Every finding on record at South Hill Rehabilitation and Care Center

Based on interviews and record reviews, the facility failed to provide regular bathing for 3 of 6 sampled residents (Resident 2, 3,and 4). This failure placed residents for potential risk of infection, skin irritation, unpleasant body order, low self-esteem, and decreased quality of life.Finding included .<Resident 2>Review of annual assessment dated [DATE], documented Resident 2 admitted to the facility on [DATE], