continues to be painful and now with dark purple and blue bruising. A provider note, dated 08/03/2020, documented, Patient is being seen today for follow-up on right heel pain. Per nursing, patient is supposed to be a 2 person Hoyer lift, however patient was transferred with a 1 person pivot and now patient is complaining of right foot pain. On exam patient is lying in bed in no apparent distress. Patient has an Ace bandage wrap around the ankle and it is elevated on 2 pillows. Upon removal of the Ace bandage, large hematoma (a solid swelling of clotted blood within the tissues) noted to back of ankle . patient was very tender to touch and pulled back. A provider note, dated 08/04/2020, documented, Patient is being seen today for continued right heel pain and confusion . On exam, patient has her foot elevated on 2 pillows. There is still a large hematoma noted to back of ankle and when touched to assess for pain patient was very tender to touch and pulled back. Patient states (the ankle) . is still very painful to touch and while at rest. Ice packs ordered for patient as needed, vitals have remained stable . Patient has a difficult time dorsiflexing (turning upward of toes) and plantar flexing (turning downward of toes) and has limited ROM (range of motion). A provider note, dated 08/05/2020, documented (Resident #1) mentions that she has some acute pain today. This is in reference to last Sunday where she now has right heel pain because of her transferring incident. A follow-up x-ray was done on her right foot that showed swelling, but no fracture . (The provider) describes that it is her ankle that is swollen and she has a large hematoma on the back of her heel. On 08/10/2020 at 3:15 PM, Staff B, Director of Nursing Services and Registered Nurse, said Staff C, Nursing Assistant, did not follow the plan of care. Staff B said in Staff C's statement to the facility she admitted she did not follow the resident's plan of care. Staff B said staff were expected to check the resident's KARDEX before they cared for a resident. On 08/10/2020 at 4:15 PM, Resident #1 said on 08/02/2020 she was coming back from a shower and during the transfer from the shower chair to her bed she was transferred with one person. The resident said she heard a pop from her ankle and it had been painful ever since. Resident #1 said she needed two people to transfer her from the shower chair to her bed, because she used a Hoyer lift. On 08/17/2020 at 10:53 AM, Staff C, Nursing Assistant, said on 08/02/2020 she assisted Resident #1 with bathing. Staff C said she knew Resident #1 required two-person assistance and a Hoyer lift because she and another staff member used the Hoyer to transfer the resident from her bed into the shower chair. Staff C said after bathing Resident #1, she returned Resident #1 to her room in a shower chair. Staff C said she waited for assistance to transfer Resident #1 from the shower chair to the bed for 15 minutes. Staff C said after waiting 15 minutes the resident was insisting on transferring and started to get up from the shower chair. Staff C assisted Resident #1 back down to the shower chair, applied a gait belt, and then assisted the resident to stand up. When the resident began to pivot towards the bed, Staff C said Resident #1 told her she felt a pain in her heel. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 4 sampled residents (#1) reviewed for abuse. This failure placed residents at risk for mental anguish and a diminished quality of life. This caused harm to Resident #1 when he was yelled and sworn at after indicating he needed to be go to the emergency room , and started hitting himself in the head with a meal tray. Findings included . The facility's Abuse Policy and Procedures, revised 02/19, documented abuse included verbal abuse, oral, written, or gestured communication to a resident that describes a resident in disparaging or derogatory terms. Allegations are to be reported to facility administrator, director of nursing, charge nurse, (the State Agency) . Training of employees included staff should be aware they may report allegations without fear of reprisal; what constitutes abuse including verbal .; responsibility for reporting; and to whom the report is to be made. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 09/27/19, showed the resident was cognitively intact with verbal behaviors that significantly interfered and disrupted care, his environment and his participation in activities. Resident #1's plan of care, revised 10/10/19, addressed behavior monitoring including to speak in a calm voice, politely remind the resident about previous discussions, immediately notify the nurse/resident care manager/social services if the resident was making suicidal statements, and call 911 or mental health services regarding suicidal ideation. The plan of care noted the resident often yells and becomes impatient . Possible short term memory issues. The plan of care showed the resident had attempted suicide (last time 10/06/19) and staff were to call 911 for immediate intervention regarding any suicidal type statement. The care plan's interventions addressing the resident's yelling and cursing included directing staff to politely intervene and to engage calmly in conversation. When addressing the resident depression, anxiety and anger outbursts, the care plan directed staff approach is important and to avoid confrontation. Progress Note, dated 10/20/19 at 11:17 AM and written by Staff F, Registered Nurse, was noted after the police were called. The note did not document the alleged incident; Staff F swearing at Resident #1, Resident #1 hitting himself in the head with a meal tray shortly after the swearing and Staff F refusing to call 911; and/or what occurred before the police were called. On 10/25/19 at 5:22 PM, the resident indicated he did not remember an incident that occurred a week ago of a staff member swearing at him. At 7:23 PM, Staff E, Resident Care Manager and Licensed Practical Nurse, said she was not aware of an incident with Staff F, Registered Nurse, swearing at Resident #1. Staff [NAME] said if she would have known, she would have removed the person and made sure the resident was okay. At 7:40 PM, Staff B, Interim Director of Nursing Services, said she was not aware of the incident when Staff F was swearing at Resident #1. Staff B said Staff F would be suspended, and the facility would have to do an investigation. On 10/30/19 at 11:00 AM, Staff A, Administrator, and Staff B said neither of them had been aware of the allegations of staff yelling and swearing at Resident #1. At 11:27 AM, Staff G, CNA, said the resident had been yelling that morning and did not get along with Staff F. Staff G said Resident #1 is usually the aggressor with yelling. Staff G said the resident was care planned for staff to call 911 if he threatened to commit suicide. Staff G said Staff F did not want to call 911 because he was requesting to go to the hospital. Staff G said Staff F told her she was not going to call. Staff G said nurse's comments created more chaos with (Resident #1). Staff G said she told Staff F 911 should be called. At 11:47 AM, Staff H, CNA, said Staff F was yelling at Resident #1, (Resident #1), shut the f*** up. Staff H said then Staff F went into another resident's room and was still yelling about Resident #1. Staff H said this happened on the 10/20/19. Staff H said when Resident #1 got up that morning, he was not feeling well and wanted to go to the hospital. Staff H said she was on the floor by herself when Staff F was yelling and cursing at the resident. Staff H could hear Staff F through a closed door. Staff F then came into the room where she was providing care. Staff H said after Staff F yelled at Resident #1, the resident started hitting his head with the meal tray. Staff H said she asked Staff G about calling 911, and Staff G said only the nurse could call 911. Staff H said Staff F continued to complain about the resident and refused to call 911. Staff H said Staff G kept asking Staff F what could be done, and Staff F said she did not want to fill out the paperwork and did not want to call 911. Staff H said the police did finally come. Staff H said Resident #1 was not a bad guy, just having a bad day. At 2:20 PM, Resident #2 said he has heard staff (nurses and CNAs) vent and fuss about residents. Resident #2 said a staff came into his room and screamed I can't take it anymore. Resident #2 said he did not remember a specific incident, but said it happened all the time, staff came in complaining about Resident #1. Summary of Investigation, dated 10/31/19, documented licensed nurse was verbally abusive to resident, telling him to shut the f*** up and then went into another resident's room with other CNAs and (made) rude statements about (the) resident in front of CNAs and (the) other resident they were caring for. On 11/07/19, Staff A and Staff B said they were unable to substantiate the allegations, but they did let the RN go. At 3:57 PM, Staff B said she believed something did happen. Staff B said the staff should have followed the care plan, and should not have been talking about one resident to another resident. Staff B said they were unable to substantiate abuse, but something happened. On 11/20/19 at 3:00 PM, Resident #1 said he had been really sick in the hospital, and indicated things were better now. At 3:18 PM, Staff C, Director of Nursing Services, said in this event, staff should first call the State Hotline even if they are not sure what happened, and then let management know even if anonymously. At 3:36 PM, Staff A said Resident #1 was readmitted on [DATE] and was now on hospice. Reference WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to ensure bed mobility was provided to maintain a safe environment for 1 of 3 sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk of injuries and a diminished quality of care. This caused harm to Resident #1 when she was fell out of bed and sustained a [MEDICAL CONDITION]. Findings included Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 08/18/19, documented Resident #1 was alert, able to express her needs, and required extensive assistance with activities of daily living (ADLs) including two-person physical assistance with bed mobility and transfers. Review of Resident #1's individualized plan of care, dated 03/07/19, documented, under ADL Self-Care Performance Deficit, due to decreased functional mobility, Resident #1 required two plus (2+) person extensive assistance for bed mobility. A nursing note, dated 08/26/19 at 5:00 AM, documented the resident's nurse was notified Resident #1 slid from the bed to the floor while care was provided by a Certified Nursing Assistant (CNA). A statement, dated 08/26/19 at 5:00 AM, written by Staff D, CNA, documented she was changing Resident #1. The resident was on her left side, and the resident slid out of bed. A hospital History and Physical (H&P), dated 08/27/19 at 7:36 PM, documented Resident #1 was sent to the hospital for evaluation and a fall at the facility. The H&P documented Resident #1 was found to have a right [MEDICAL CONDITION]. On 10/26/19 at 12:42 AM, Staff D said at that time (08/26/19) Resident #1 was a two-person cares and she did not know that when she assisted the resident on 08/26/19. Staff D said she thought Resident #1 only needed two persons for transfers, not bed mobility. At 2:45 AM, Staff B, Registered Nurse and Interim Director of Nursing Services, said Staff D thought Resident #1 only required two staff for transfers only, and not bed mobility. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to prevent a facility acquired pressure ulcer and obtain timely orders for treatment for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This failure placed the resident at risk for worsening pressure ulcers and diminished quality of care. This caused harm to Resident #2 when the Stage 1 pressure ulcer continued to develop in to a Stage 4/Unstageable Pressure Injury. Findings included . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 08/02/19, documented Resident #2 was sometimes able to understand others, responded adequately to simple, direct communication only, and required extensive assistance with activities of daily living. The facility's Policy and Procedure on Skin at Risk/Skin Breakdown, revised 03/2019, documented, Upon admission . and development of a new pressure ulcer, residents will be reviewed using the Braden Scale (tool used to determine risk of pressure ulcers) to determine risk for development of pressure ulcer/injury. Upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the Licensed Nurse will: Document skin impairment .; Complete incident report .; Document presence of pain .; Notify the physician and obtain a treatment order if needed, document on the TAR after implemented; Notify Responsible Party/Family Member of skin condition and treatment plan; Document findings on the Skin Grid .; Evaluate environment .; Implement interventions and document on the resident's Care Plan (CP) and In Room Care Plan (IRCP) .; Document all of previous actions and resident's response in the Progress Notes. The facility's Admission Database, dated 07/26/19 at 12:15 PM, regarding Resident #2's skin noted an abdominal surgical incision, a scar on one knee, a foot callous, and a rash in the groin and both buttocks. On 08/06/19 at 9:38 AM, Resident #2 went to the hospital Emergency Department (ED) for symptoms related to low blood pressure. An emergency department nursing note, dated 08/06/19 at 9:51 AM, documented Resident #2 had redness noted to right buttocks. Blanchable large area noted upon arrival to ED from SNF (skilled nursing facility) An emergency department nursing note, dated 08/06/19 at 2:45 PM, documented, Patient has a 10 x 8 cm (centimeter) Stage I red coccyx (tailbone) that blanches with no skin breakdown. 2 cm area base of the post scrotum is Stage 1. Allevyn (soft foam-type wound dressing) adhesive foam protectant applied to coccyx region. (Physician) updated and he came to bedside to visualize coccyx . Per hospital documentation, dated 08/06/19 at 6:06 PM, Resident #2 returned to the facility. A physician note, dated 08/08/19 at 12:07 PM, documented, (Resident #2) is seen in a wheelchair in the hall . He denies any concerns although his bottom hurts from sitting up too long and wants to go back to bed. A nursing note, dated 08/12/19 at 9:01 AM, documented Resident #2 had a Stage 1 to buttock. Resident #2's clinical record showed Resident #2 was on alert related to his recent Emergency Department visit, dated 08/06/19. No documentation was found in Resident #2's medical record regarding assessment, notification, interventions, and monitoring of the Stage I pressure injury identified in the hospital on [DATE] and in the facility on 08/12/19. On 08/18/19 at 7:47 AM, Resident #2 was transported to the hospital for evaluation related to a possible urinary tract infection. A hospital physician note, dated 08/18/19 at 10:53 AM, documented Resident #2 had a Stage 3 (full thickness tissue loss) sacral decubitus ulcer present on admission to the hospital and a wound care consultation was ordered. On readmission to the facility, a nursing Readmission Database, dated 08/24/19 at 3:06 PM, documented Resident #2 had a Stage III pressure injury on his sacrum (tailbone area), which measured 11 cm x 4 cm. A request for a wound care consultation was dated 08/24/19. Review of Skin Grid for Pressure, Venous, Arterial and Diabetic Ulcers, showed documentation began on 08/24/19 for a pressure ulcer to Resident #2's sacrum, measuring 11 cm x 4 cm. The highest stage description was left blank. Wound consultation documentation, dated 08/29/19, described Resident #2's wound as an unstageable pressure injury with full-thickness skin and tissue loss. The wound consultation documentation noted the wound started in the sacral region and extended up to both buttocks. Nursing notes, dated 08/29/19, documented the pressure ulcer was unstageable and increased in size to 11 cm x 7 cm. Nursing notes, dated 09/05/19, documented the ulcer measured 13 x 8 cm. A nursing note, dated 09/05/19 at 2:26 PM, documented nursing received a verbal order for an air mattress. Nursing notes, dated 09/12/19, documented the ulcer measured 15 x 8 cm. On 10/11/19, at 2:35 PM, Staff C, Licensed Practical Nurse and Resident Care Manager, was unable to locate additional documentation after 08/12/19 related to the Stage I pressure injury to Resident #2's buttock until a request for a referral to a consultative wound service on 08/24/19. At 3:35 PM, Staff A, Administrator, said Resident #2's skin should have been monitored after the Stage I pressure ulcer was identified on 08/06/12, and after a nursing note documented a Stage I pressure ulcer on 08/12/19. Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to obtain prescribed pain medication in a timely manner for 2 of 3 sampled residents (#1 & 2) reviewed for pain management. This failure placed residents at risk for increase pain and a diminished quality of life. This caused harm to Resident #1 when the facility failed to follow up on a prescription that was not refilled and the resident experienced pain and became suicidal. Findings included . 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 07/04/19, documented Resident #1 was alert and oriented, and required extensive assistance with activities of daily living, including bed mobility and transfers. The (MONTH) 2019 physician orders [REDACTED]. given every 6 hours, related to low back pain. The [MEDICATION NAME] was scheduled four times a day, at midnight, 6:00 AM, 12:00 noon, and 6:00 PM. Review of Resident #1's chart showed Resident #1 was hosptalized on [DATE] to 06/20/19 for treatment of [REDACTED]. The (MONTH) 2019 Medication Administration Record [REDACTED]. The order for [MEDICATION NAME] was changed to 10 mg every 6 hours, as needed, for pain. The MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. Review of the (MONTH) 2019 and (MONTH) 2019 MARs documented Resident #1's use of the as-needed [MEDICATION NAME] increased to three times a day after 06/30/19. Review of the (MONTH) 2019 MAR indicated [REDACTED]. Review of Resident #1's chart did not show documentation of an order to discontinue or change the order for buprenorphine. A nursing note, dated 07/03/19 at 9:08 AM, three days after the resident received the last dose of buprenorphine on hand in the facility, nursing documented a request to an on-call provider for a new prescription for the pain medication, and the on-call provider could not order the medication. No other interventions were documented. A nursing note, dated 07/03/19 at 12:02 PM, documented the resident had complained of pain in the morning, and was given all of his medications with a PRN [MEDICATION NAME]. The nursing note documented the arrival of paramedics, who were directed to Resident #1's room. The note documented the resident called the paramedics and stated he needed to go to the hospital for pain control, and left with the paramedics via stretcher. A nursing note, dated 07/03/19 at 3:00 PM, documented Resident #1 returned to the facility with a [DIAGNOSES REDACTED]. A nursing note, dated 07/07/19 at 3:29 PM, documented Resident #1 was found sitting on the floor in front of his wheelchair, yelling for help. When LN asked resident if he was having any pain, he stated YES, that his back hurt . A nursing note, dated 07/07/19 at 9:08 PM, documented Resident #1 was found in his room by a certified nursing assistant with his call light cord wrapped around his neck. After the cord was removed, the resident attempted to wrap a sheet around his neck. Review of the police report, dated 07/07/19, documented Resident #1 told law enforcement his actions were because he was tired of being in pain. The facility's investigation, revised on 07/10/19 at 9:38 AM, documented under Other Info the resident voiced can't stand pain anymore. The resident was administered all ordered medication the resident could receive and was sent to the emergency room for suicide attempt. On 07/17/19 at 12:05 PM, when asked about the incident on 07/07/19, Resident #1 stated, I just wanted to get out of pain for good and forever. I don't know if I was trying to actually end my life or if I was just trying to get attention. On 07/19/19 at 11:25 AM, Staff D, Registered Nurse and the nurse on duty on 07/03/19, said Resident #1 claimed he was in pain all the time and always rated his pain at 10/10 (highest). Staff D said after running out of the buprenorphine, the staff gave Resident #1 more as-needed doses of [MEDICATION NAME], so that should have taken care of it. On 7/25/19 at 11:20 AM, when asked about calling the paramedics to the facility, Resident #1 stated, I told (the facility) to call 911 because my pain was so bad, but they wouldn't do it so I took it upon myself to call 911. At 3:32 PM, Staff C, Licensed Practical Nurse and the nurse who cared for the resident the day of the incident, said it was the first time he knew of the resident doing anything like that. When asked about Resident #1's medications, Staff C said they had run out of the buprenorphine a couple of weeks before. The resident was still getting the [MEDICATION NAME] but that was not enough because he had been getting the other med (buprenorphine) two times a day. Staff C said even though he said his pain was 10/10 sometimes, the [MEDICATION NAME] and buprenorphine would handle it. On 07/30/19, at 11:55 AM, Staff B, Registered Nurse and the Interim Director of Nursing Services, said Resident #1 last received a dose of buprenorphine on 06/30/19. When asked why it was not refilled at that time, Staff B said they needed a new prescription. When asked why there was no follow-up for a new prescription with the resident's primary provider, Staff B said there was confusion over whether the provider could order the medication. After reviewing Resident #1's chart, Staff B said the provider had ordered it in the past. Staff B said the provider did not recall getting a call from a nurse asking to reorder the prescription. Staff B said she had two people telling her two different things. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#2 was alert and oriented, and required assistance with activities of daily living, including bed mobility and transfers. The MDS showed the resident was in almost constant pain, rated 10/10, and received scheduled pain medications, as needed pain medications and non-medication interventions for pain. Review of (MONTH) 2019 physician orders [REDACTED]. Per orders, dated 06/24/19, Resident #2 could receive [MEDICATION NAME] 5 mg every four hours as needed for pain, or 10 mg every four hours as needed for pain. The (MONTH) 2019 MAR indicated [REDACTED]. A nurse's progress note, dated 07/01/10 at 11:55 PM, documented the resident was informed he only had one more tab that could be pulled from the ekit (facility emergency medication kit) and the resident still wanted [MEDICATION NAME]. The provider was informed of the resident being out of [MEDICATION NAME] and spoke with the on call physician, who requested the nurse fax over a form for the [MEDICATION NAME]. The note showed the form was faxed at 6:33 PM, the pharmacy confirmed they had not received the form for the [MEDICATION NAME], and the resident was made aware. The nurse documented, (Resident) noted very angry about his pain med. Under Additional Information, the nurse documented, (Pharmacy) called for the last time at 12:10 (AM) spoke with (technician) who reports she still does not have a prescription for this (resident). Night nurse made aware. (Resident) threatened to leave 911 if med issue not resolved. (Resident) requested to make a formal grievance and this nurse assigned a fell ow staff member to get (resident's) voiced concerns. Night nurse made aware ([MEDICATION NAME]) issue not resolved. The (MONTH) 2019 MAR indicated [REDACTED]. A nursing progress note, dated 07/05/19 at 9:57 PM, documented the resident left to go to the emergency room without anyone's approval. The resident complained of back pain at 3:00 PM, and received as needed [MEDICATION NAME] at 3:08 PM, which can be given every 4 hours. At 6:15 PM, the resident called 911 and requested EMR (emergency medical response), without notifying the staff. EMR showed up and picked up the resident. The resident said he was not going to wait the additional 45 minutes until the next available as needed [MEDICATION NAME]. The (MONTH) 2019 MAR indicated [REDACTED]. On 07/19/19 at 12:30 PM, Resident #2 said the pain medicine he received was not enough. The resident said he talked to his nurses about it, but it was not working. Resident #2 said he eventually called 911 because he was in pain and he could not take it anymore. At 12:45 PM, Staff E, Licensed Practical Nurse caring for Resident #2, said the resident's pain medications were ordered PRN (as needed), so he had to ask for them. Staff [NAME] said sometimes there was an issue with getting the medications filled. Staff [NAME] said the medications could be obtained from the emergency supply kit if there was a current order, but sometimes it took time to get a new prescription. Staff [NAME] said she tried to look ahead and fax requests for refills, but sometimes there were delays. On 07/25/19 at 5:05 PM, Staff B said there were other steps that could have been taken to ensure the resident's pain medications were refilled before he experienced a gap in pain treatment. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to permit a resident to be readmitted to the facility after going to the emergency room for suicidal ideation and pain management for 1 of 1 sampled residents (#1) reviewed for hospital transfer. This failure placed residents at risk for psychosocial distress and a decreased quality of life. This caused harm to Resident #1 when he was not allowed to return to the facility after becoming stable in the hospital. Findings included . Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 07/04/19, documented Resident #1 was alert and oriented, and required extensive assistance with activities of daily living including bed mobility and transfers. The (MONTH) 2019 physician orders [REDACTED]. The (MONTH) 2019 physician orders [REDACTED]. Review of Resident #1's Jun 2019 and (MONTH) 2019 Medication Administration Records (MAR) documented the resident last received a dose of buprenorphine on 06/30/19, and did not receive any doses throughout the remainder of his stay at the facility, until 07/07/19. The (MONTH) 2019 and (MONTH) 2019 MAR indicated [REDACTED]. A nursing note, dated 07/03/19 at 12:02 PM, documented the resident had complained of pain in the morning, and was given all of his medications with a prn [MEDICATION NAME]. The nursing note then noted the arrival of paramedics, who were directed to Resident #1's room. The nurse documented the resident called the paramedics and stated he needed to go to the hospital for pain control, and left with the paramedics via stretcher. A nursing note, dated 07/07/19 at 3:29 PM, documented Resident #1 was found sitting on the floor in front of his wheelchair, yelling for help. When LN asked resident if he was having any pain, he stated YES, that his back hurt . A nursing note, dated 07/07/19 at 9:08 PM, documented Resident #1 was found in his room by a certified nurses aide with his call light cord wrapped around his neck. The note documented after the cord was removed, the resident attempted to wrap a sheet around his neck. Review of the police report, dated 07/07/19, documented Resident #1 told law enforcement his actions were because he was tired of being in pain. Hospital ER provider documentation, dated 7/7/19 at 8:28 PM, noted, Patient ran out of [MEDICATION NAME] (a week and a half) ago and has not been able to refill his prescription at (facility). A hospital discharge planning note, dated 07/08/19 at 4:48 PM, documented the facility administrator stated they were willing to take the patient back if he was stable, and said they would send someone the next day to evaluate if they could accept the resident back at the facility. A hospital Mental Health Provider note, dated 07/09/19, documented, Patient was assessed by (mental health) and not detained. Patient has been given his [MEDICATION NAME] and other pain meds which were discontinued for some reason at facility. Patient is no longer S/I (suicidal ideation) and is now cooperative since his pain meds have been received by patient. The note described Resident #1's mood as fearful, anxious, angry, depressed and hopeless. The facility's investigation, revised on 07/10/19 at 9:38 AM, documented under Other Info the resident voiced can't stand pain anymore. The investigation documented the resident was administered all ordered medication that the resident could receive, and was sent to the emergency room for suicide attempt. A emergency room provider note, dated 07/10/19, documented Resident #1 had been brought to the hospital on [DATE] with suicidal ideation. Per ER and (resident), he has been on chronic high dose opioids including [MEDICATION NAME] for his back pain, which was unfortunately discontinued while at Skilled Nursing Facility. He became belligerent and aggressive when he started experiencing withdrawal and reported suicidal ideation. He was assessed by Mental Health in ER and no grounds were found for involuntary hold. He was recommended voluntary psych inpatient, which he refused. ER has been in contact with (facility) multiple times since then to transfer him back, but they have refused. Patient abandonment report has been filed against them and since he does not have a place to go he is being admitted till safe disposition. He denies any suicidal ideation and reports he said that out of frustration in pain. On 07/17/19 at 12:05 PM, when asked about the incident on 07/07/19, Resident #1 said he had crushing back pain from a horrible accident years ago, and surgery was not an option. Resident #1 stated, My back bothers me so much. I fight that back pain every day . I did something stupid at (the facility). I just wanted to get out of pain for good and forever. I don't know if I was trying to actually end my life or if I was just trying to get attention. Resident #1 became tearful and stated, I don't really want to go to another facility because I'd have to start all over again. At 12:35 PM, when asked about Resident #1's pain management, a hospital Registered Nurse and Unit Manager for the hospital unit stated, He isn't here for pain management. He is here for placement. (The facility staff) have been here to see him and will not take him back. On 07/19/19 at 11:25 AM, Staff D, Registered Nurse and the nurse on duty on 07/03/19, said Resident #1 claimed he was in pain all the time and always rated his pain was 10/10 (highest). Staff D said after running out of the buprenorphine, staff gave Resident #1 more as-needed doses of [MEDICATION NAME], so that should have taken care of it. At 11:30 AM, Staff F, Nursing Assistant and the person who found the resident when he attempted to commit suicide, said she would describe Resident #1 as difficult. Staff F said she felt bad for the resident and knew it was difficult for him to be in so much pain. Staff F said she was relieved he wasn't there right then, and stated, It is easier without him here. At 11:42 AM, Staff G, Licensed Practical Nurse and Resident Care Manager, said she visited the resident at the hospital. The resident said his pain was at 10/10. Staff G stated, We have no guarantee that he won't try something like that again. On 7/25/19 at 11:20 AM, when asked about calling the paramedics to the facility, Resident #1 said he told the facility staff to call 911 because my pain was so bad, but they would not do it so he took it upon himself to call 911. The resident stated, They got pissed off. That's probably why they don't want me back. Resident #1 said facility staff brought over his belongings in boxes. Several cardboard boxes were observed stacked in the resident's hospital room. At 3:32 PM, Staff C, Licensed Practical Nurse and the nurse who cared for the resident the day of the incident, said that was the first time he knew of the resident doing anything like that. When asked about Resident #1's medications, Staff C said they had run out of the buprenorphine a couple of weeks before. The resident was still getting the [MEDICATION NAME] but that was not enough because he had been getting the other med (buprenorphine) two times a day. Staff C said even though the resident said his pain was 10/10 sometimes, the [MEDICATION NAME] and [MEDICATION NAME] would manage the pain. At 5:05 PM, Staff A, Registered Nurse and Administrator, said the emergency room documentation recommended inpatient psychiatric treatment. Staff A said if they were able to obtain documentation the resident had been cleared by Mental Health, we would take him back tonight if we could. On 07/30/19 at 12:39 PM, when asked about Resident #1's status, Staff A said Resident #1 was not stable and she did not believe they could watch the resident as closely as he needed. On 08/05/19 at 4:19 PM, the hospital social worker said she told the facility Resident #1 had been cleared and was determined to be stable. The hospital social worker provided a copy of the Psychiatric Emergency Services MHP (mental health provider) Daily Assessment, dated 07/09/19, documenting, (Resident) has no need for inpatient placement at this time for mental health. The hospital social worker said the facility would not allow Resident #1 to return to the facility, and he remained in the hospital. Reference WAC 388-97-0120(4)(b)

Based on interview and record review, the facility failed to recognize and act on low temperature readings when a resident's temperature became critically low and required hospitalization for 1 of 3 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for medical complications, unmet care needs and a diminished quality of care. This caused harm to Resident #1. Findings included . The facility's policy and procedure on Vital Sign Monitoring, revised 02/2018, documented, If there is a deviation in blood pressure readings or other vital signs from the resident's normal readings, the nurse will assess the resident for a change in condition.The nurse will recheck vital sign and determine if it represents a change in condition. If a change of condition is identified, resident will be placed on alert charting (MACC) until the resident's vital signs return to baseline. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 01/18/19, documented Resident #1 was alert and oriented and required limited assistance with activities of daily living. A Nurse-to-Nurse Handover, dated 01/11/19, documented Resident #1's temperature was 36.4 Celsius (equivalent to 97.5 Fahrenheit (F)). On 01/12/19 at 9:50 AM, the day after admission, Resident #1's temperature was documented as 97.3 F. On 01/13/19 at 4:51 PM, Resident #1's temperature was documented as 96.4 F, marked with a red triangle and exclamation point next to the number. At the bottom of the page was a statement that Values in (triangle with exclamation point) RED indicate 'Out of Range.' On 01/15/19 at 2:07 PM, Resident #1's temperature was documented as 95.1 F, with a red triangle indicating out of range. On 01/21/19 at 12:38 PM, Resident #1's temperature was documented as 96.0 F, with a red out-of-range indicator. At 4:31 PM, Resident #1's temperature was documented by an LPN as 95.8 F, with a red out-of-range indicator. On 01/22/19 at 3:07 PM, Resident #1's temperature was documented as 95.7 F, with a red out-of-range indicator. On 01/23/19 at 2:53 PM, Resident #1's temperature was documented by an LPN as 96.1 F, with a red out-of-range indicator. A nursing note, dated 01/25/19 at 1:16 PM, documented, Resident is up in his wheelchair, appears somewhat confused; asked where he is at, got reoriented easily. Complained of not feeling well. VS are stable. Will continue to monitor . Record review of the resident's medical chart did not show re-checks of the resident's low body temperature readings, additional assessments, notifications to the provider, and other interventions taken. A nursing note, dated 01/25/19 at 3:39 PM, documented, This LN received notification from CNA of decreased temp of 84.8 tympanic. This LN obtained axillary temp: 89.5. Resident is cool to touch. More lethargic and confused than baseline. Gave report to (hospital nurse). Informed daughter . (Ambulance) called and will be in approx.: 10-15 minutes priority response. Emergency Department Encounter, dated 01/25/19, documented Resident #1's core temperature on arrival at 32.2 Celsius, or 90.0 F. The resident was sleepy and disoriented, and his extremities were cold to touch. Hospital staff documented the facility staff were unsure when Resident #1's symptoms of altered mentation, weakness and hypothermia (low body temperature) started, and noted .nursing staff had different stories. One nurse said started a couple days ago, another states a week ago. An ED nursing note, dated 01/25/19 at 4:30 PM, documented, (Staff D) noted facility nursing staff identified Resident #1's drop in temperature to 96.1 F on 1/24/19, and the patient had become increasingly lethargic and confused. On 01/25/19, The Emergency Department physician documentation, dated 01/25/19, showed, The very real possibility of deterioration of this patient's condition required the highest level of my preparedness for sudden, emergent intervention (for an emergency/urgent situation). On 02/26/19 at 11:52 AM, Staff E and Staff F, certified nurse assistants (CNAs) said normal temperatures for residents should be between 97-ish F and 98.9 F. Staff E and Staff F said they notified the nurse when vital signs were outside of normal range. At 12:10 PM, Staff C, a Registered Nurse, said when residents' vital signs were outside of the normal range, they should be re-checked. Staff C said any interventions, including notification to the physician, should be documented in a note and the resident placed on alert for follow-up monitoring. Staff C reviewed the temperatures recorded in Resident #1's chart prior to being sent to the hospital on [DATE]. Staff D said temperatures of 96.7 F and 96.9 F were low and should have triggered follow-up, including re-check, assessment and notifications. When asked about Resident #1's recorded temperatures of 96.4 F on 01/13/19, 95.1 F on 01/15/19, and 95.8 F on 01/21/19, Staff D said those should have had follow ups. Staff D said on the day Resident #1 was sent to the hospital, his temp was low, he was cool to the touch, his lower legs were black, and his mental status was altered. At 12:25 PM, Staff D, a Licensed Practical Nurse (LPN) and the Resident Care Manager who was in charge of Resident #1's care while he was at the facility, said the normal range for temperatures was between 97 F and 100 F. Staff D said when a resident's vital signs were outside normal limits, they should be repeated and the doctor should be notified. After reviewing the temperatures recorded in Resident #1's chart, including the ones marked with the red out of range indicator, Staff D was not able to locate documentation where the abnormal temperatures were re-checked, progress notes about interventions taken, notifications made to the physician and family, and the resident's status. When asked why Resident #1 had several temperatures below the normal range for two weeks before being sent to the hospital, Staff D said the staff missed it. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure residents were free from neglect when staff failed to provide necessary services to avoid physical harm for 1 of 3 sampled residents (#60) reviewed for abuse. This failure placed residents at risk for injury, abuse and/or neglect, and a diminished quality of life. This caused harm to Resident #60. Findings include . 1) Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 12/02/18, indicated the resident had severe cognitive impairment and was totally dependent on staff for transfers. The Activities of Daily Living care plan, dated 07/26/17, documented an intervention for staff to see the resident's In-Room Care Plan (IRCP) for mobility and transfer information. Resident #60's IRCP, dated 09/14/18, documented, Resident is Hoyer (mechanical lift) transfer. When transferring resident do not take off wheelchair foot and pedals for safety. A facility incident investigation report, dated 12/03/18, documented Resident #60 received a left lower leg laceration around 5:00 PM on 12/03/18 when Staff Z, Nursing Assistant, transferred the resident without using a Hoyer lift. The report showed Staff Z informed the facility she had performed another transfer without a Hoyer lift earlier in the day without issue so she decided to do the second transfer without a Hoyer. The facility investigation determined Staff Z was neglectful due to a pattern of failure to prevent harm. An emergency department provider note, dated 12/03/18 at 5:45 PM, documented Resident #60 had a large left leg laceration with some fat tissue exposed. The resident received a local anesthetic, extensive irrigation, cleaning and about 10 sutures. On 01/10/19 at 1:05 PM, Staff FF, Registered Nurse (RN) and Resident Care Manager (RCM), said she was acting Director of Nursing Staff (DNS) at the time of the incident. Staff FF said Staff Z had to get the resident up, was short for time, had transferred the resident earlier in the day without a Hoyer lift without incident so she did it again. Staff FF said she would expect staff to request assistance and use a Hoyer lift when transferring the resident. Staff FF said all staff on duty at the time of the incident were interviewed and none had received a request for assistance from Staff Z. At approximately 1:10 PM, Staff Z said she did not use a Hoyer lift to transfer Resident #60 earlier that day and it went well, so she transferred the resident a second time without a Hoyer lift, just before dinner. Staff Z said she did not use a Hoyer lift for the transfer and did not attach the resident's wheelchair foot pedals before transferring her. Staff Z said upon leaving the resident's room she turned, saw a trail of blood on the floor and saw the resident's left lower leg had been cut during the transfer. Staff Z said she knew the resident was to be transferred using a Hoyer lift. WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to provide necessary care and services for 2 of 3 sampled residents (#196 and #58) when the facility failed to accurately assess and treat Resident #196's complaint of pain and nausea and to identify and treat Resident #58's non-pressure alteration in skin. Staff failure to identify, assess and monitor these residents conditions placed all residents at risk for unmet care needs. Findings include: 1) Resident #196 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Do Not Resuscitate (DNR) order was in Resident's record, and she had been on comfort care Hospice at the Assisted Living Facility (ALF) she had lived at prior to being admitted to the hospital. On 2/16/17 at approximately 2:10 p.m., resident was observed in bed slightly diaphoretic, moaning, holding her chest and complaining of severe nausea and stated, Oh please help me; I don't feel good, I think I'm going to throw up. She stated, I just don't feel good, I don't know what it is, but I just don't feel right. The resident roommate stated, The poor thing has been sick all day. I will push the button for someone to come help her. At approximately 2:15 p.m., NA N came in and the resident said she was not feeling well and felt like she was going to vomit. NA N stated she would go report this to the Licensed Nurse (LN). At approximately 2:25 p.m., LN S asked the resident if she was feeling nauseated. The resident said, Yes. LN S stated he would look if there were any orders for medication that would help. At approximately 4:30 p.m., when asked if Resident #196 was doing better, LN S stated, Yes. On 2/17/17 at 4:14 a.m., Resident #196 was observed in bed unresponsive with her eyes open, chin tucked toward chest, head of bed up at approximately 45 degrees and breathing in a slow, shallow rhythm, and her skin was pale. At 4:22 a.m., LN P was observed going to Resident #196's room with oxygen and tubing, applied it to Resident #196 and took Resident's vital signs. There was no attempt to reposition the resident to open her airway. At 4:26 a.m., when akded about the last time the resident received care, NA O stated, I saw her at about 3:30. I didn't want to move her too much because she had a bad night, meaning she was nauseous. At approximately 4:34 a.m., LN P left a message for Resident #196's doctor (second call, first care approximately ten minutes before) and stated (Resident #196) has had a change, has labored breathing, was placed on 2 liters of oxygen, breathing rate is 14, blood pressure was 80/50 and pulse was 46 and has a DNR order. I put the oxygen on her and will try to keep her as comfortable as possible. Call me to let me know if there is anything else I should be doing for her. At 4:36 a.m. LN P called Resident #196's son to inform him the resident was having some trouble breathing and stated she would call him back once she heard from the doctor. At 4:41 a.m., LN P called Resident #196's son back and offered to send Resident #196 to the hospital. LN P stated to the son, I'm having trouble getting ahold of the doctor and I wanted to make sure you are not in disagreement to send her to the ER. At approximately 4:42 a.m., LN P placed a call to 911 and stated, I have a lady who is having shortness of breath. At 4:50 a.m., Resident #196 was observed in the same condition as at 4:14 a.m. There appeared to be no change in position or attempt to open airway. Emergency Medical Technician's (EMT's) arrived at approximately 4:55 a.m. and pronounced her death at approximately 5:09 a.m. On 2/17/17 at approximately 8:10 a.m., a record review showed there had been no further assessment or follow up of Resident #196 during the hours of 10:45 p.m. on 2/16/17 and 4:14 a.m. on 2/17/17. There was no documentation of current vital signs taken during the period Resident #196 complained of epigastric pain and nausea. (The last documentation of vitals signs had been on 2/15/17, a day before Resident #196 complained of pain and nausea.) On 2/21/17 at 10:47 a.m., when asked about the expectation when a resident has an immediate change in condition, the Director of Nurses Services (DNS) stated, If it's life or death, the LN's need to put down what they are doing and go assess the resident. If the resident is a code, call overhead. They need to notify the doctor and resident representative. If they are a no code, the staff should be repositioning for comfort, be given any medication they can have to help with symptoms, collaborate with doctor .I expect them to do something. The facility's failure to identify, assess and treat Resident #196's change of condition and/or reposition for highest level of comfort and airway patency during a time the resident was actively dying, placed the resident and all residents in similar situations, at risk for delay in treatment. 2) Resident #58 was admitted to the facility in 2013 with multiple medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 1/29/17, documented the resident required extensive assistance for activities of daily living (ADLs), was at risk for developing pressure ulcers and had one unhealed pressure ulcer. Resident #58's current Physician's orders, documented the resident had treatments ordered for wounds on his lower back, buttocks, and left lower leg. On 2/16/17 at 3:06 p.m., Licensed Nurse (LN) O and LN D were observed to complete wound care for the areas on Resident #58's lower back, buttocks and leg. At 3:42 p.m., dried dark red spots (appeared to be wound drainage) were observed on the resident's right sock. LN O removed Resident #58's sock, and a petroleum gauze strip was noted on the resident's right toes. LN O removed it. Resident #58 was observed to have a small open area to the top of his big toe surrounded by red, fragile tissue. The right third toe had an open area that appeared red and bleeding near the nail edge. LN D stated, that is from the podiatrist. Review of Resident #58's medical record of the physician's orders, treatment administration record, skin grids, and nursing progress notes, did not document the presence of wounds to Resident #58's right toes. The physician orders did not include wound care and monitoring of the toes. A physician visit note, dated 2/10/16, had no documentation regarding wounds to Resident #58's right toes. At 3:53 p.m., LN D indicated she did not know how long Resident #58 had open areas on his right toes and when the podiatrist had last seen Resident #58. LN D stated she thought it was approximately one month ago the podiatrist saw Resident #58. LN D was unable to state how often the areas to the resident's right toes were monitored, assessed and treated. LN D stated, The nurses take care of the toes and I measure and track the area to his bottom. At 3:54 p.m., LN O was unable to state how often Resident #58's right toes were monitored and treated. When asked how the nurses would be aware of the area to Resident #58's toes, LN O did not provide an answer.

Based on observation, interview and record review, the facility failed to provide incontinence care (#72, #70), nail care (#70, #190, #72), shaving (#70), oral care (#72, #1), and personal grooming (#1) for 4 of 8 current sampled residents (#190, #72, #1, and #70) reviewed for activities of daily Llving (ADL's). The facility's failure to assist dependent residents placed all residents at risk of health complications, injury to skin, unsightly nails, discomfort, embarrassment and an overall decreased quality of life. Findings include: 1) Resident #190 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #190's Minimum Data Set (MDS), an assessment tool, dated 2/8/17, indicated the resident required extensive assistance to complete personal hygiene tasks. On 2/17/17 at 8:48 a.m., the resident was observed with long fingernails that appeared to have debris under them and dried substance around cuticles. A review of resident's record showed a progress notes that Resident #190 had been given a suppository earlier that morning and had removed it. On 2/21/17 at 9:07 a.m., the resident was observed with long nails and debris under the nails and around cuticles. Record review showed the resident received a shower on 1/28/17, 2/2/17, 2/4/17, 2/9/17 and 2/11/17. The resident's Treatment Administration Record (TAR) showed Licensed Nurse (LN) was to check fingernails and toenails once a week on bath day and to trim as needed. There were initials on 1/25/17, 2/1/17, 2/8/17, 2/15/17 and 2/22/17 to document the fingernails and toenails were checked and/or trimmed. On 2/27/17 at 7:45 a.m., it was observed that Resident #190's fingernails were long and had debris under them and around cuticles. At 10:39 a.m., the Director of Nurses (DNS) said Resident #190's fingernails were long and had debris. The DNS stated, I will discuss this with the nurse who documented nail care last. 2) Resident #70 was admitted to the facility in 2012 with multiple [DIAGNOSES REDACTED]. Resident #70's MDS, dated [DATE], documented the resident had severe cognitive impairment, required extensive assistance with ADLs, and did not reject care. The resident's Urinary Incontinence care plan, updated 1/7/17, documented a goal for the resident to remain, clean, dry and odor free and toileting needs met by staff. Approaches included, assist extensive of two staff with toileting. Needs staff to anticipate needs. On 2/14/17 at 9:11 a.m., Resident #70 was observed to have several days of beard growth on his face and his fingernails were untrimmed. On 2/16/17 at 4:01 p.m., Resident #70 was observed sitting in his wheelchair in the dining room with a strong smell of urine and with his pants visibly wet along the sides and groin area. No aides or staff were seen in the hallway to provide assistance. Between 4:14 p.m. and 4:21 p.m., LN O was observed to be walking up and down the hall looking in rooms for nursing assistants while another resident was overheard yelling they needed the bathroom. At 4:25 p.m., Nursing Assistant (NA) E and NA D appeared in the hallway briefly and were promptly summoned to assist another resident with positioning for an x-ray. Resident #70 remained in the dining room. His pants were visibly wet and he smelled strongly of urine. At 4:33 p.m., Resident #70 remained in the same spot and condition. Staff were made aware of Resident #70's need for incontinence care. On 2/17/17 at 9:45 a.m., Resident #70 was observed sitting in his wheelchair in the hallway. Resident #70's shirt had food debris on it and a large amount of drainage from his nose. On 2/21/17 from 9:15 a.m. through 11:10 a.m., Resident #70 was observed to be sitting in his wheelchair in the dining room. His shirt was dirty, the resident had a dried white substance on and around his lips and he had several days of beard growth on his face. Between 9:15 a.m. and 11:10 a.m., staff were not observed to interact with Resident #70 or attempt to toilet him. At 12:09 p.m., the resident remained in the same spot. His shirt remained dirty and his mouth had a dried white substance on it. On 2/22/17 at 4:07 p.m., NA D and NA E were observed providing care for Resident #70. Resident #70's brief was observed to be saturated with strong smelling urine and bowel movement and his pants were wet with urine. NA E stated Resident #70 was probably changed after lunch, but was not sure of the time. At 4:34 p.m., when asked how often residents were shaved, LN D indicated residents get shaved twice per week on their bath days. After observing Resident #70, LN D stated, Yes he does need a shave. LN D described, residents should be changed before they are saturated with urine. 3) Resident #72 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#72's care plan, dated 11/07/16, listed the resident has a self-care deficit related to the need for assistance with ADL's and mobility, with the potential for further functional loss due to the natural progression of [MEDICAL CONDITION] and dementia. Staff's approach indicated set up hygiene and oral care supplies each morning and evening, encourage to participate, and need for extensive assist with oral care and hygiene. Care plan, dated 11/01/16, indicated the resident has an alteration in oral status related to natural teeth. Staff were to assist with oral care, extensive assist of one for oral care am and pm. Record review indicated the resident had orders for a LN to perform nail care. Documentation stated, Licensed nurse to cut and clean finger nails and toe nails once a week. On 2/14/17 at 9:05 a.m., Resident #72 was observed to have long fingernails with brown debris and dirt under them. The resident was observed to have aged finger polish on her nails with appearance of unkempt nail care. On 2/16/17 at 9:46 a.m., the resident was observed to have long untrimmed nails. Nails were observed with brown debris and dirt under them with same nail polish. Resident was observed with a blanket across her lap with food and other debris across her lap and down the front of shirt. On 2/22/17 at 3:38 p.m., Resident #72 was observed to be lying in her bed with feet hanging out from the side. The resident was asking for help. Resident was instructed to press her call light and did so. Resident indicated she was uncomfortable in her bed and needed to use the restroom. Resident repeating, Hurry up, can you hurry? Hurry! Hurry! Hurry! On 2/22/17, Resident #72 indicated she had not had her teeth brushed that day, and stated she would have liked to have had her teeth brushed. The resident was observed to have food and debris in her teeth. At 3:48 p.m., NA E came to the room and assisted the resident to the restroom. The resident was observed to have a wet area on the hip area of her pants. At 4:15 p.m., Resident #72 was observed in the hallway wearing the same pants. Resident was observed with food on her shirt. Resident was observed with her nails to be long and dirty with unkempt nail polish the same as the first day of survey. On 2/22/17 at 3:55 p.m., LN D indicated nail care was expected to be done weekly for residents and some ladies get manicures during activities. The resident's nails would be cleaned on their bath days. LN D indicated the LN on the floor is responsible for performing this and signing off on it on the administration form, and the Aides are responsible for brushing teeth and doing all other ADL's as part of the resident's am and pm care. LN D indicated Resident #72 had her nails last cleaned and trimmed on 2/18/17. LN D indicated she was surprised to learn the resident's nails were observed to be in the same fashion as they were found on 2/14/17. LN D indicated it was her expectation for the LN to document when care was performed. 4) Resident #1's MDS dated [DATE], indicated the resident was totally depending on staff for personal hygiene. The resident's care plan showed to provide the resident's oral care every shift and PRN (as needed). On 2/22/2017 at 2:48 p.m., NA K stated she was told by the floor nurse and the outgoing NA about the care needs for each resident. She stated the care plan was in the closet. On 2/23/2017 at 11:31 a.m., LN D stated the aides should be combing the residents' hair, change if incontinent, bath, and provide oral care for the am and pm if the resident was total assist. Staff need to anticipate Resident #1's needs. On 2/27/2017 9:39 a.m., NA B stated Resident #1's oral care was done with swab sticks or dental sponges and done every shift. At 9:47 a.m., LN N stated it's not in resident's treatment plan to brush teeth. LN N stated the mom does the brushing. If staff had to brush, they would need a brush and suction. At 9:50 a.m., LN D stated they use toothettes and rinse with little water and swab to remove anything. LN D stated Resident #1's family member drives her care. LN D stated they have never tried a suction toothbrush.

Based on interview and record review, the facility failed to promptly identify and/or implement interventions to prevent unplanned significant weight loss for 3 of 5 sample residents (#190, #73 and #121) reviewed for weight loss. This failure of not monitoring and/or responding to residents weight loss resulted in harm for one resident (#73) as evidenced by unplanned, avoidable significant weight loss of 17 pounds in approximately 2 months. Findings include: 1) Resident #73 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 1/15/17, documented the resident's current weight as 119 pounds, required supervision/set up with meals. Resident #73's Physician Order's documented the resident was offered 2 Cal, a high calorie dietary supplement, three times daily. The Facility Weight Monitoring and Documentation Policy, dated 1/16, documented, It is the policy of this facility to monitor nutrition parameters including weights. The policy further outlined monthly weights, including reweights for residents, will be completed by the 9th of every month. On 2/22/17 at 3:43 p.m., Licensed Nurse (LN) E stated the residents on the 300 hall all get weighed monthly by the 9th of the month unless identified as needing more frequent weight monitoring. LN E indicated all weights were reviewed by her. LN E stated any weekly, missed weights, or reweights on residents are completed by Fridays and placed on the agenda for the following weeks meeting for the team to discuss and analyze current resident interventions. She stated any weight refusals by the resident would be documented in the chart as refused. LN E said she noted Resident #73 was losing weight after a pain patch was prescribed to the resident. LN E stated the facility expectation is if a resident eats less than 50% of a meal, the resident would be offered an alternative meal and/or be given an additional 2 Cal dietary supplement drink. On 2/22/17 at 3:36 p.m., Nursing Assistant (NA) K stated, If resident doesn't eat at least 50% of meal, I would go to nurse and ask what I should do. At 3:36 p.m., NA N indicated if a resident doesn't eat 50% of their meal we would offer an alternate, a snack, or ask the nurse if they can have an additional 2 Cal drink. Record review of Resident #73's daily intake record for 1/1/17 through 2/1/17, noted the resident had eaten 0-50% of meals on 39 occasions. There was no documentation of alternate meals being offered to the resident or that the resident was provided additional 2 cal. drinks, other than what the resident had ordered daily. On 2/22/17 at 2:58 p.m., the Registered Dietician (RD) said she used the weights documented in the resident record as well as the facility Weight Variance Report, a computer generated report that listed and analyzed weights over time, to identify weight loss when completing her assessments. The report monitoring weights from 8/22/16 through 2/22/17 showed the resident with a weight of 119 on 12/7/16. There was no weight documented for the month of January 2017. The next documented weight of 105.9 was on 2/1/17, a 13 pound weight loss, a decrease of 11.1% of her body weight in 56 days. The report listed Resident #73 as having a significant weight loss. The RD stated she normally completed her assessment with MDS schedule, but was late due to heavy workload and not having time to get in until 1/25/17. A Medical Nutrition Therapy Reassessment Report, dated 1/25/17, listed the resident's current weight as 119.1 which was a weight obtained on 12/7/16, over 50 days earlier. The report listed 121 as the weight obtained 30 days prior to the assessment, which was the weight from 11/12/16, 75 days prior to assessment date of 1/25/17. This led to the resident's weight loss to be incorrectly reported as a small weight loss. On 2/22/17 at 2:58 p.m., the RD said when reviewing the assessment together with no January weights obtained, that was why she used the weight obtained on December 7, 2016 on her assessment. She was now aware the assessment she completed misrepresents the resident weight loss percentage as much lower than it actually was. On 2/22/17 at 5:00 p.m., the Director of Nursing Services (DNS) stated long term care residents are to be weighed monthly. If weights are not done prior to meeting they would bring the resident over the following week to the Nutrition at Risk Meeting meeting to follow up on. The DNS indicated the facility recognized they have serious weight issues as they have switched from having Restorative Assistants weighing residents to the Bath Aides doing the weights currently. The DNS indicated they are working on fixing the problem currently. On 2/22/17 at 3:15 p.m., the Food Service Manager (FSM) stated he used the 12/7/16 weight as the current weight when entering data for the MDS, dated [DATE]. That was the last weight recorded for the resident. The FSM stated he had notified the resident care manager that weights had not been taken in January. The facility's failure to monitor resident's weights per policy, follow assigned interventions with alternate meal choices, snacks, or administer additional 2 Cal dietary supplements per management expectation resulted in Resident #73 having a significant weight loss of 17.5 pounds in 60 days (from 12/7/16 to 2/9/17). 2) Resident #190 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 2/16/17 at 10:21 a.m., Resident #190 was observed in bed and extremely thin with cheekbone and rib bones prominent. Resident #190 stated his usual body weight was 162 pounds, but he knows he had lost weight, though he was not sure how much he had lost. Resident stated, I just can't eat. I feel like I'm going to throw up if I eat more than a few bites. When asked how long this has been going on, the resident stated, A couple of weeks. Record review of the resident's chart showed the following weights: On 1/25/17, the day of admit, Resident #190 weighed 153 pounds; on 1/26/17, 146 pounds; on 1/27/17, 141 pounds; on 1/30/17, 140 pounds; on 2/7/17, 130 pounds; and on 2/14/17, 129 pounds. The Medication Administration Record [REDACTED]. A Nutritional Risk Review, dated 2/15/17, showed the resident had weight loss and the plan was to talk to the resident's doctor about alternate feeding options such a feeding tube. It also showed the resident was started on [MEDICATION NAME] 37.5 milligrams daily for depression and for appetite stimulation. On 2/16/17 at 4:25 p.m., when asked who was responsible for documenting and ensuring residents were receiving/offered snacks between meals and at bedtime, NA C stated, We are. When asked who and how often an NA would report when a resident had no intake, NA C stated, We let the nurse know if they don't eat or drink at every meal. NAs are supposed to report any changes in resident condition to the LNs using a Stop and Watch form. On 2/17/17 at 7:14 a.m., LN R stated, (Resident #190) has been refusing most of his meals . LN R stated, I need to talk to the Resident Care Manager (RCM) and see what kind of interventions we need to do for him. We need to try something new. At 12:48 p.m., NA M was observed to take and offer the lunch meal to Resident #190, and he declined it. The NA took it back to the dining cart and did not offer Resident #190 any alternatives. At 12:52 p.m., when asked why he was not eating, Resident #190 stated, Because if I do, it will be a constant cycle of eating and feeling like I'm going to vomit, and the acid is terrible pointing to his lower throat/upper chest area. When asked if he was hungry, Resident #190 stated, Yes, of course, I am. On 2/21/17 at 5:08 p.m., LN E stated, (Resident #190) will take a few bites with assistance, but then doesn't want any more. When asked what the expectation of NA and LN staff for Resident #190, LN E stated They are to carry out care planned interventions such as offer, encourage and re-approach and We are using [MEDICATION NAME] for depression and weight loss. We are going to have a care conference tomorrow and get a better handle on how things are going for him. He has a POLST and wants tube feeding, but he sometimes says he wants to die. We did discuss with him his previous desire to be full code and tube feeding, but he doesn't respond when we ask him if this is still his desire. On 2/22/17 at 11:35 a.m., the RD stated she interviewed residents when they were admitted , reviewed their medical record, planned with the Food Services Manager (FSM) for preferences and applied interventions of therapeutic diet, snacks and supplements. She then sees residents monthly and as needed. She had not seen Resident #190 since the initial review because he had not been in the facility long enough and is not due for a re-evaluation and the facility was waiting for [MEDICATION NAME] to take effect. The RD said she does not attend care conferences. At 11:45 a.m., the FSM stated, I get resident food preferences when they are admitted and then I go back in a few days to see if anything has changed to try to get a many preferences as possible. Resident #190's perferences were for fruit and yogart. At 2:13 p.m., at a Care Conference, Resident #109 said he did not eat much because the nausea and heartburn made it too difficult for him. He stated, I am very hungry, but after a few bites my acid indigestion flares up and I can no longer eat and I feel like I'm going to vomit. The resident stated, I don't eat big meals, and I don't usually eat so early in the morning. I only want fruit for breakfast, and strawberry Ensure. I will gain a lot of weight with that. Resident #190 stated And I can't feed myself right now. My wrists and arms hurt. Record review of Resident #190's medical chart showed no new weights were documented since 2/14/17. The hospital discharge summary, dated 1/25/17, showed Resident #190 had severe protein-calorie malnutrition, and was eating well by day of discharge from the hospital, preferring Ensure. The facility did not obtain Ensure until 2/22/17 after the care conference. The facility's failure to timely assess Resident #190's needs for treatment of [REDACTED].#190, a resident admitted to the facility with known malnutrition, to have continued unplanned and probably avoidable weight loss. 3) Resident #121's MDS indicated the resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], did not include a recent weight or identify significant weight loss. The facility's form, Skilled Nursing Facility Transfer Orders, dated 2/13/17, indicated Resident #121's weight was 125 pounds on 2/13/17. The facility documentation, showed Resident #121 had 4 weights from 2/15/17 - 2/17/17 documented at 115 pounds. Resident #121's weight prior to the hospitalization , on 2/4/17, was on average 145 pounds. A review of Resident #121's meal intake showed fifteen meals documented between 2/15/17 - 2/26/17 of which nine were refused, four were 1-25% consumed and two were 26-50% consumed. A progress note, dated 2/13/17, noted Resident #121 had readmitted to the facility and diet orders were general diet with pureed texture, thin liquids and small portions. Very close supervision and assistance was required due to potential choking risks. Progress notes, beginning 2/14/17, documented Resident #121 refusing medications on an almost daily basis. Progress notes, beginning 2/16/17, documented Resident #121 taking in very little or refusing food on an almost daily basis. A progress note, made 2/21/17, documented Resident #121 was refusing all intake of nourishment and documented, looks very thin ribs are prominent. There was no documentation from 2/13/17 through 2/22/17 that the family, guardian and physician were notified of Resident #121's poor intake and weight loss. A Nutrition at Risk (NAR) form, dated 2/23/17, noted Resident #121 was re-admit with weight loss. The form documented Resident #121's responsible party and physician were notified of the weight loss on 2/23/17. On 2/27/17 at 9:42 a.m., LN D said if significant weight loss is noted a NAR was opened on that resident. The resident would then be followed weekly by the NAR team. When asked when the resident representative and physician would be notified of the weight loss, LN D stated they would be notified when the weight loss was identified. LN D indicated she had knowledge of Resident #121's weight at the hospital being 125 pounds on 2/13/17. LN D said Resident #121's physician and guardian were notified of the weight loss on 2/23/17 when the NAR was opened on the resident, 8 days after the 10 pound weight loss was documented.

Based on interview and record review it was determined the facility failed to immediately respond, provide, and obtain timely emergent interventions during an emergent event for 1 of 3 Residents (#1) who were reviewed for necessary care and services. The failure to obtain timely, emergent, immediate help and provide basic lifesaving interventions delayed the activation of emergency services for Resident #1 and placed all other residents in danger of not having their needs met in a similar emergent situation. Findings include: Resident #1 was re-admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) an assessment tool, dated 10/18/2016 documented Resident #1 was cognitively intact and had an active care plan to discharge to the community. The resident's medical record contained a valid, signed, physician's orders [REDACTED]. On 11/16/16 at 11:15a.m., Nursing Assistant (NA) D stated that on 11/5/16 at approximately 8:26p.m., Resident #1 was transferred to a bedside commode by NA D. NA D stated that during the transfer Resident #1 became short of breath and requested that a nurse evaluate him. NA D stated that at 8:30p.m., she requested help from Licensed Nurse (LN) A, who was sitting at the nursing station with LN C. NA D returned to Resident #1's room and found Resident #1 to be white with his eyes rolled back in his head. NA D returned to the nursing station and explained to LN A and LN C that Resident #1 was really short of breath and turning white. LN A told NA D hold on I'll be right there. NA D returned to Resident #1's room and found him foaming at the mouth. NA D again went to the nursing station and requested help for Resident #1 and was told by LN A I'm coming, I'll be right there, just make sure he does not fall. NA D returned to find Resident #1 gasping for air stating I don't want to die, I need help. NA D states that she had to request help 5 separate times before LN A went to Resident #1's room to assess the resident. On 11/17/16 at 3:12 p.m., LN A confirmed that NA D requested help at least 4 or 5 times. NA D stated that once LN A got to Resident #1's room NA D was sent to get Oxygen for Resident #1. NA D went to the nursing station and asked LN C where to get oxygen and was directed to the clean utility room. NA D discovered that all 5 oxygen canisters in the clean utility room were empty. NA D and LN C returned to Resident #1's room and informed LN A that the Oxygen canisters were empty. LN A instructed NA D to stay with the resident while he/she looked for a full canister of oxygen. LN A ran into LN B at the nursing station and informed LN B of Resident #1's need for oxygen. LN B then grabbed the crash cart from the nursing station and moved it to Resident #1's room. On 11/17/16 at 3:05 p.m., LN B stated he/she entered Resident #1's room Resident #1 was basically flaccid with an irregular breathing pattern. LN B set up the oxygen mask and instructed NA D to hold it on Resident #1's face. LN B state that an ambu bag (device commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) was located in the crash cart but was not used for Resident #1. NA D stated that when LN B arrived with the crash cart Resident #1 was white, foaming at the mouth, unresponsive and not breathing. On 11/17/16 at 3:12 p.m., LN A confirmed that NA D and LN C supported Resident #1 on the bedside commode while LN A called the Residents physician. LN A was instructed by the Physician to call 911 and transport the resident to the Emergency Department. LN A activated Emergency Medical Services (EMS) at 8:45 p.m., 15 minutes after NA D requested help for Resident #1. LN A completed the transfer paperwork prior to returning to the resident. LN A stated while awaiting for EMS LN A, LN B, LN C and NA D were all in the residents room. LN A stated that the resident was placed on a pulse oximetry monitor (device that monitors blood oxygen levels) which recorded erratic readings from 14%-100% (normal values <96%) and a heart rate reading of 135-34 beats per minute (Normal value 60-100). NA D indicated that at approximately 8:45 p.m. he/she attempted to get guidance from LN A, LN B and LN C on how to help Resident #1 who remained unconscious, foaming at the mouth and sitting on a bedside commode. NA D stated I was told we just need to wait until EMS arrives. On 11/17/16 at 3:12 p.m., LN A stated that no other interventions were preformed while awaiting EMS. LN A stated that while awaiting EMS we did not feel it was warranted to transfer the resident to the floor or bed, I thought the resident was not stable enough for a safe transfer. According to EMS documentation EMS arrived at Resident #1's bed side at 8:51 p.m., American Medical Response pre-hospital care report dated 11/5/16 documented On scene to find Patient unconscious/unresponsive, GCS 1-1-1 (no eye opening, no verbal response, and no response to pain), Skin mottled/cyanotic (discolored in irregular patches/blue), being supported by staff on a bedside commode, foaming at the mouth, neck flaccid (resident unable to open airway), thorax without chest rise (no inhalation/exhalation), agonal respirations (inadequate pattern of breathing associated with extreme physiological distress). The resident was transferred out of the facility by EMS at 09:01 p.m. and transported to Providence Centralia's Emergency Department and did not return. The facility failed to immediately respond to Resident #1's emergency condition. The facility failed to timely identify Resident #1 as having a life threatening event. The facility failed to immediately activate EMS. The facility failed to provide basic lifesaving interventions during an Emergency situation involving Resident #1. On 11/17/2016 at 4:05 p.m., the Acting Director of Nursing (ADON) stated that a mandatory staff meeting was held on 11/9/16 and 11/10/16 in response to the facility investigation into Resident #1's emergency event. The meeting covered the use of the crash cart and high flow oxygen, rapid response and resident assessment, the immediate activation of EMS, proper positioning of a resident during an emergent event, and a mock code drill. ADON stated that all facility staff were required to attend.

Based on interview and record review, it has been determined the facility failed to ensure 1 of 3 residents (Resident #1) reviewed for medications were free from a significant medication error. Resident #1 received a narcotic (a strong pain reliever) medication that was ordered for another resident, resulting in harm to Resident #1, who required hospitalization to treat symptoms of accidental overdose, including decreased respirations and lethargy. Findings include: Resident #1 was a [AGE] year old who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/24/2016 a review of Resident #1's medical record indicated that on 08/07/2016 at approximately 9:00 pm Resident #1 received 90mg of [MEDICATION NAME], a strong narcotic medication, which had been ordered for the resident's roommate. According to documentation of information obtained during the facility's investigation, LN A, who was a new employee being orientated to the facility's routines and processes, was working with another LN who was to be supervising LN A as medications were given to residents. LN A realized immediately after giving the medication that the medication had been given to the wrong resident and notified the doctor who gave order to give [MEDICATION NAME], a medication to help reverse the narcotic medication, in hopes that resident would not have any adverse effects. LN A administered the reversal medication at approximately 9:10 p.m. and it was documented that Resident #1 had no indications of adverse reaction to the narcotic medication at that time. LN A re-assessed the resident at approximately 10:40 p.m. before going off shift and resident was noted to be awake, alert and oriented, respirations were counted at 15 per minute, breathing was unlabored and consistent, and she stated she had no difficulty breathing. On 08/08/16 at approximately 12:30 a.m., the night shift nurse had observed that resident was taking approximately 7-8 breaths a minute (12 to 20 breaths per minute is considered a normal amount of respirations in adults), and heart rate was slightly low at 58 beats per minute, blood pressure was 100/60, and Resident was a bit more difficult to arouse. LN B gave Resident #1 another dose of the reversal medication ([MEDICATION NAME]) at approximately 12:45 a.m. Approximately two hours after the second dose of the reversal medication was given, and the resident had shown a temporary improvement, the resident's respiratory rate again decreased to six breaths per minute and was then sent to the hospital for evaluation where she was admitted for further observation. Resident #1 spent 2 days in the hospital to monitor for adverse effects to the medication given in error at the facility. In an interview on 09/13/16 at 4:55 p.m., LN A stated I poured the medication, locked the cart and went in to give the medication. The resident said yes when I asked if her name was (resident's roommate), so I gave her the medication. When I came out of the room, I asked the LN (LN C) I was working with if that was (Resident #1's) medication, and (LN C) said No, that's (the roommate's) medication! We called the doctor immediately and got an order for [REDACTED]. State Surveyor asked LN A what the process is for administering medications, and LN A stated We are supposed to use the 5 rights of medication administration, including right name, medication, dosage, time and route. When asked if LN A had asked the resident her name, LN A stated No. I asked her if she was (the roommate' s name) and she nodded or said yes . She was hard of hearing and I know now I should have asked her name and not offered a name, and I should have asked her date of birth. The facility's failure to accurately administer medications places residents at risk of experiencing potential health related complications from receiving medication not ordered by a physician.

Based on observation, interview and record review, it was determined the facility failed to protect 1 of 3 residents reviewed for accident hazards (#1) from a hot beverage injury. The facility failed to have interventions in place to prevent a hot beverage spill. This caused harm to Resident #1 when he dumped hot coffee onto his lap and sustained a significant burn to his leg. The facility also failed to ensure a portable oxygen tank was securely stored in one of 20 rooms reviewed for accident hazards. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set, an assessment tool dated 5/1/16, documented the resident had cognitive impairment and was able to eat independently with set-up. A Hot Beverage Risk Screening for Resident #1, dated 5/3/16, documented the resident had risk factors including impaired cognition/confusion/dementia and left-sided weakness. The assessment tool directed staff to conduct a full assessment and identify interventions if any risk factors were checked. The box regarding follow-up was checked no. Review of the facility's accident and incident log revealed Resident #1 sustained a burn on 6/29/16 at 8:00 a.m. A Coffee Temp Log for June 2016 was reviewed on July 12th at 1:00 p.m. The coffee temperatures ranged from a low of 168 degrees Fahrenheit (F) to a high of 170 degrees F. On 7/8/16 at 4:00 p.m., Resident #1 was observed sitting in his wheelchair in his room. The resident indicated he had spilled hot coffee on his leg a few days ago. The resident stated, I can't believe it was so bad! Resident #1 stated the area was painful when it was touched. Observation of the area with Licensed Nurse (LN) A showed an open area to the resident's right thigh covered with white slough (tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy) with a small amount of tan drainage to the old dressing. LN A stated the dressing was changed daily and the area was cleansed and burn cream applied with each dressing change. According to the facility's policy and procedure regarding hot beverage, dated 01/16, a resident identified as at risk is to be identified on the individual tray card, and specific risk factors and appropriate interventions reflected on the resident's individualized care plan. A progress note dated 6/30/16 at 12:07 a.m., written by LN B sixteen hours after the incident, documented resident had spilled hot coffee on himself and a blister had formed. On 7/15/16 at 10:45 a.m., in a follow-up telephone interview, the DNS agreed Resident #1's Hot Beverage Screen was completed incorrectly on 5/3/16. The DNS indicated the resident should have had follow-up including interventions identified and put into place to prevent hot beverage injuries. The facility caused harm to Resident #1 when it failed to protect the resident, who was identified as at risk for hot beverage injuries, from a significant burn. <Oxygen Tank> On 7/8/16 at 9:44 a.m., a portable oxygen tank was observed in room 117 in an upright position. The oxygen tank was not in a holder or secured from tipping or falling. When asked about the portable oxygen tank, NA H indicated the oxygen tank did not belong to the facility and stated, we don't take care of them. The NA indicated a contracted agency brought in the oxygen tank. The NA indicated the tank should be secured in a holder and stated she would have to ask somebody what should be done. The NA then left the room. At 9:46 a.m., LN D was brought to room 117 and was asked about storage of portable oxygen tanks in resident rooms. The LN stated the unsecured portable oxygen tank was a safety hazard because it could fall over and shoot off. LN D picked up the tank and stated, I will take it out right away.

Based on observation, interview and record review, it was determined the facility failed to provide necessary care and services to 1 of 3 residents reviewed for accident hazards (#1) from a hot beverage injury. This caused harm to Resident #1 when he dumped hot coffee onto his lap and sustained a significant burn to his leg. The facility failed to initiate first aid and promptly assess and treat the burn. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set, an assessment tool dated 5/1/16, documented the resident had cognitive impairment and was able to eat independently with set-up. Review of the facility's accident and incident log revealed Resident #1 sustained a burn on 6/29/16 at 8:00 a.m. On 7/8/16 at 4:00 p.m., Resident #1 was observed sitting in his wheelchair in his room. The resident indicated he had spilled hot coffee on his leg a few days ago. The resident stated, I can't believe it was so bad! Resident #1 stated the area was painful when it was touched. Observation of the area with Licensed Nurse (LN) A showed an open area to the resident's right thigh covered with white slough (tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy) with a small amount of tan drainage to the old dressing. LN A stated the dressing was changed daily and the area was cleansed and burn cream applied with each dressing change. A progress note dated 6/30/16 at 12:07 a.m., written by LN B 16 sixteen hours after the incident, documented resident had spilled hot coffee on himself and a blister had formed. No documentation could be found in the Resident #1's medical record from the nurse on duty detailing what happened the morning of 6/29/16, if immediate first aid had been administered, if an assessment had been conducted, or if the doctor had been promptly notified of the burn. On 7/12/16 at 11:44 a.m., Nursing Assistant (NA) G stated the resident liked his coffee very hot. NA G stated the resident's thumb got twisted in the handle of the cup and it ended up in his lap. NA G stated the incident happened about half way through breakfast. NA G indicated the resident was assisted to lie down after breakfast, approximately 20 minutes later, to change clothes and that was when NA G noticed the blister on his leg. When asked if any first aid had been applied or if NA G had considered laying the resident down sooner, NA G stated, I had no idea it was that bad, and indicated the resident was not crying out and did not seem in pain. NA G indicated that LN C, who was working that day, was informed as soon as the NAs saw the blister. On 7/12/16 at 2:26 p.m., LN B stated she came on for evening shift (beginning at 2:00 p.m.) on 6/29/16. LN B indicated the day shift NAs told her about the area. LN B stated when she went to assess the area, the blister had popped. LN B indicated she covered the area with a clear bandage and notified the doctor who was in the building that evening. LN B was unable to describe if any first aid had been administered to the resident earlier that day. At 2:44 p.m., when asked how the staff should respond to a burn, the Director of Nursing Services (DNS) stated, of course first aid and treatment. They should notify the doctor, place them on alert charting and start an investigation. When asked if the nurse should assess the burn and document the assessment in the medical record, the DNS responded, Absolutely. At 2:46 p.m., the Administrator stated, I don't see any documentation from the day shift. At 3:15 p.m., in a telephone interview, LN C indicated the nursing assistants informed her of the resident's burn after breakfast that day. LN C stated, I looked at it (the burn), made myself a note, and then I honestly forgot to follow up. When asked directly if she applied any first aid or a cool compress to the area, the LN stated, Well, yeah, I applied a cool cloth. The LN indicated she was very busy that day and agreed she should have notified the doctor and completed an investigation. The facility caused harm to Resident #1 when facility staff failed to promptly apply first aid to the burn area and failed to assess and treat the resident's burn in a timely manner.

Based on observation, interview, and record review it was determined the facility failed to ensure a care environment that humanized, individualized and enhanced the quality of life for 2 of 2 current sampled residents reviewed for quality of life. This failure caused harm to Resident #1 when the resident was isolated in her room and not given the opportunity to have her life [MEDICATION NAME] by being in the company of other residents. Resident #182, who was receiving hospice services, had a diminished quality of life and unmet needs related to hydration, mouth care, activities and psychosocial needs. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool, dated 11/1/15, the resident required extensive assistance of two persons for all activities of daily living (ADLS). The resident's care plan, dated 2/13/2002, documented the resident was unable to participate in her own daily care and was dependent on staff for all mobility including transfers and repositioning. According to the resident's activity care plan, dated 8/6/15, the resident was at risk for isolation and lack of social contact. On 1/8/16 at 3:00 p.m., a stop sign was observed outside of Resident #1's room indicating the resident was on isolation and/or precautions were required for care. An isolation cart outside of the resident's room contained gowns, gloves, and masks. At 3:05 p.m., Resident #1 was observed in her room, facing the window in her wheelchair. At 3:30 p.m., when asked if the resident came out of her room, Nursing Assistant (NA) C stated, The resident doesn't come out of her room unless family is here and they will take her out. On 1/11/16 at 12:00 p.m., the resident's family member stated, I come in three times a week and give her a shower and take her out of the room. She stated, The staff used to take her out in the common areas but don't anymore. The resident was observed facing the window and up in her wheelchair. On 1/12/16 at 10:35 a.m., the resident was observed in her room sitting in her wheelchair facing the window. At 11:43 a.m., Licensed Nurse (LN) A stated, She's been on isolation for quite a while. The LN stated, The resident came out of her room sometime during the last month. Her mom takes her out and rolls her around. At 11:56 a.m., LN B stated, The resident had been on isolation since she started working with her about a year ago. She comes out for a shower. At 12:04 p.m., when LN M, the facility's infection control nurse, was asked about the isolation equipment and signage posted at Resident #1's room, the LN stated, She has a history, and only a history, of respiratory [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). She is not necessarily contagious. She occasionally comes out of her room, but not often. I know they bring her out for showers and her mother takes her out around the facility. She should not be on isolation. At 12:17 p.m., the Activity Director (AD) stated, When inviting residents to activities I have gone to the nurses and asked if she could come out, and usually they say no. It's been a good two weeks since she has been out of her room. At 12:32 p.m., the resident was observed in her room, sitting in her wheelchair facing the window. At 12:33 p.m., LN M stated, I took the stop sign off the door. It shouldn't have been up there. At 12:39 p.m., when asked how often Resident #1 was out of her room, NA S stated, When her mother comes to visit she takes her out and she loves it. When asked why the resident wasn't out of her room more often, the NA stated she was not sure, but thought it might be because her equipment would have to be unplugged and moved. The NA stated a nurse who no longer works at the facility told her not to take Resident #1 out of her room. NA S continued, I would like to see her come out and be involved with, or at least observe activities and be around people. NA S stated she takes her out of her room for showers and talks and sings to her and she gets a big smile on her face. NA S stated, I see her looking out her window often and feel bad the resident isn't brought out of her room more. At 12:40 p.m., LN L stated, She has been on isolation ever since I've worked with her, and is on isolation currently. She only comes out for showers. At 12:44 p.m., NA J stated, She is on isolation. At 12:57 p.m., when the surveyor asked if Resident #1 ever came out of her room with her equipment and sat in activities, LN A stated, It depends on how the other people feel about her. Medical conditions are scary for people and her equipment would take up a lot of room. You will have to understand she has a condition and we have kept her breathing for [AGE] years. At 1:15 p.m., when LN N was asked how often Resident #1 came out of her room, she stated, I park her in front of her window most of the time. Her mom takes her outside. When asked why staff didn't take her out more often, the LN stated, Staff and other residents might be uncomfortable if we brought her out. 1/13/16 at 12:40 p.m., when LN M was asked how long the resident had been on isolation precautions, the LN stated, As long as I have worked here, going on 5 years. When asked how long the stop sign had been up, she stated, Probably forever. <Observations of the Resident's Environment> Each day of the survey the resident was observed in her wheelchair facing the window. The view outside of the resident's room included the side of the building and a barren concrete patio. There were no trees, shrubbery, flowers, birdfeeders or decorations observed where the resident spends the majority of her time. <Family Interview> On 1/19/16 at 2:31 p.m., the resident's family member stated, I wish they had time to take her out of her room. I would like to have her out amongst other patients. I would like them to take her out of her room, but I have grown accustomed to it, and got tired of asking. The family member stated, Due to [MEDICAL CONDITION], they have isolated her. I think it has changed the way they treat her. She is not exposed to others patients. I know they have people come in and play music for the residents. It would be nice if they took her to those activities. She loves music. I think she would enjoy being in the hallway to hear conversations that could stimulate her. I am sure she feels isolated. When the staff go into her room, they quickly buzz in and out and usually don't stay long. I used to ask for her to be out of her room and more involved. I don't see those things being done. I think they are just too busy. The family member became tearful and stated, I don't feel like the resident has much quality of life. 2) Resident #182 was admitted to the facility on [DATE] with a terminal [DIAGNOSES REDACTED]. On 1/5/16 at 9:24 a.m., Resident #182 was observed laying in her bed with her breakfast tray on her over the bed table. The resident's food had not been eaten and her hand was in her food as the resident slept. The resident's water and coffee had been spilt on the resident's table and bedding. At 9:45 a.m., LN K entered the room and removed the resident's breakfast tray. The resident remained asleep as the food tray was removed and the resident was not offered any eating assistance. At 12:22 p.m., during the lunch meal service, the resident was observed awake, in her bed, and without a meal tray. At 12:25 p.m., LN K stated the resident required an aide to assist her with meals. The LN stated the resident falls asleep or forgets to eat and is on hospice care. The LN stated the resident didn't require actual assistance to eat, but ate better if she had company. On 1/10/16 at 12:13 a.m., during a night time observation, Resident #182 was observed in bed saying, Water. I need water now. The resident's cup was empty and her straw was on her bed. At 12:14 a.m., the surveyor assisted the resident by pressing the call light to alert staff of the resident's need for water. At 12:15 a.m., LN E entered the resident's room and said he would return with water. The resident was observed saying, This is horrible, I've been asking for water. The resident's mouth and lips appeared dry. At 12:19 a.m., when the LN returned with water, the resident sipped the water for a few minutes. On 1/11/16 at 12:01 p.m., Resident #182 was observed to be unable to reach the call light where it had been positioned and asked the surveyor for water. The surveyor assisted the resident by pushing the call light and waited until the nursing assistant (NA) entered the room to provide assistance. At 12:25 p.m., the resident was observed with ¼ cup of water on her table. When asked if staff normally ensured she had an adequate amount of water, the resident stated, Sometimes I wait and wait and wait and wait. The resident said, Don't go. I like visitors. My daughter visits but only stays five minutes. At 4:20 p.m., Resident #182 was observed lying on her back muttering something quietly. When the surveyor bent down to ask what she was saying, the resident grasped the surveyor's wrist and asked for water and for her head to be raised up. When the surveyor stated she would use the call light to request help, the resident stated, No, please, you do it, they won't come. I've been waiting and waiting and waiting. Please, please, water and please lift my head up. On 1/12/16 at 3:25 p.m., the resident was observed with ¼ cup of water on her table. The resident was unable get any of the water through her straw due to the small amount of water in the cup. When the cup was filled from the water pitcher at the bedside table, the resident stated, That's too warm. When asked if she liked ice in her water she said, Yes. At 4:14 p.m., NA L stated she normally passed out fresh water at the beginning of her shift or by 4:00 p.m. At 4:27 p.m., Resident #182 stated, I am so dry I can hardly swallow. On 1/13/16 at 12:13 p.m., NA M was asked if any residents she cared for needed extra mouth care or needed to be provided with moist mouth swabs. The NA stated, Resident #182 might. When asked about the frequency that type of care should be done, NA M stated, It should be done every two hours. When asked if that care would be charted anywhere, the NA said it was not charted by NAs but might be by nurses. At 12:48 p.m., the resident was observed with ¼ cup of water. The resident stated, The doctor wants me to drink three big cups of water a day. Where is it? When asked if the staff assisted her by providing moist mouth swabs, the resident stated no one had offered that to her. During observation, no swabs were observed in the resident's room. At 1:15 p.m., when LN F was asked if special mouth care was provided to Resident #182, she replied she didn't know and when she looked on the resident's In-Room Care Plan, the LN stated, I don't see it on there. At 1:20 p.m., LN C, a care manager, stated mouth care was provided once a shift. When asked if special mouth care such as moist swabs were provided to Resident #182, she stated it was not on the resident's care plan. At 2:01 p.m., Resident #182 was observed without any fluids available on her bedside table. At 2:02 p.m., when asked if the resident had enough water, LN G stated, I am sure she does. At the surveyor's request, the LN checked the resident's water and said, She needs a refill. <Social Services and Activities Departments involvement> On 1/13/16 at 12:48 p.m., the resident stated she enjoyed music. When asked if she would like a radio in her room she stated, That would be nice. The resident indicated she liked old fashioned and Christian music. At 1:25 p.m., the activities director provided an activity sheet which documented the activities the resident had been provided. The activities mainly consisted of watching television in her room or staff talking to her. The resident's activity involvement lacked individualized programming that could have comforted, soothed and enhanced the resident's quality of life as she experienced a decline in her health status. At 1:26 p.m., when asked about services provided to residents on hospice services, the Social Services Director (SSD) stated, Hospice provides a nurse, social worker and shower aide to attend to the resident a couple of times a week. When asked who would provide support for a hospice resident who was having a difficult time being on hospice, dealing with loneliness or in need of emotional support, the SSD stated she would call in the hospice counselor. When asked if the facility's Social Services Department would be involved the SSD stated, It depends. When the surveyor informed the SSD the resident had asked the surveyor not to leave her room and stated she loved visitors, the SSD stated, Oh, maybe we need to provide more support. At 1:30 p.m., the Social Services Assistant (SSA) stated, The resident's daughter comes in one or two times a week but usually doesn't stay long. The SSA stated, From talking with the daughter, she and her mom weren't very close. At 3:55 p.m., the DNS stated, There are things that can be done for the resident. I have talked to the Care Manager about using aritfical saliva or lemon drops for her dry mouth. At 4:15 p.m., the Adminisrator stated, She has people here from hospice a lot, not that it's all hospice's responsibility. On 1/20/16, the facility faxed a letter from the AD which indicated the AD had initiated a care plan that documented the resident was at risk for boredom, loneliness and helpfulness. The resident's Activity Care Plan listed only one intervention which was to allow staff to write her life story. There were no interventions related to the resident's interests and hobbies and the care plan did not direct staff on the types of activities that could be offered to the resident on a daily basis while she spent most of her time in bed. .

Based on interview and record review, it was determined the facility failed to ensure a resident's pain was adequately managed for 1 of 3 sampled residents reviewed for pain, causing harm to Resident #158. The facility also failed to provide necessary care and services for 2 residents (#162 & #172) reviewed for the provision of care and placed resident's at risk for increased pain or unmet needs. Findings include: 1)Resident #158 was admitted to the facility on [DATE] following spinal surgery. Review of the resident's progress notes and resident's Medication Administration Record [REDACTED]. According to the MAR, the resident was prescribed scheduled pain medication as well as [MEDICATION NAME] 5 mg ,[DATE] tablets every three hours as needed or PRN. The resident's October MAR indicated [REDACTED]. A progress note, dated [DATE] at 8:11 p.m., indicated the resident's surgical incision to the back showed slight dehiscence, (opening of the wound) on the lower half of the incision, with some blood present. At 9:03 p.m., a progress note indicated increased pain, with bleeding. On [DATE], a progress note at 12:21 a.m., documented continued pain and bleeding. A progress note, dated [DATE] at 11:45 p.m., indicated the nurse had faxed the pharmacy for a refill of Resident #158's [MEDICATION NAME] and the resident was given Tylenol and [MEDICATION NAME] (anti-anxiety medication) for pain relief. A progress note, dated [DATE] at 3:34 a.m., indicated the resident required repositioning, had muscle spasms and was given 10 mg of PRN [MEDICATION NAME]. According to the narcotic count sheet, the resident was only given 5 mg at 2:45 a.m. which was the last remaining tablet available from the resident's prescription. On [DATE], two 5 mg tablets of [MEDICATION NAME] were taken from the facility's emergency kit for Resident #158 and were given at 12:00 p.m. and 4:10 p.m. According to an interview with the Director of Nursing Services (DNS) on [DATE] at 3:10 p.m., both of the facility's emergency kits were already exhausted, which was the reason only two tablets were taken out for Resident #158. A progress note, dated [DATE] at 8:42 a.m., documented the resident had been restless during the night, with a complaint of back spasms. Tylenol and [MEDICATION NAME] were given for pain relief, not much relief noted. At 3:22 p.m., the resident's nurse documented the resident had complained of pain when she arrived on shift. Tylenol had been given at 6:20 a.m. without adequate relief. It was noted the physician and pharmacy were called in the morning and the resident was given [MEDICATION NAME] 10 mg at 10:00 a.m., when the resident's pain level was ,[DATE]. The resident's as needed [MEDICATION NAME] prescription was unavailable to the resident after the 4:10 p.m. dose on [DATE] until the 10:00 a.m. dose on [DATE], which was a 15 hour time span without any [MEDICATION NAME]. Nursing progress notes showed the residen't pain was unrelieved during that time. At 11:20 p.m., it was documented that the resident had complained of increased leg/back pain during the shift and the resident's wound was cultured on [DATE]. On [DATE], progress notes indicated the resident's dressing had drainage soaking through. The wound remained opened, was red around edges and the drainage was yellow and bloody. The physician who had ordered the wound culture called to have the resident admitted to the hospital as the wound culture showed it was infected and the resident required immediate surgery. The resident's as needed [MEDICATION NAME] was unavailable to the resident as the wound was becoming infected and increasing in pain. On [DATE] at 1:07 p.m., when asked how the facility ensured a resident's pain medication did not run out, LN C, a care manager, stated, The nurses are supposed to be looking at that. If the weekend is coming up, nurses should be ordering the medication two to three days ahead of time. At 1:13 p.m., when asked about what had happened with Resident #158's [MEDICATION NAME] prescription, LN C stated, I don't know what was in their head. I wasn't here. LN C stated, If you know your resident is taking their PRN regularly, I expect nurses to be paying attention to that and reorder the medication. When I came back on Monday I found this out. That's when crap hit the fan. The resident was given [MEDICATION NAME] and Tylenol on [DATE] and [DATE], with little relief noted, when the resident's prescription of [MEDICATION NAME] and the facility's emergency kit of [MEDICATION NAME] had been depleted. On [DATE] at 3:15 p.m., the DNS stated, The nurse could have called the doctor and requested an order for [REDACTED]. On [DATE], according to facility investigation documentation, Resident #158 experienced another incident of unmanaged pain. On [DATE] at 1:00 a.m., the LN working on the South wing received a telephone call from Resident #158 who stated she was in severe pain and had been waiting for an hour and hadn't received medication. According to the South wing LN's statement, the LN called the North wing on the intercom and relayed the information to LN J. At 1:30 a.m., Resident #158 called again and told the South wing LN she still had not received her medication and her pain was severe. The South wing LN went over to the North wing to make sure the medication was given to Resident #158 and LN J was just getting it prepared. The South wing LN's statement indicated, There were no physical injuries just psychological due to the unrelieved pain. On [DATE] at 1:15 p.m., when asked how long a resident would reasonably be expected to wait after requesting pain medication, LN C stated, I would hope they could get it to the resident within 10 minutes. 2)Resident # 172 was admitted to facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. A POLST (physician orders [REDACTED]. on [DATE]. The resident was working with therapies and was expected to discharge soon. A progress note, dated [DATE] at 12:26 p.m., documented Licensed Nurse (LN) D went into Resident #172's room on [DATE] at approximately 8:15 a.m. to give him his morning medications. When the LN did not see the resident, she entered the resident's bathroom and found the resident face down on the floor. When the LN turned him over, the LN found the resident with no respirations, no pulse and purple in color. The physician was phoned and an order was given to call 911 to transport the resident to the emergency department. When the paramedics arrived they did an EKG and determined the resident was not able to be resuscitated. On [DATE] at 11:21 a.m., LN D stated, He was alert and very private and didn't like to be bothered. He liked the door shut. I don't know when he was last seen before I went looking for him and found him. At 11:41 a.m., the Director of Nursing Services (DNS) stated, When I did my investigation, I determined the day shift nurse did not see him until 8:,[DATE]:15 a.m. and the night shift nurse said he saw the resident on [DATE] when resident's medications were given. Review of the resident's In Room Care Plan, dated [DATE], showed an intervention to Supervise resident carefully. On [DATE] at 12:42 p.m., Nursing Assistant (NA) B stated, I check on them at the beginning of the shift and end of shift or when the call light comes on. At 12:45 p.m., when asked what the expectation of staff checking on residents, LN C, a Care Manager stated, It depends on the resident. I would expect them to come on and do rounds and then every couple of hours during the shift. At 12:49 p.m., when asked how often she expected staff to see residents, the DNS stated, Per the standard of practice, every two hours, unless a resident requested otherwise and then we would care plan it. At 4:30 p.m., when the DNS was asked about her expectations for a resident who was care planned to be closely supervised, the DNS stated, I would expect they would be supervised. When asked if a resident could be closely supervised with the door closed, the DNS replied, No. <Statements from staff> Review of a statement, dated [DATE], from NA A, showed the NA started safety checks on [DATE] at 10:00 p.m. and reached Resident #172's room at 10:20 p.m. The statement documented the door was closed and resident was okay. A Statement written by NA B, dated [DATE], documented she had not seen Resident #172 on the morning of [DATE] and assumed he was in the dining room. A Statement written by LN E, dated [DATE], documented LN E gave the resident evening medications on [DATE] and did not see the resident again during the shift. According to documentation in the resident's medical chart and statements from staff, the resident was not seen or checked on by staff for nearly 10 hours on [DATE] until the morning of [DATE] when the resident was found deceased in his room. The facility failed to monitor the resident closely and did not provide care per the standards of practice. 3)Resident #162 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The residents MDS, dated [DATE] documented the resident was cognitively intact and required the assistance of one person with most activities of daily living (ADLs). On [DATE] at 2:34 p.m., a family member indicated there was a concern about facility staff not following the correct weight bearing instructions for Resident #162 following her hip surgery. The family member described the resident wasn't supposed to put much weight on her right leg yet the facility directed Resident #162 that it was the left leg she shouldn't put much weight on. The family member stated her mom had a lot of pain to the right leg and continues to have pain in that leg. Review of the hospital discharge orders, dated [DATE], showed the resident was to be toe-touch weight bearing (TTWB) to the left lower extremity (LLE) and could weight bear as tolerated (WBAT) to the right lower extremity. Review of the hospital notes found in Resident #162's facility medical chart, documented right acetabulum fracture, right sacral fracture, and right pubic ramus fracture throughout. The notes also document the resident's weight bearing orders at the hospital were TTWB to the RLE and WBAT to the LLE, which contradicted the hospital discharge orders. A Physician's Telephone Order, dated [DATE] at 7:00 p.m., clarified the confusion regarding the weight bearing orders received from the hospital and documented 1) clarify weight bearing restrictions to read TTWB RLE and WBAT LLE. 2) D/C (discontinue) WB restrictions of TTWB LLE; WBAT RLE. A History and Physical, dated [DATE], and signed by the orthopedic physician documented, Therapeutic recommendations from the orthopedic surgeons at (the hospital) were for non-operative management of the right acetabular, right pubic ramus, and right sacral fractures but interestingly they wrote in the management recommendations toe-touch weight bearing left lower extremity and weight bearing as tolerated right lower extremity. Unfortunately, this is the opposite of what should have been done based on the side the fractures were on and it was followed to the letter in the current care facility that she is in so she has been unable to walk or do anything for a while because they have been forcing her to be toe touch on the left side which is uninjured. On [DATE] at 3:13 p.m., the Director of Rehabilitation (DOR) stated, We went by the hospital orders, and those were the weight bearing restrictions that therapy staff used during all her occupational and physical therapy sessions. The DOR stated therapy staff thought the resident's fractures were in the left hip area and thus did not question the weight bearing instructions. The DOR stated the therapy department never received notification there had been new clarifying orders on [DATE] regarding the resident's weight bearing restrictions. Review of the Physical Therapy and Occupational Therapy Treatment Encounter Notes, from [DATE] to [DATE] documented ongoing pain to the resident's right extremity. At 3:57 p.m., LN C stated there was confusion regarding Resident #162's weight bearing restrictions when she was first admitted to the facility. LN C stated the nursing department noticed the confusion with the orders from the hospital and got the orders clarified. LN C stated the therapy department was verbally told about the order clarification and stated the therapy department is supposed to review the residents chart for new orders. The facility failed to follow the clarified weight bearing restrictions for Resident #162's right [MEDICAL CONDITION]. This placed the resident at risk for experiencing delayed healing of the fractures as well as increased pain levels.

Based on observation, interview, and record review it was determined that the facility failed to implement interventions to reduce hazards and risk for 5 of 7 current sampled residents (Resident #49, 107, 124, 151, and 182) reviewed for accidents and supervision. This failure caused harm to Resident #151 when the resident had 31 falls over a four month period, including one fall which caused a laceration to the resident's head. These failures placed all residents at risk for further harm and injury. Findings include: 1) Resident #151 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of Resident #151's preliminary care plan, dated 9/11/15, showed documentation that the resident was at high risk for falls. Care plan interventions included one on one supervision as needed and to keep in staff sight as able, when increased restlessness or anxiety occurred. Between 9/12/15 to 1/9/16, the resident's record documented 31 falls, with at least six injuries including a head laceration, deep skin tears, large bruises on his body, and multiple falls on the head and complaints of pain to his elbow. The record also indicated that at least three of these falls happened while the resident was on one on one supervision by a staff member. On 1/5/16 at 2:38 p.m., while the surveyor was in Resident #151's room, the resident was observed to be leaning over the side of his bed. The surveyor stopped to see what the resident was doing and at that point the resident began to fall out of bed. The surveyor put one hand on his right shoulder, catching him to prevent him from falling out of bed completely and striking his head. Resident #151's head was inches from the hard floor when the surveyor was able to activate the resident's call light which had been out of reach and underneath the resident's bed. This surveyor called, NURSE, NURSE and waited approximately one minute. No nurse responded to this surveyor's call for assistance, so this surveyor called NURSE again. No staff responded. After a few moments, the Social Services Assistant SSA walked by the resident's room and this surveyor called to her for assistance. The SSA took over and repositioned the resident. The SSA stated, Oh my god, oh my god, then thanked this surveyor that she prevented the resident's fall. As the surveyor left the resident's room, approximately two minutes after the incident, three staff were osberved standing two doors down at the medication cart and another two-three were observed standing at the nurse's station. None had responded to the call for help. Another surveyor was at the nurse's station and indicated that she heard this surveyor calling out nurse and was observing staff and their response but did not know it was a fell ow surveyor calling out nurse. The surveyor at the nurse's station indicated she did not see any nursing staff attempt to respond to the call for help. Following this incident, Nursing Assistant (NA) P was interviewed and indicated that Resident #151 has a history of falls and that they are doing the best they can. On 1/10/16 at 12:49 a.m., during a night observation, Resident #151 was observed to be up in bed leaning over the side of his bed shouting out his first name. LN E was observed to walk past the resident's room without stopping or slowing down to visually observe the resident in his bed to see if the resident required repositioning or had other needs. At 12:54 a.m., NA H was observed to walk past Resident #151's room and did not look into his room. NA H was observed to walk past Resident's room multiple times in a 15 minute time period and did not look into the resident's room or assess his positioning or safety. At 1:17 a.m., the resident was observed lying on the edge of his bed. On 1/11/15 at 9:37 a.m., the resident was observed in bed and the grey bedside mat had not been placed on the floor next to his bed as the resident's care plan, dated 1/6/16, had directed staff to do. On 1/12/15 at 11:12 a.m., the resident was observed sitting up in bed and leaning forward, fidgeting with his pants. The grey mat had not been placed. At 11:20 a.m, when the surveyor asked LN F about the resident's mat, the LN stated she was unfamiliar with Resident #151 and wasn't sure if they were supposed to have placed the mats. LN F looked on at the resident's In Room Care Plan and acknowledged the mats should have been put in place as directed. On 1/13/016 at 10:04 a.m., the resident was in bed and the grey mat was observed under the bed. At 10:38 a.m., LN C, a Care Manager was asked about the physician's orders [REDACTED]. LN C acknowledged the order and when she observed the resident in bed without the grey mat, LN C stated, Ah they didn't pull them (mats) out. LN C indicated that it was her expectation to have bedside mats out at resident's bedside per the physician's orders [REDACTED]. Record review of Resident #151's Care Area Aseesment, dated 9/21/15 showed Resident is now a 1:1 at this time. Resident is a new admit; this may contribute to behaviors. <Record Review of Progress Notes> On 9/20/15 at 6:08 a.m., Resident agitated over not being able to have a smoke, states if people would just give him a cigarette he would feel better . After (paramedics) assisted with getting him into bed, gave resident Tylenol and then resident ate a sandwich, milk, banana and yogurt. On 11/06/15 at 12:30 a.m., it was documented by the Medical Director (MD), Pt was evaluated by staff and DNS requested no restraints as she felt pt's agitated behavior was related to pain he experienced in being tied to WC (wheelchair). The facility failed to regularly assess the resident for hunger, pain or other causes that could have contributed to the resident's anxiety/agitation and fall risk. Resident has noted injuries with previous falls, complaints of back spasms, headaches, and other complaints of pain. Resident has orders of Tylenol and Ibuprofen only. Medication/Physician order [REDACTED].#151 was ordered multiple antipsychotic drugs including; Ativan (antianxiety drug) 2mg every 8 hours as needed, Haldol (antipsychotic) 1mg two times daily, and Seroquel (antipsychotic) 50mg in the morning and 75mg at bedtime. Side effects of these drugs include restlessness, or the need to keep moving, agitation, anxiety, aggressiveness, anger, dizziness and headache. The facility failed to assess the resident for these side effects and if they contributed to his falls. <Interviews Regarding Interventions> On 1/8/16 at 10:50 a.m., NA R stated Resident #151 was heavy care and assistance. The NA indicated that before the mats were placed the only intervention to reduce falls she was aware of was the safety belt and 1:1 supervision a couple of months ago. The NA indicated the resident could stand up and take a few steps, maybe 4-5, on a good day, to the toilet. At 11:11 a.m., LN K stated she was familiar with this resident's care and knew he had fallen recently. The LN indicated the resident could undo his safety belt and stated she had requested physician for the floor mats to be placed, three days prior on 1/5/16. The LN also stated it was her expectation that when staff walk down the hall that they will look into the rooms and look in on the residents to assure their safety, not just walk down the hall with their eyes forward. The facility failed to consider environmental hazards, internal needs such as hunger or pain as contributors to the resident's ongoing pattern of falls and accidents and failed to implement aggressive interventions or provide adequate supervision to the resident to prevenr further accidents, injuries and falls for Resident #151. 2) Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's Minimum Data Set (MDS), an assessment tool, dated 12/1/15, the resident required extensive assistance for activities of daily living (ADLs) and was cognitively intact. A nursing progress note, dated 12/18/15, documented the resident had fallen near the nurse's station while walking with her walker. The resident complained of pain to her tail bone area and right knee. A nursing progress note dated 12/20/15 documented the resident had a dark purple bruise on her left buttock and purple bruise on her left knee. Review of the resident's Comprehensive Care Plan showed interventions were not added to the resident's care plan to prevent falls and accidents. A nursing progress note, dated 12/22/15, documented the resident had another fall on 12/22/15 and was found on the floor in her room. The resident stated she stood up from her wheelchair, took a few steps, reached for her water, and tipped over backwards landing on her bottom. Following the resident's second fall, the facility failed to implement a care plan to prevent falls and accidents. The resident's comprehensive care plan did not include interventions to prevent falls until 1/7/16, when the surveyor asked Licensed Nurse A where the resident's interventions could be found. 3)Resident #124 was admitted to the facility on [DATE] and according to the resident's MDS, dated [DATE], the resident required supervision with ADLS and was moderately cognitively impaired. On 1/4/16 at 4:10 p.m., LN A stated the resident had fallen once during the previous month which resulted in a fractured wrist. Review of the resident's medical record showed the resident had three falls between December and January. Following Resident #124's December falls, the alert charting/MACC form contained a note to consider referring the resident to therapy. On 1/11/16 at 4:24 p.m., Therapy Staff (TS) A stated a therapy referral from nursing was received on 1/6/16 and said, I did not get any referrals in December for her. On 1/11/16 at 3:39 p.m., LN B, the resident's Care Manager, stated she usually only updated Comprehensive Care Plans on a quarterly or annual basis and indicated she had not updated Resident #124's Care Plan following the three falls. <Unsecured Oxygen Tank> 4) On 1/10/16 at 12:25 a.m., an unsecured oxygen tank was observed laying on its side under a chair in Resident #182's room. The oxygen tank was not in a holder to prevent it from being kicked or bumped. At 12:46 a.m., LN E stated, We normally keep those in a cart. That is a very sloppy way to keep it. When asked if the tank had oxygen in it, LN E applied a regulator to the tank and turned the tank on. The tank made a loud hissing sound and LN E stated, Yes it is full. LN E stated, I agree that it should be secured for safety. On 1/11/16 at 3:49 p.m. the Administrator (ADM) stated no one knows anything about those oxygen tanks. The ADM indicated the facility uses oxygen concentrator machines and liquid oxygen which is kept in a different type of container. The ADM stated the tanks were likely delivered by Resident #182's Hospice Services.

Based on observation, interview and record review it was determined the facility failed to ensure residents did not receive unnecessary medications and medications given were adequately monitored for 4 out of 6 current sampled residents (#151,49, 83,124) reviewed for unnecessary medications. This failure harmed resident #151 when the resident received duplicative therapies and excessive doses of sedatives which contributed to multiple falls with injury and a decline in the resident's ability to walk and feed himself. Other residents were at risk of receiving unnecessary medications due to a lack of behavior monitoring. Finding include: 1)Resident #151 is an [AGE] year old male with multiple [DIAGNOSES REDACTED]. Resident #151 was admitted on [DATE]. The resident's preliminary care plan, dated 09/11/2015, gave the resident the high fall risk score. Resident #151's care plan indicated the resident's behaviors would be monitored using a log kept at the nurses station. The resident's care plan directed staff to apply a nicotine patch per MD orders to help decrease withdrawal related anxiety. Throughout the survey period Resident #151 appeared lethargic and over medicated. Surveyors had multiple observations of the resident in his wheelchair unable to sit upright and slumped over. The resident was also observed to be unable to feed himself and in his bed asleep for extended periods of time during daylight hours (01/08/2015 11:32a.m- at least 1:50p.m.). There was no documented clinical rational for the resident's posture or why he was slumped over forward and unable to sit up straight. Record review indicated that on 09/11/2015 the resident frequently transferred himself from the bed and walked into the hallway, and on 09/12/2015 the resident came out into the hallway unassisted and walked. Resident #151's record further indicated the resident was able to self-ambulate in hallways twice this shift but was easily redirected to sit in w/c (wheelchair) and ask for help. On 01/08/2016 at 10:50 a.m., Nursing Assistant (NA) R indicated Resident #151 was heavy care and need extensive assistance. NA R indicated the resident could stand up and take a few steps, maybe 4-5 on a good day, to the toilet. The medications the resident was prescribed put him at increased risk for accidents, including falls and injuries. Between 09/12/2015 and 01/09/2016, Resident #151's record reflected 31 falls, with at least six injuries; the injuries included a [MEDICAL CONDITION], deep skin tears, large bruises on the body, and multiple falls hitting his head, and complaints of pain to his elbow. The record also indicated at least three of these falls happened while the resident was on a 1:1 supervision provided by a staff member. The facility failed to reevaluate the resident and the indications for use or continued use for [MEDICAL CONDITION] medications, and the possibility of adverse consequences of the medications including a new, persistent, or recurrent symptom, and evidence of extrapyramidal symptoms (EPS) (described as drug induced movement disorders including muscle spasms, restlessness, and rigidity). <Excessive dose; including duplicate therapy> Resident #151 was prescribed four different [MEDICAL CONDITION] medications (ABHR cream ([MEDICATION NAME]), [MEDICATION NAME], and [MEDICATION NAME]) over the course of a week (09/13/2015-09/19/2015); these drug doses have since been increased. Two of the medications contained the same drug (ABHR cream and a separate order for [MEDICATION NAME] 1mg increased to 2mg). Duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. The facility failed to give clinical rational for the duplicate therapy of [MEDICATION NAME] ([MEDICATION NAME]). Resident #151's orders well exceeded the threshold of 1mg per day per the Center for Medicaid and Medicare (CMS) precautions for the daily threshold for [MEDICATION NAME] ([MEDICATION NAME]). <Without adequate monitoring/Indications for use> Record review indicates the pharmacist (PH) reviewed Resident #151's medications monthly and on 10/13/2015 sent a formal citation form to the Medical Director (MD) indicating, Possible duplication of therapy for antipsychotic type medication. The PH recommended additional documentation to support the use of multiple antipsychotics. The MD's answer back to the Pharmacist's recommendation was Pt is stable on dual meds, dated 10/15/2015. The facility failed to give clinical rational for the duplicate therapy of [MEDICATION NAME] and [MEDICATION NAME]. Duplicate therapy is generally not indicated, unless current clinical standards of practice and documented clinical rationale confirm the benefits of multiple medications from the same class or with similar therapeutic effects. There is a Black box warning for [MEDICATION NAME] (Rx) Increased mortality in elderly patients with dementia-related [MEDICAL CONDITION], Dementia, affect, orientation, LOC, reflexes, gait, coordination, sleep pattern disturbances, risk for death in dementia-related [MEDICAL CONDITION]. (p618)(Linda Skidmore-Roth, RN, MSN, NP (2014), Mosby's 2014 Nursing Drug Reference). There is a Black box warning for [MEDICATION NAME]: Increased mortality in elderly patients with dementia related [MEDICAL CONDITION]. Mental status before initial administration, AIMS assessment; affect, orientation, LOC, reflexes, gait, coordination, sleep pattern disturbances; suicidal thoughts/behaviors (child/young adult); dementia (geriatric patients). (p1023) (Linda Skidmore-Roth, RN, MSN, NP (2014), Mosby's 2014 Nursing Drug Reference). On 01/12/2016 at 11:59 a.m., the Pharmacist (PH) indicated in the instance of a black box warning he would put this information into a formal citation form; such as the one that was in the resident's chart and bring this to the Medical Director's (MD) attention. The PH further indicated that he first went after the duplication of therapy. The PH indicated that he would expect to see that the MD would follow up by the next visit and if was not dealt with that he would repeat it with a duplicate recommendation. The facility failed to follow up on the pharmacist's recommendation of additional documentation for the duplication of medication, furthermore, the facility failed to follow up on the black box warning for [MEDICATION NAME] and [MEDICATION NAME]. A progress note, dated 11/04/2015, from the MD documented Pt (patient) continues to be a psychological problem despite increased med doses and addition of [MEDICATION NAME] 2 weeks ago and increase from BID (twice daily) to TID (three times daily). Staff suspects he acts out due to pain issues/not feeling well. A progress note, dated 11/06/15, the MD documented, Pt was evaluated by staff and DNS requested no restraints as she felt pt's agitated behavior was related to pain he experienced in being tied to WC (wheelchair). Pt [MEDICAL CONDITION] and agitation has not differed from his initial admission except he is better controlled on current meds and less verbally abusive and less uncooperative to staff. Plan: we will try 24-48 hr without belt and monitor, continue same meds despite supervisor requesting alteration or decrease. The facility failed to assess the resident for pain or other causes of anxiety and agitation. Resident had noted injuries with previous falls, complaints of back spasms, headaches, and other complaints of pain. Resident had orders for Tylenol and [MEDICATION NAME]. Documentation did not show a stronger pain medication had been trialed. A Physician Fax form, dated 11/5/15 from Licensed Nurse (LN Q), documented Situation: We would like to try to wean Resident #151 off of so much antipsychotic medication. Background: Was taking [MEDICATION NAME] 75mg Q Am and PM and [MEDICATION NAME] 1mg TID. Could we please add [MEDICATION NAME] to stabilize mood? (MD response- NO) Decrease [MEDICATION NAME] back to 75mg Qam and PM? (MD response- NO) Could we please add Tylenol 650 PO BID Routinely? He won't ask for pain medication. (MD response- OK DONE) PT eval and treat as appropriate for strengthening (MD response- YES) The facility failed to assess the resident and appropriately evaluate the mental, physical, psychosocial and functional status of the resident, and failed to assess the possibility of a different medication that would have a better effect for the resident's needs. Record review indicates Resident #151 had a Pre-Admission Screening and Resident Review (PASRR) Level II done on 10/26/2015. The PASRR indicated service needs for the resident are that Cascade Behavioral Health or another mental health agency follows through with an intake as Resident is having complex mental health symptoms that need to be evaluated by a psychiatric prescriber. The PASRR indicated the Resident's [MEDICATION NAME] 1mg BID (twice a day) was to be discontinued on 11/07/2015. Record review indicates a referral from facility to Cascade Mental Health on 10/27/2015 in which Resident #151 was denied services. No other referrals for mental health services were found in record. The facility failed to continue to refer the resident to another mental health agency or seek a psychiatric prescriber. The facility also failed to follow the PASRR suggestions of discontinuing the [MEDICATION NAME] on 11/07/2015. The facility failed to have a behavior log for September, December, and January per the resident's care plan. The facility failed to adequately track and assess the Resident's behavior and ongoing need for [MEDICAL CONDITION] medications. Record review of the resident's Behavior Monitoring Logs indicate for the month of October 2015 there were behaviors listed for the dates of 10/16, 10/21, 10/23, 10/24, 10/25, 10/26 and 10/31, for November 2015 there was behavior only listed for 11/13 and there are no behavior logs available for December 2015 or January 2016. <Blood Pressure Monitoring> Record review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. Hold for SBP (systolic blood pressure) less than 110 or DBP (diastolic) less than 60. On the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. On 01/13/2016 at 10:12 a.m., LN F indicated she begins morning medication administration at approximately 6:45a.m. and is finished by 9:00-9:45a.m. The LN F indicated that on 01/09/2016 the Resident's blood pressure was 88/53 at 9:00am, 93/64 at 9:30a.m, 131/63 at 10:00a.m. LN F indicated that she had administered all of Resident #151's medications by 9:30am. The facility failed to follow the physician's orders [REDACTED]. 2) Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the resident's MDS, dated [DATE], the resident was cognitively intact and required extensive assistance with activities of daily living (ADLs.) Review of the resident's Medication Administration Record [REDACTED]. On 1/12/16 at 11:26 a.m., when Licensed Nurse (LN) A was asked about the facility's policy for administering and managing as needed anxiety medication, the LN stated when an as needed medication is given, the nurses should be documenting the behaviors on behavior logs and documenting the effectiveness of the medication on the resident's MAR. LN A stated, That information needs to be documented so it can be sent to the doctor. Review of the resident's January MAR indicated [REDACTED]. At 11:30 a.m., when asked if non-medication interventions were offered and/or provided to Resident #49, LN A stated, She started smoking and she is having a hard time complying with the smoking policy. When asked if smoking was the resident's non-medication intervention, LN A stated, That is one of them. The LN stated the resident wanted to get an I-pad and if she did, the LN would encourage her to play games on it. Resident #49's Behavior Logs were reviewed during the time the resident was receiving the maximum ordered amount of as needed antianxiety medication on most days. The review showed the November and January behavior logs were blank and the December log had a few entries. On 1/12/16 at 11:33 a.m., LN A stated, We need to get that behavior monitoring going. I told them we can't get help with the behaviors if they don't fill the logs out. 3) Resident #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively impaired and required supervision with ADLs. Review of the resident's MAR indicated [REDACTED]. The resident's behavior monitoring log was reviewed and was found to be blank and lacking documentation of the resident's problematic behaviors for the months of November, December and January. On 1/13/16 at 4:22 p.m., the Administrator stated, We know we have a problem with behavior monitoring. 4) Resident #124 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the resident's MAR indicated [REDACTED]. Review of an Interdisciplinary [MEDICAL CONDITION] Drug Review on 12/23/15 showed the recommendation was documented as No changes to the resident's medication regimen. However, on 1/2/16, the resident was started on [MEDICATION NAME], an antipsychotic medication. On 1/11/16 at 3:39 p.m., when LN B was asked about the reason Resident #124 was started on [MEDICATION NAME], the LN stated the doctor prescribed it for an escalation in paranoid behaviors. LN B acknowledged the resident's behavior monitoring logs were mostly blank and said, We should be using those sheets. LN B continued, We told the doctor we didn't think the [MEDICATION NAME] was helping her after several days on the initial dose, and we weren't sure she needed it, but the doctor said to increase it. On 1/13 at 5:10 p.m., the DNS stated, The resident's behavior changed after she fractured her wrist in December. .

br>Based on interview, record review and observations, the facility failed to provide food to 1 of 1 residents, Resident #1, after a disagreement with staff regarding needed personal care. Resident #1 refused his dinner tray because he required incontinent care. When incontinent care was actually provided, the resident was told there was no food available. The failure to ensure that the facility had food available when it was well known that Resident #1 only refused his meal because of personal needs not being met, was determined to be an act of reprisal for earlier demands made by the resident. Findings: Resident #1 has been a resident of the facility since 2013. He was admitted for long term care. He was observed on 9/8/15 in his wheelchair, unable to ambulate himself in the wheelchair, sitting in his room with his wife present. According to record review, on 8/25/15, Resident #1, just before dinner, asked to have his brief changed. Resident #1 is a two person transfer with a Hoyer lift. Staff A said she would go find another person to help her transfer him. Staff A consulted a nurse at the desk who told her, according to the investigative interviews, that Resident #1 just wants to go back to bed. Staff A returned and told Resident #1 he would have to wait to get his brief changed and proceeded to push him to the dining room. Resident #1 got upset and told her he was not going to the dining room with a soiled brief, and to take him back to his room. Resident #1 was left in his room during the dinner hour sitting in his soiled brief. He received his dinner tray but refused to eat it because he was still in his soiled brief. After his dinner tray was taken away, and Resident #1 had his brief changed, he asked for food. According to his wife, on 9/8/15, I asked for a snack for him but they said no. According to the investigative report Resident #1 asked for a snack but was not given one as there is no food at this time of night. The facility was well aware that Resident # 1 had not eaten and why. Resident #1 went without food for the night and into the morning.

Based on observation, interview and record review, it was determined the facility failed to implement interventions consistent with the resident's needs and recognized standards of practice, to ensure that a resident without a pressure ulcer did not develop one, and to promote healing when a pressure ulcer did develop, in 1 of 2 current sampled residents (#35) reviewed for pressure ulcers. These failures resulted in the resident developing a painful, unstageable pressure ulcer after admission. Findings include: Resident #35 was admitted in April of 2007 with multiple medical [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS), an assessment tool dated 12/17/14, indicated the resident had severe cognitive impairment, did not exhibit rejection of care, and required extensive assistance of two people with bed mobility and transfers. The resident was frequently incontinent of bladder and bowel. The MDS, dated [DATE], indicated the resident was not at risk for skin breakdown, was on a turning and repositioning program and did not have a pressure relieving device to her bed or wheelchair. <Wound development> On 12/29/14, the facility documented the resident had a 3.5 centimeter (cm) by 3.5 cm purple area with a small intact blister to her coccyx. On 1/21/15, the facility documented the area to the resident's coccyx was open, 4 cm by 3.5 cm, with 20% slough (dead tissue in the process of separating from the viable portions of the body) and a red/purple thick center. <Care & Services> Review of the Pressure Ulcer Care plan, last updated on 1/21/15, directed staff to turn and reposition the resident every 1 hour and keep the resident clean and dry to minimize skin exposure to moisture. Throughout the survey period (multiple days and times), the resident was observed to be sitting up in her wheelchair in the common area as detailed below. Staff were not observed to be frequently repositioning the resident or keeping the resident clean and dry, as outlined in the resident's care plan. On 1/23/15, the resident was observed sitting in her wheelchair in the common area at 9:15 a.m., 9:50 a.m., 10:25 a.m., 11:45 a.m., 12:14 a.m., 12:43 p.m., and was assisted to bed at 2:00 p.m. when the surveyor requested to observe the resident's wound. At 2:10 p.m., observation of the resident's coccyx wound was conducted with Licensed Nurse (LN) D and LN F. Observation revealed an approximately 4 cm x 5 cm tan/white area with black, necrotic (dead) tissue noted on one edge. The entire wound was red on the edges. LN F stated, "it is getting bigger" and described the wound as unstageable (a full thickness wound where the depth of the wound is unable to be visualized due to a layer of dead tissue). Resident #35 was observed to be moaning and crying throughout the dressing change, despite having received pain medication prior. During this observation, the resident's Rojo cushion (special wheel chair cushion that relieves pressure) felt low in air. At 3:00 p.m., LN F examined the resident's Rojo wheelchair cushion with the surveyor. LN F stated, "it does need some air in it." At 3:26 p.m., LN F and LN A indicated they did not know how to determine if the Rojo wheelchair cushion was properly inflated to provide pressure relief. At 3:55 p.m., LN F placed four pumps of air into Resident #35's Rojo wheelchair cushion. On 1/1/15, the resident's physician's assistant (PA) recommended daily monitoring of the wound, an egg-crate foam pad to the chair and bed (for pressure relief) and "frequent position changes (every hour)." On 1/23/15 at 2:10 p.m., observation of the resident's bed found there was no egg crate in place. On 1/26/15 at 3:09 p.m., when questioned about why the egg crate was not applied to the bed, LN F indicated that staff had missed the order. LN F indicated the facility did not use egg-crate and that the 1/1/15 order from the PA should have been clarified to place an air overlay (pressure relieving device) on the mattress instead. The surveyor directly observed Resident #35 from 4:30 p.m. until she was assisted to bed at 9:45 p.m. The resident appeared asleep in her wheelchair for most of the observation period. Staff interaction with the resident during the observation period consisted of Nursing Assistant (NA) A bringing the resident her dinner tray at 5:43 p.m., LN A picking up resident's dinner tray at 6:15 p.m., and NA D attempting to put resident to bed at 8:40 p.m. Resident #35 refused stating, "it is too early." The resident ate all of her dinner, except the roll, and appeared well-nourished. During four hours of observation, between 4:30 p.m. and 8:40 p.m., staff did not reposition Resident #35, assist her to the toilet, or attempt to change her brief. Resident #35 was not observed to independently shift her weight in the wheelchair or reposition. At 9:13 p.m., LN G, the nurse assigned to care for Resident #35, was not aware that resident #35 had any skin issues. At 9:54 p.m., NA A and NA B assisted the resident to bed using a mechanical lift. NA B stated resident #35's usual routine is to go to bed at 9:00 p.m. NA B indicated that they are a little late tonight putting resident #35 to bed because, "we are short-staffed." Observation revealed the resident's brief was saturated with urine. NA B indicated that sometimes the resident's clothes are soaked through, but tonight they were dry. The bandage to the resident's wound was saturated, bunched up, and only covering ½ of the wound bed. The NAs summoned LN F to change the bandage. On 1/24/15 at 7:26 p.m., staff were observed assisting Resident #35 to bed to provide care. Resident #35 was observed to scream, "oh my god, my poor butt! You don't know how that hurts!" when staff transferred her from the wheel chair to the bed. LN J then provided Resident #35 a pain pill. Observation revealed that the resident's brief was saturated, foul-smelling, heavy in weight, and dark in color. NA A indicated the day shift NA told her Resident #35 refused to be changed after lunch, so she hasn't been changed since she got up that morning. LN J stated, "that dressing is just falling off isn't it?" LN J replaced the bandage according to the MD order. Resident #35 cried and moaned throughout the procedure. On 1/26/15 at 11:30 a.m., the Registered Dietician (RD) indicated she saw the resident on 12/23/14 because she had some slow weight loss in December. Interventions at that time included laboratory recommendations (basic metabolic panel), notify the physician, and to encourage increased intake between meals. The RD stated she was not aware the resident had developed a pressure ulcer. The RD indicated she relied on nursing staff to refer residents to her for things like weight loss and skin issues. The RD indicated she would assess the resident right away. On 1/26/15 at 12:35 p.m., the RD documented the resident was eating nutritionally enhanced meals to maximize intake and that her weight has stabilized the past month. Review of the Medication Administration Record [REDACTED]. The facility failed to prevent pressure ulcers from occurring and prevent a current pressure ulcer from getting worse when they did not ensure the resident was frequently repositioned, keep the resident clean and dry, and follow the physician's orders [REDACTED].#35 harm when she developed a painful, unstageable pressure ulcer. .

Based on observation, interview and record review, it was determined the facility failed to ensure 5 of 23 sampled residents (#72, 161, 22, 36 & 35) reviewed for care and services, received ordered medications to relieve chest pain, were monitored and treated for [REDACTED]. These failures resulted in one resident with unrelieved chest pain, one resident with a life threatening infection related to untreated skin problems, and one resident developing medical conditions related to lack of foot care. Findings include: 1) discharged Resident #72 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident was assessed on admission as alert, oriented and made her own care decisions. She wanted all heroic measures implemented to save her life if needed per her signed physician's orders [REDACTED]. A physician's orders [REDACTED]. The progress note dated 11/24/14 indicated the resident started to complain of left-sided chest pain at 4:00 p.m. Her oxygen saturation (reference range on room air 92% to 100%) was critically low at 78% while receiving 3.5 L (Liters) of oxygen via nasal prongs. The resident was short of breath and was given a breathing treatment. The nurse did not give [MEDICATION NAME] for the chest pain. Oxygen saturations remained critically low. The nurse contacted the physician and received orders to send the resident to the hospital for evaluation. Review of the Medication Administration Record [REDACTED]. On 1/28/15, at 1:15 p.m., interview with Licensed Nurse (LN) C who was the nurse on duty at the time the resident experienced the chest pain, was asked why the resident did not receive the ordered [MEDICATION NAME] when she began experiencing chest pain and transferred immediately to the hospital. The LN stated s/he did not remember the resident. S/he reviewed the record and stated the Oxygen was at 3.5 L which "was worrisome because it could cause CO2 (carbon [MEDICATION NAME]) retention in someone with her [MEDICAL CONDITION] that was what the doctor ordered." S/he "wasn't sure why the LN charted the resident was on 2 L of oxygen at 3:00 p.m. other than 2 L is the normal requirement for [MEDICAL CONDITION]." The LN could not explain why the oxygen order was not questioned. The LN found the physician's orders [REDACTED]. When asked if he could read the initials of the nurse on the MAR indicated [REDACTED]. LN C thought maybe it was (named nurse) and stated: "No she is not an RN (Registered Nurse) but if she did the admission assessment, she most likely should have transferred the orders to the MAR." Without transferring the orders to the MAR, nurses were not aware of the [MEDICATION NAME] order and the resident did not receive the necessary medication to help relieve the chest pain. The resident was transferred to the hospital where she passed away. 2) Resident #161 was initially admitted to the facility on [DATE] following a hospitalization due to gangrene of the left foot [MEDICAL CONDITION] (a serious infection which can cause organ damage or death). The resident discharged to the hospital on [DATE] with a foot ulcer and osteo[DIAGNOSES REDACTED] (bone infection) and underwent a toe amputation. When the wound showed signs of necrosis (dead tissue), the resident was admitted to the hospital for a below knee amputation. The resident was readmitted to the facility on [DATE] following the below knee amputation. The resident's [DIAGNOSES REDACTED]. On 11/26/14 Resident #161's lab report showed the resident had an elevated white blood cell (WBC) count indicating the resident was experiencing an infection. The WBC normal reference range is 3.8 to 11.0 and the resident's WBC count was 14. Record review revealed a nursing chart note on 11/28/14 which indicated the resident had been seen by an outside doctor that day regarding his left knee amputation. The nursing note documented Resident #161's spouse arrived at the facility after the appointment and stated the doctor wanted her husband to go to the hospital right away. The wife provided written instructions from the outside doctor to "Have your toe on your right foot looked at immediately. It needs to be addressed because we are concerned that you may lose your toe." Resident #161 was examined at the hospital emergency department and diagnosed with [REDACTED]. "Obvious infection of right great and second toe, some necrotic tissue; patient was started on antibiotics and admitted for further management due to the fact that he is a high risk with a previous left below knee amputation." On 1/28/15 at 10:18 a.m., when asked if she was aware of the reason Resident #161 had been admitted to the hospital on [DATE], LN A stated, "I think he was septic." Record review showed a consultation by a podiatrist during Resident #161's hospital stay. The report documented ulcerations of the second and third toes on the right foot. The notes indicated the resident felt this had occurred due to bumping his foot approximately one week prior and although a nurse at the facility examined it, the nurse did not feel it was problematic. At 12:32 p.m., LN A stated, "I remember when he said that. He reported it." When the surveyor stated there was no record in the chart of the resident bumping his foot, LN A stated, "I know it." When asked how Resident #161's right foot had been monitored, the LN A stated it should have been documented on skin assessment sheets and the Treatment Administration Record (TAR). The LN stated Resident #161 should have had daily charting done. The LN reviewed the resident's November chart notes and was not able to locate any documentation about a concern with the resident's right toes. At 1:53 p.m., LN E provided the resident's skin sheet that indicated a skin problem on the right foot, second toe at knuckle. There was no documentation of the date the skin problem was identified and the section to document if or when the physician was notified was blank. The first two dates on the skin sheet were difficult to read. LN Linda said the dates were 10/31/14 and 11/7/14. On both dates, the skin problem was described as a scab which measured 1 cm x .5 cm and remained the same on 11/14/14. There was no evidence to support that the resident's right foot/toes were assessed by an LN any other time prior to the "out of facility" appointment and being admitted to the hospital on [DATE]. The resident's November TAR documented the skin check on 11/7/14 and 11/14/14 and stated "Resolved." An empty box on 11/21/14 was noted. When LN E was asked if the 11/21/14 skin assessment was missed, the LN stated, "I guess so." At 2:04 p.m., LN A stated "It was missed on the 21st." When asked if Resident #161 had risk factors that warranted the need for a licensed nurse to monitor his feet more than weekly, LN A said "Ya." They (Nursing Assistants) looked at him when they dressed him each day. Failure to notify and consult with the resident's physician given the resident's [DIAGNOSES REDACTED]. 3) Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS), an assessment tool, dated 9/22/14 documented the resident was moderately cognitively impaired and was totally dependent on staff for personal hygiene care. On 1/21/15 at 11:40 a.m., a family member of resident #22 stated, "Last time I was in, I asked LN A to do something with her (Resident #22) toenails." On 1/26/15 at 12:57 p.m., the surveyor asked LN F to examine the resident's toenails. LN F transported Resident #22 to her room and the LN and the surveyor observed the condition of the resident's toe nails. The resident's toe nails were observed to be excessively long, jagged and thick. The right great toe was at least 1/4 inch thick and many of the resident's toenail extended 1/8 inch to ¼ inch past the end of the toe. LN F stated, "Those are pretty long and there may be a fungal disease. She might need to see the podiatrist." At 1:08 p.m., LN A stated a podiatrist visited the facility monthly and residents on the list would be seen by the podiatrist every 2-3 months. At 1:15 pm, LN A reported, "I found the chart (Resident #22's chart) but the consult section was empty." LN A stated she would go to medical records and look for any reports from the consulting podiatrist to see if Resident #22 had ever received foot/toe nail care. At 2:05 p.m., LN A stated she had not located any consult reports from the podiatrist regarding the foot care of Resident #22. At 2:07 p.m., when asked about Resident #22's plan of care, LN A stated the care plan documented the resident's nails should be trimmed as needed. The LN stated the care plans normally say something about the podiatrist but Resident #22's care plan didn't. Record review of the resident's TAR showed nail care had not been included as a task on the Resident #22's TAR. A list of residents who had been seen by the podiatrist for the previous six months was provided by the Social Services Director on 1/27/15. Review of the list showed that resident #22 had not been seen. On 1/28 p.m. at 1:58 p.m., LN A stated, "I trimmed and filed Resident #22's toenails last night. I couldn't do the big ones though." The LN said the resident would need to see the podiatrist for care of the two great toe nails and stated, "I have it on the TAR now for the resident to have her nails trimmed weekly. 4)Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 14-day MDS, dated [DATE], indicated the resident had some cognitive impairment and required two-person extensive assistance with bed mobility, transfers and toilet use. The Fragile Skin Care plan dated 12/22/14 indicated the resident was to wear geri gloves on both arms for protection. The care plan also indicated staff were not to hold on to the resident's hands during transfers due to fragile skin. Staff were to use a gait belt with two person assistance. On 1/22/15 at 11:04 a.m., Resident #36 was observed with bruising and a clear dressing to the back of her left hand. A 1/12/15 progress note, written at 4:37 a.m., documented the resident had a new skin tear. "Caregiver was using resident's hands to bring her to a sitting position." An eight (8) centimeter skin tear was identified across the top of the resident's left hand. Veins and tendons on the back of the resident's left hand were exposed. The area was cleansed with normal saline, the skin flap was replaced over the area, steri strips were applied, covered with [MEDICATION NAME] and secured with [MEDICATION NAME] wrap. At 9:42 a.m., a fax was sent to the doctor indicating the resident had sustained a skin tear to the back of the left hand during a transfer. At 8:30 p.m., a progress note documented, "Changed dressing to hand to [MEDICATION NAME] (clear, adhesive bandage) per (Resident Care Manager)." an order for [REDACTED]. Beginning on 1/12/15, the TAR documented orders to monitor the skin tear to the back of the left hand every shift, chart on skin sheet weekly for skin tear to back of left hand, and change dressing to dorsal of L hand every day. Documentation for monitoring the skin tear was completed nearly every shift since 1/12/15 and an entry had been made on the skin sheet. There were no signatures on the TAR indicating the daily dressing change was completed. On 1/26/15, the Respiratory Flowsheet documented the resident was to wear geri gloves due to fragile skin, often refuses. The record indicated the resident accepted the geri gloves each day beginning 1/14/15-1/26/15 Progress notes dated 1/17/15-1/21/15 documented the dressing to the Right hand skin tear was clean, dry and intact. The resident did not have a skin tear to the right hand during this time period. 01/23/15 3:01 p.m., the resident was observed not wearing geri gloves. On 1/23/15, the physician documented the left dorsal hand with peeling dressing and slight milky drainage, the hand was to be re-dressed with a dry, sterile dressing. A physician order [REDACTED]. A note placed on the TAR on 1/26/15 stated a fax was sent to the physician, "for daily dressing change to left hand, very fragile skin will cause more damage. Has [MEDICATION NAME] now." The TAR had a line drawn from the first of the month through 1/23/14 for the Change dressing to dorsal of left hand every day order. The TAR was not signed to indicate the dressing change had been completed since the physician reordered daily dressing changes. On 1/26/15 at 12:12 p.m., the resident was observed with a clear adhesive wound dressing, the edges of the dressing were dried and rolling. A date was not observed to indicate placement date. The resident was not wearing geri gloves. On 1/27/14 at 1:32 p.m., the resident was observed with a clear, adhesive wound dressing. The edges of the dressing were dried and rolling. A date to indicate when the dressing was placed was not observed. The resident was not wearing geri gloves. On 1/28/15 at 1:38 p.m., the Director of Nursing Services (DNS) was interviewed regarding the resident's skin tear orders. The DNS stated she would look for clarification of the orders and see what care was being provided. No further information was provided by the facility. 5)Resident #35 was admitted in 2007 with multiple medical [DIAGNOSES REDACTED]. The resident developed a pressure ulcer on 12/29/14. On 1/1/15, the physician's assistant (PA) ordered, "add egg-crate foam pad to chair and bed." The order was noted by facility staff on 1/1/15. On 1/23/15 at 2:10 p.m., the resident was observed to have a standard facility mattress. The resident had a Rojo cushion (specialized pressure relieving cushion) in place to her wheelchair. On 1/26/15 at 3:09 p.m., LN F indicated the order for "egg-crate" to the bed and wheelchair should have clarified because the facility does not use egg-crate. LN F stated, "I will see if I can get an air-overlay (alternating air-pressure mattress cover) ordered instead of the egg-crate." On 1/8/15, the physician's assistant (PA) ordered a [MEDICAL CONDITION] Stimulating Hormone (TSH) blood test to be obtained. The order was noted by facility staff on 1/10/15. A Progress Note, dated 1/26/15 at 12:35 p.m., created by the registered dietician, documented, "note MD ordered TSH (laboratory test of [MEDICAL CONDITION] function) to be drawn 1/2/15 but note no results in chart." On 1/27/15 at 9:51 a.m., LN F indicated the results from the TSH blood work requested by the PA on 1/8/15, were not available. LN F indicated, "I guess we missed it." The TSH test was obtained on 1/28/15, twenty days after the PA had requested it. On 1/27/15 at 9:45 a.m., record review showed that only page 2 of laboratory (lab) results drawn on 1/23/14 (complete metabolic panel and complete blood count) was available in the medical record. The first page of the results was not available in the medical record. At 10:03 a.m., LN F indicated that the process for identifying and carrying out physician's orders [REDACTED]. At 10:20 a.m., LN F presented the fax sent to the physician regarding the lab results. The fax contained only page 2 of the lab results. LN F then accessed the lab system and printed out page 1. Page 1 included fourteen results that were out of range, including the potassium and chloride levels. LN F indicated she would fax both pages to the physician right away. LN F indicated the facility had recently switched the way they receive the lab results and that the nurse must have missed printing page 1. LN F agreed the nurses need more education regarding the new lab system. .

Based on interview and record review, it was determined the facility failed to ensure 1 of 5 current sampled residents (#161) reviewed for nutrition, received necessary nutritional care and services. This failure contributed to an unplanned 19 pound weight loss during a two week period and placed the resident at risk for a decline and potential complications with multiple medical diagnoses. Findings include: Resident #161 was initially admitted to the facility on [DATE] following a hospitalization due to gangrene of the left foot [MEDICAL CONDITION] (a serious infection which can cause organ damage or death). The resident discharged to the hospital on [DATE] with a foot ulcer and osteo[DIAGNOSES REDACTED] (bone infection) and underwent a toe amputation. When the wound showed signs of necrosis (dead tissue), the resident was as admitted to the hospital for a [MEDICAL CONDITION]. The resident was readmitted to the facility on [DATE] following the below knee amputation. The resident's [DIAGNOSES REDACTED]. Resident #161's medical record indicated a Registered Dietician (RD) assessed the resident on 11/04/14 during a routine readmission nutritional evaluaion. At that time, the nutritional interventions included: Encourage PO (eating by mouth) and a weight goal to maintain 201 lbs + or - 5%. Nutrition monitoring: weights. The facility's policy titled "Weight Monitoring and Documentation" stated admission/readmission weights were to be obtained within 24 hours and re-weighs would be obtained within 24 hours if a weight variance of + or - 3 pounds occured. Prior to the below knee amputation, the resident's weight was 221 pounds. The first documented weight after readmission was 202 pounds on 10/31/14, which accounted for the weight loss due to amputation. On 11/06/14, records show the resident weighed 200 pounds. On 11/11/14, the resident weighed 186 pounds. The resident was re-weighed on 11/12/14 and was 183 pounds. Record review showed the routine readmission nutritional assessment on 11/4/14 occurred before the 19 pound weight loss and the RD had access to one weight taken on 10/31/14 which was 202 pounds. On 1/27/15 at 1:10 p.m., the Registered Dietician (RD) confirmed she assessed the resident on 11/4/14 after readmission from the hospital. The surveyor and RD reviewed the resident's weights and discovered a 19 pound weight loss between 10/31/14 to 11/12/14. The RD stated she had not been notified of the 19 pound weight loss or asked by nursing to assess the resident during that time. The RD stated if she had known about the resident's 19 pound weight loss, she likely would have recommended nutritional interventions for Resident #161. The RD referred to the facility's weekly "weight" meeting when residents are reviewed for nutritional risks. The RD directed the surveyor to contact the Director of Nursing Services (DNS) to see if Resident #161 had been discussed at the meetings. At 1:15 p.m., the DNS reviewed notes from November weight meetings and stated, "I don't see anything about him. I will see what I can find for you." At 1:56 p.m. the DNS said, "I don't see that we addressed that situation." At 4:05 p.m., Licensed Nurse (LN) A stated, "The nursing assistants and nurses should have alerted me to the weight loss and I should have caught it myself as well. LN A stated if a three pound weight loss occurred, the aides should have weighed the resident for 3 days in a row to determine accuracy of the weights. LN A stated, "I asked the aides about it and they said they thought the weight difference was from the wheelchair. No matter what, it's wrong. I should have caught it." When asked how often LN A reviewed resident's weights, LN A stated she reviewed weights about once a month. The facility provided information to the survey team on January 30, 2015 indicating fluid retention and implementation of an indwelling catheter may have contributed to the resident's weight loss. Review of nursing chart notes showed documentation on 10/29, 10/30 and 10/31/14 that stated, "No [MEDICAL CONDITION]." Chart notes did not indicate [MEDICAL CONDITION] or concerns with [MEDICAL CONDITION] between 10/28/14 to 11/12/14, during the two week period of weight loss. Documentation showed the indwelling catheter was placed within several hours after the resident was reamitted to the facility on [DATE]. Resident #161, with multiple serious [DIAGNOSES REDACTED]. .

Based on interview and record review it was determined the facility failed to implement policies and procedures and monitor for compliance to prohibit the use of personal cell phones during work time, in the work place and in areas where resident care is provided. This failure allowed staff to photograph, video record and electronically send Resident #1's image while undressed and on a toilet. This failure placed all residents at risk for harm and caused Resident #1 to be abused. Findings include: All interviews took place on 2/12/14 unless otherwise indicated. According to facility policy, Section 8.12 ; Personal Cell Phones, Use of Telephones, Equipment and Supplies, "Personal cell phones are to be turned off during working hours and may be used during rest and meal breaks only." Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 required two staff persons for transfers and toileting. On 2/7/13 at approximately 8:30-9 am, while working in the facility, Nursing Assistant (NA) C, received notification on her smart phone (personal electronic device that can make phones calls, videos, pictures, access the internet) of a SnapChat (a smart phone application that can send a message, picture or video that can be viewed for a set amount of time designated by the sender that will delete after the determined time via a social media site) video recording sent by NA A who was working in the facility on the opposite side of the building. The silent video recording was Resident #1, her face visible while sitting on a bedside commode (a portable toilet), with pants below her knees, legs spread and cleaning herself in the front private area while laughing/singing. NA D was shown the video by NA C. NA C stated she showed the video to NA D because she was so shocked and knew it was inappropriate. NA C, a mandated reporter, knew the video recording of a resident was a reportable incident. NA C stated she texted NA A she needed to speak with her regarding NA A actions. NA A replied via text that she understood and it was her fault because she had taken the video (NA B was suspended because she was in the room with NA A when Resident #1 was videoed was recorded). NA D stated she was shocked when she saw the SnapChat video of Resident #1, but cell phone/electronic device use had been going on in the facility for an extended time. NA D stated there was a picture of Resident #10 with NA B and NA E taken with a cell phone that was hanging in Resident #10's room. Housekeeping Staff (HS) A stated several nursing staff had been using their personal phones/electronic devices during their shifts, while residents were in the immediate area. HS A described NA A taking "selfies" (a picture taken of one's self ) in the dining room while residents were present. HS A stated she approached NA A regarding her cell phone use, but was dismissed. HS A stated even Licensed Nurses (LN)s use their phones during their shifts, stating weekends are particularly bad because upper management is not around. HS B stated staff are not to use their personal electronic devices/phones but it has been happening for some time. HS B has seen nursing staff take pictures of themselves and texting while in resident rooms, but was not aware if there were residents in the pictures. NA E had been aware of NA A taking the video recording of Resident #1, and that NA B was in the room with NA A when it occurred after it was reported by NA C to administration. NA E stated a large number of staff had been using their phones during their shifts. NA staff had complained about Licensed Nursing staff using their phones and having to wait for nursing services to be provided until they finished texting/playing games on their cell phone/electronic device. NA E stated LN A frequently played a game on her cell phone and care and services were delayed until she completed her game. NA E said it was unfair, because the NAs were dismissed when they attempted to address the issue with LN A. SSD stated cell phone/electronic device use had been an ongoing problem in the facility and was aware of LN A's playing games on her cell phone during her shift. NA D stated since the incident involving Resident #1, the NAs had not been using their phones, but the LNs were allowed to continue using their phones as well as management. NA D stated "it doesn't set a very good example." The ADM stated the facility was aware the night shift staff had been using their personal phones to text (message) each other for assistance or to let others know their whereabouts but it would need to be reviewed after the incident with Resident #1, and during the current facility investigation it had come to their attention several LNs were not using their cell phones/smart phones according to policy. The Director of Nursing (DNS) and Administrator (ADM) stated the facility policy regarding cell phones/personal electronic device use during approved times had been very difficult to enforce and the corporate policy was very vague, and needed to be changed. Refer to F-tag 223 .

Based on interview and observation, the facility failed to ensure residents were not subjected to willful abuse from facility staff for 1 of 10 (Resident #1) residents reviewed for abuse. Failure to recognize continued facility employee use of personal electronic devices in resident care areas allowed electronic sexual exploitation to occur. This failure caused Resident #1 to be abused by staff when she was video recorded in a compromising vulnerable position while toileting and the video was posted to a social media application and viewed by recipient. Failure to prevent unauthorized use of electronic video type recording devices placed residents at risk for abuse/exploitation. Findings include: All interviews took place on 2/12/14 unless otherwise indicated. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Resident #1's Minimum Data Set (MDS) an assessment tool, dated 1/2/14, the resident was dependent for all activities of daily living including two staff for transfers and toileting. On 2/7/13 at approximately 8:30-9 am, while working in the facility, Nursing Assistant (NA) C, received notification on her smart phone ( personal electronic device that can make phone calls, videos, pictures, access the internet) of a SnapChat (a smart phone application that can send a message, picture or video that can be viewed for a set amount of time designated by the sender that will delete after the determined time via a social media site) video recording sent by NA A who was working in the facility on the opposite side of the building. NA C was in a room not occupied by residents with NA D when she viewed the SnapChat video. The silent video recording was of a woman, her face visible while sitting on a bedside commode (a portable toilet), with pants below her knees, legs spread and cleaning herself in the front private area while laughing/singing. NA D was shown the video by NA C. NA D stated that previous to the video recording of Resident #1 she spoke with NA A about not using her smart phone to take pictures and texts because she could get in trouble. NA D stated NA A dismissed her and would not speak to her after she was approached with her concerns. Resident #1 was observed in her room sitting in her wheelchair. Resident #1 had difficulty hearing and understanding the attempted interview and was oriented only to herself. Resident #1 was impulsive while NA F assisted her to get ready for the morning. Resident #1 required cues and prompts from NA F to maintain her dignity/privacy while getting ready for the day. Resident #1 was unable to give any information regarding the incident. NA C stated when she saw the video taken by NA A, she did not know the name of the resident because she did not work on that side of the facility, but knew it was a facility resident. NA C stated she showed the video to NA D because she was so shocked and knew it was inappropriate. NA C, a mandated reporter, knew the video recording of a resident was a reportable incident. NA C stated she texted NA A she needed to speak with her regarding NA A actions. NA C showed the investigator the text conversation between herself and NA A that occurred on 2/7/14 at 12:23 pm and spanned several hours. NA C told NA A she was sorry but she had to report her for the inappropriate video. NA A replied via text that she understood and it was her fault because she had taken the video, and that NA B had been suspended as well because she was in the room with NA A and Resident #1 while the video was recorded. NA D stated she was shocked when NA C showed her the video. She said NA C was horrified and embarrassed by the content of the video and knew it was abuse, and could not believe what her friend (NA A) had done. NA D stated cell phone/electronic device use had been going on in the facility for an extended time. The Director of Nursing (DNS) stated NA A would be terminated for her actions but at the time of the investigation that had not occured, and NA B would be able to return to work with disciplinary action. The DNS and Administrator (ADM) stated the facility policy regarding cell phones/personal electronic device use during approved times had been very difficult to enforce and the corporate policy was very vague, and needed to be changed. Refer to F226 .

Based on observation, interview and record review, the facility failed to provide necessary care and services for 1 of 10 residents (#2) when licensed nurses failed to ensure proper catheter placement. These failure caused harm for Resident #2 when hospitalization was required to drain the bladder. Findings include: <Resident #2 > Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, the Resident was not able to express care needs, did not walk and required supervision of all activities of daily living. The Resident was continent of bowel, but frequently incontinent of bladder. On 04/20/12, an unavoidable skin issue developed on the left buttock. Risks and benefits of catheter placement were discussed with the physician and the family. It was decided that a Foley catheter would be inserted for a short period of time to assist in keeping the wound clean and dry. A Foley catheter is a tube used to drain urine from the bladder. The tube is secured into place with a balloon which is inflated after the catheter is inserted. The balloon is inflated when measures are taken to ensure the catheter has reached the inside of the bladder. On 04/20/12, at 12 noon, a Foley catheter was inserted without difficulty. No mention was made of the size of the catheter or the amount of inflation of the balloon. According to nursing notes, the Resident pulled the catheter out about 2 hours later at 2:00 p.m. The Resident was noted to have some bleeding from the meatus (opening into the urinary tract). The family and physician were notified and a decision was made to leave the catheter out. The Resident urinated a small amount during the evening of 04/20 and during the night shift of 04/21. On 04/21/12, at 3:30 p.m., the Resident was complaining of pain and nurses notes reflected the "bladder area was distended and firm." The physician was notified and orders were received for re-insertion of the catheter. On 04/21/12, nursing notes for the evening shift reflected the catheter was re-inserted. No time was listed. The catheter size was recorded as a #22, but no mention was found regarding the balloon. The catheter was flushed with 500 milliliters (cc) of normal saline, although the physician's orders [REDACTED]. No bleeding was noted during the procedure, no mention was made of whether or not the saline inserted through the catheter was returned. Notes reflected 100 cc of urine was returned later in the shift and noted "Resident possibly retaining urine." No assessment was completed regarding whether the catheter was in place or functioning properly. During the night shift of 04/22, nursing notes reflect the "Catheter was draining with 100 cc blood-tinged urine. Abdomen slightly distended and tender to touch." Notes did not reflect whether the catheter was assessed to be in place. During the day shift of 04/22, nursing notes reflected "30 cc urine in cath {catheter} bag." The Resident's abdomen was assessed to be distended and firm. No mention was made of the placement of the catheter. The Resident was sent to the Emergency department for evaluation of possible [MEDICAL CONDITION]. Emergency department notes reflect "Upon arrival, the nurse noted that the balloon for the Foley could be palpated inside the shaft of penis. The balloon was deflated. The catheter was removed and then reinserted fully into the bladder. At this point, 1800 ml dark urine came out. The patient was having significant blood in the urine at that point. The Foley did remain patent, however, after telephone consultation with urology, the decision was made to admit the patient..." On 05/03/12, the Director of Nursing stated "I was aware of the note from the emergency department regarding the bulb in the catheter being located in the shaft of the penis, I thought the Resident may have dislodged the catheter on the way to the emergency department. I will call the nurse and find out if she instilled 200 cc of saline as the doctor ordered, or 500 cc as she charted."

Based on observation, interview and record review, the facility failed to follow accepted standards of clinical practice for 2 of 10 residents (#2 and #10) when licensed nurses failed to ensure proper catheter placement and failed to remove medication patches as ordered. These failures caused harm for Resident #2 when hospitalization was required to drain the bladder and caused the potential for harm by drug overdose for Resident #10 when new medication patches were applied without removing the old patches. Findings include: Per the American Nurses Association, Scope and Standards of Practice, 2011, " According to standards of care, a licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client 's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. " <Resident #2 > Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, the Resident was not able to express care needs, did not walk and required supervision of all activities of daily living. The Resident was continent of bowel, but frequently incontinent of bladder. On 04/20/12, an unavoidable skin issue developed on the left buttock. Risks and benefits of catheter placement were discussed with the physician and the family. It was decided that a Foley catheter would be inserted for a short period of time to assist in keeping the wound clean and dry. A Foley catheter is a tube used to drain urine from the bladder. The tube is secured into place with a balloon which is inflated after the catheter is inserted. The balloon is inflated when measures are taken to ensure the catheter has reached the inside of the bladder. On 04/20/12, at 12 noon, a Foley catheter was inserted without difficulty. No mention was made of the size of the catheter or the amount of inflation of the balloon. According to nursing notes, the Resident pulled the catheter out about 2 hours later at 2:00 p.m. The Resident was noted to have some bleeding from the meatus (opening into the urinary tract). The family and physician were notified and a decision was made to leave the catheter out. The Resident urinated a small amount during the evening of 04/20 and during the night shift of 04/21. On 04/21/12, at 3:30 p.m., the Resident was complaining of pain and nurses notes reflected the "bladder area was distended and firm". The physician was notified and orders were received for re-insertion of the catheter. On 04/21/12, nursing notes for the evening shift reflected the catheter was re-inserted. No time was listed. The catheter size was recorded as a #22, but no mention was found regarding the balloon. The catheter was flushed with 500 milliliters (cc) of normal saline, although the physician's orders [REDACTED]. No bleeding was noted during the procedure, no mention was made of whether or not the saline inserted through the catheter was returned. Notes reflected 100 cc of urine was returned later in the shift and noted "Resident possibly retaining urine." No assessment was completed regarding whether the catheter was in place or functioning properly. During the night shift of 04/22, nursing notes reflect the "Catheter was draining with 100 cc blood-tinged urine. Abdomen slightly distended and tender to touch." Notes did not reflect whether the catheter was assessed to be in place. During the day shift of 04/22, nursing notes reflected "30 cc urine in cath {catheter} bag." The Resident's abdomen was assessed to be distended and firm. No mention was made of the placement of the catheter. The Resident was sent to the Emergency department for evaluation of possible [MEDICAL CONDITION]. Emergency department notes reflect "Upon arrival, the nurse noted that the balloon for the Foley could be palpated inside the shaft of penis. The balloon was deflated. The catheter was removed and then reinserted fully into the bladder. At this point, 1800 ml dark urine came out. The patient was having significant blood in the urine at that point. The Foley did remain patent, however, after telephone consultation with urology, the decision was made to admit the patient..." On 05/03/12, the Director of Nursing stated "I was aware of the note from the emergency department regarding the bulb in the catheter being located in the shaft of the penis, I thought the Resident may have dislodged the catheter on the way to the emergency department. I will call the nurse and find out if she instilled 200 cc of saline as the doctor ordered, or 500 cc as she charted." <Resident #10 Resident #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was able to speak, but could not identify or express care needs. According to the MDS, the resident required extensive assistance with most activities of daily living. Resident #10 was found to be wearing 2 [MEDICATION NAME]es on 04/28/12 when the nurse went to apply the new daily patch. No assessment or documentation of observations relating to possible side effects for the Resident to include nausea, vomiting or dizziness was completed. On 05/03/12 at 11:20 a.m., the Resident Care Manager (RCM) A stated "We should have placed the Residents on alert charting for at least 72 hours after the errors were discovered. I did not think about checking to see whether the Residents had been assessed or not." Refer to F 309 and F 333

Based on interview and record review the facility failed to report an allegation of abuse for 2 of 3 sampled residents (#'s 1 & 3) to the state survey agency and to facility administrator in a timely manner as directed by CFR 483.13 (c) (2). The facility also failed to prevent further potential abuse when the alleged perpetrator was allowed to continue to work in resident areas which resulted in harm to 1 of 3 sampled residents (#2) and placed additional residents at risk for abuse. Findings include: All interviews took place 1/27 or 1/31/2011. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 was confused and had memory problems. Resident #1 used a wheelchair for mobility. Report revealed on 1/11 Resident #1 was pushed by floor technician/housekeeper (FT) into the hallway unattended. Resident #1's wheelchair was moving rapidly and Resident #1 was not able to stop it. Resident #1 was headed towards a group of other residents at a table and his wheelchair was eventually stopped by a nursing assistant (NA) A. The incident was reported to Housekeeping Supervisor (HS). HS reportedly started an investigation, but did not remove FT from resident care areas. The state reporting agency was not notified. Resident #1 when interviewed had no recollection of the event. Resident #2 had [DIAGNOSES REDACTED]. He ambulated with a walker. Report indicated on 1/12 Resident #2 wandered into a room FT was waxing. FT was heard to yell at Resident #2 to get out and pulled Resident #2 by his arm out of the room. Resident #2 said he felt as if his arm was pulled out of the socket. Resident #2 was given [MEDICATION NAME] (pain medication) for complaint of increased pain and discomfort. According to the multi-disciplinary notes dated 1/12/11 the resident had complained of increased generalized back and upper extremity discomfort. Resident had history of occasional complaints of upper extremity discomfort in the past. A full assessment of Resident #2 took place after the incident, no obvious injury was noted. [MEDICATION NAME] was helpful. The incident was reported to the appropriate parties and FT was removed from the facility. Resident #2 when interviewed had no recollection of the event and denied pain to his shoulder. When interviewed HS said she did not remove FT from resident care areas on 1/11 because she did not have proof he had actually pushed the resident. She said she did not realize she could remove him when she did not have proof he was guilty. She said she reported it to the Director of Nursing (DNS) but did not inform the Administrator. She did not report to the state reporting agency at the time because she did not know how to do it. The following afternoon she reported to the state reporting agency but by then FT had abused Resident #2. HS agreed if she had removed FT from the facility on 1/11, Resident #2 would not have been abused. During an interview with the DNS and according to her written statement, she was informed of the interaction between Resident #1 and FT the afternoon of 1/11. She did not realize HS had not reported the incident to the administrator. DNS did not report the allegation of abuse to the state reporting agency. She was not aware FT had not been removed from the building, but said facility policy was to remove anyone who had allegedly abused or neglected a resident from the building to protect the resident during an investigation. Resident #3 had [DIAGNOSES REDACTED]. Resident #3 was on hospice. On 1/25 at 2045 Resident #3 fell in her room and suffered a head injury. The physician, family and hospice agency were notified. Review of Resident #3's multi-disciplinary progress notes dated 1/25 @ 2350 indicated she was able to ambulate independently after the fall but was very unsteady on her feet. Resident #3 sat in the recliner for long periods and was 1:1 with staff. On 1/26 @0745 it was written "...is unable to walk by self. Very unsteady." The documentation continued to state Resident #3 was monitored every 15 minutes while resting but was 1:1 while awake. In a telephone interview with NA - B, she went to work on 1/25 around 11pm. She stated Resident #3 was sitting in a recliner chair with 2 gait belts connected and wrapped around the resident and the chair, restraining Resident #3, so she could not get up. She said when she received report from LN - F he volunteered the fact Resident #3 had fallen and had to be tied to the chair so she would not get up and fall again. She said she did not report it to anyone until she came to work at 11 pm on 1/26 when she told LN - G who said she would call it in. NA - B said she called the hotline on 1/27 because she did not think LN - G did, because RCM - D had not come in yet. During an interview with LN - F he stated Resident #3 was not restrained to the chair. He stated she had fallen and hit her head. She wanted to walk but was unsteady on her feet. He stated Resident #3 had a gait belt around her waist so staff could hold onto her when she wanted to walk. He stated staff asked about restraining her but he told them it was against policy to restrain any resident. He stated he kept Resident #3 on 1:1 monitoring with staff. He denied 2 gait belts were ever hooked together and placed around the resident and the chair, "If it happened it must have been after I left." When interviewed, LN - E said she was told in report the morning of 1/27 Resident #3 had been restrained to a chair during the evening or night on 1/25. She said the night shift nurse, LN - G, said she was told by NA - B at the beginning of the shift but had not seen Resident #3 restrained. RCM - D said she was notified the morning of 1/27, by LN - G of the allegation Resident #3 had been restrained to a chair and immediately began an investigation. She did not immediately call the state survey agency because she had been told it was called in. When interviewed about the allegation of Resident #3 being restrained DNS stated it was under investigation, and she had just been informed by RCM - D. She stated the LNs involved had been suspended while the investigation was ongoing. She felt the restraining of Resident #3, if it occured, was for the resident's safety, though admitted it appeared facility policy had not been followed. In an interview with RCM - C she said allegations of abuse or neglect need to be called into the state within 24 hours. In separate interviews with NAs C & D, both said they would report possible abuse or neglect to their LN and then call the state. They also said restraining a resident would be a form of abuse. In separate interviews with LNs E & H, both said restraining a resident would be a form of abuse and would need to be called to the hotline (state reporting agency) right away.

Based on observation, interview, and record review, the facility failed to recognize, evaluate, and implement interventions to address weight loss for 1 of 5 current sampled residents (#6) reviewed for weight and nutrition. This failure resulted in harm to the resident, who experienced a severe loss of 10% of his body weight in one week. Findings include: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented with periods of confusion. Documentation on the date of his admission said he weighed 130.8 pounds. The resident was 5 feet 10 inches tall. The resident had physician orders [REDACTED]. The admission assessment and care plan said the resident was able to eat independently and had a history of [REDACTED]. On 9/11/10, the resident fell and was transported to the hospital. The resident was readmitted to the facility on [DATE] after treatment for [REDACTED]. Facility documentation said the resident weighed 123.5 pounds on 9/14/10. On 9/15/10, the resident weighed 120.9 pounds. In five days, the resident lost 9.9 pounds. The Registered Dietitian (RD) completed a nutrition assessment for the resident on 9/15/10. The assessment said the resident weighed 130.8 pounds, which was his admission weight. The assessment did not identify the resident's more current weights and his significant weight loss. The RD noted the resident was underweight even at 130.8 pounds, which was 88% of his ideal body weight. Documentation said the resident had increased energy needs because he had a healing wound (hip incision). The RD identified the resident at nutritional risk because he ate, on average, only 62% of his regular meals, because he was already underweight, and because of the healing incision. The RD recommended adding 60 milliliters of [MEDICATION NAME] (high calorie, nutritionally complete liquid shake) three times a day with medication pass. The physician was not notified about the RD's recommendations to add [MEDICATION NAME] until after business hours on 9/17/10 (Friday) via fax. The facility served four meals/snacks each day: continental breakfast, brunch, siesta (afternoon) snack, and dinner. The resident's tray monitor form showed he consistently ate 100% of his breakfast meals. The resident ate 50% or less of brunch or siesta snack on 6 of 14 occasions. The resident consistently ate 25% or less of his dinner meals. When the resident's intake was 50% or less, staff offered an alternative or replacement to the meal. The resident accepted the replacement approximately half the time. On 9/10/10, the resident ate pudding as an alternative to his dinner. On 9/14/10, the resident ate applesauce as an alternative to dinner. On 9/19/10, the resident ate a candy bar as an alternative to dinner. On 9/19/10, the resident weighed 113.1 pounds. On 9/20/10 at 11:25 a.m., the resident was in his room sitting in his wheelchair. The resident was thin, and his clothes hung loosely on his body. The resident was aware he had lost weight since he came to the facility. The resident said he had a poor appetite because of his hiatal hernia (part of stomach protrudes protrudes through the wall of the muscle used to breathe; causes heartburn) and because of the pain medication he took. The resident said he could not eat very much food at one time. At 11:30 a.m., Nursing Assistant (NA) D said the resident's weight would be checked for three days in a row (9/19, 9/20, and 9/21) because his weight had decreased by three pounds. NA D said she told Licensed Nurse (LN) E about the resident's weight loss on 9/19/10. At 11:35 a.m., LN C said a resident with a significant weight loss like the resident's would be weighed for three days in a row. LN C said the LN on duty was supposed to assess the resident to ensure the weight loss was not due to [MEDICAL CONDITION] (fluid retention) or an inconsistent weighing technique. LN C said the physician was to be notified by fax and a referral made to the RD. LN C said the RD was at the facility once a week and showed the investigator the referral list for the RD. The resident was not on the list to be seen by the RD. LN C showed the investigator a fax from the physician dated 9/20/10. In the fax, the physician approved use of [MEDICATION NAME] for the resident. The orders had not been transcribed to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Facility policy for weight loss said the weight loss protocol was to be implemented if a resident had a weight loss of 3% in one week, 5% in 30 days, 7.5% in 90 days, or 10% in 180 days. The facility weight loss protocol instructed staff to do the following: 1) Do a thorough head-to-toe assessment. Assess for any infectious process and/or further evidence of weight decline. Document assessment in progress notes. 2) Notify the physician and family. Discuss the weight loss and try to identify the cause. 3) Placed resident on tray monitor and alert charting. 3) Notify dietary manager of weight loss. 4) For weight loss above 5%: Refer to the RD. Assess lab work. Notify the interdisciplinary team. Refer to Social Services. Do a medication review with pharmacy. There was no documentation the facility identified and assessed the resident's weight loss according to its own policy. There was no documentation showing the facility talked to the resident and/or his family about possible reasons for the weight loss. There was no documentation showing the facility identified the resident's poor intake at dinner and his frequent refusal of meal alternatives. There was no documentation showing the facility notified or discussed the resident's weight loss with the physician, the dietary manager, the RD, and/or the pharmacy. On 9/20/10 at 12:00 p.m., NA B assisted the resident to the scale to check his weight. The resident weighed 111.2 pounds. The resident lost 12.3 pounds, or 10% of his body weight, in the seven days since he had been readmitted to the facility. At 2:00 p.m., Resident Care Manager (RCM) A said the NAs who weighed residents were expected to report a weight change of two pounds or more to the LN or RCM. RCM A said the LN or RCM was responsible for reviewing how the resident was eating, the impact of the resident's medications, and any relevant treatments, like use of intravenous fluids. RCM A said the LN or RCM was expected to talk to the resident about the weight change. RCM A said the LN's assessment of the resident's weight change was to be documented in the progress notes. RCM A said the physician was to be notified and a referral made to the RD. RCM A also showed the investigator a dedicated form entitled "Weight Loss/Gain" to guide assessment and referrals for a resident with a weight change. RCM A said she usually faxed RD recommendations to the physician and received a response the same day. RCM A said there was a delay in faxing the RD recommendations to the resident's physician because she had been on vacation. RCM A said no one checked her in box while she was gone. RCM A said she was not aware the resident had lost weight.

Based on observation, interview and record review, the facility failed to complete a comprehensive assessment to to correctly identify factors that placed a resident at risk for falls, develop a resident-specific plan of care, and/or provide supervision to decrease the likelihood of falls for 1 of 4 current sampled residents (#1) reviewed for falls. This failure resulted in a harm to the resident, who sustained a [MEDICAL CONDITION]. 1) Resident #1 was admitted to the facility on [DATE] following surgery of her fractured right hip. The resident broke her right hip when she fell at home on 8/30/10. The resident had significant memory impairment and balance problems. A fall risk assessment completed by Resident Care Manager (RCM A) on 9/3/10 documented Resident #1 did not have the risk factors of confusion, dizziness, certain medications, impulsiveness, and/or history of falls. Resident #1 was assessed as being at "no risk of falling". No care plan was developed to prevent injury to the resident. According to facility documentation, Resident #1 had an unwitnessed fall in her room on 9/6/10 at 5:55 p.m.. She was unable to state what happened, except that she had to go to the bathroom. The resident was sent to the hospital, where she was diagnosed with [REDACTED]. On 9/20/10 at approximately 11:15 am, Resident #1 was in her wheelchair in the dining room. The resident was not interviewable about the incident secondary to her cognitive status. On 9/20/10 at approximately 12:35 pm, RCM A stated she was in a hurry to leave the facility on 9/3/2010, the day the resident was admitted . RCM A said Resident #1 was at risk for falling and should have had fall prevention measures implemented on the date of her initial admission to the facility.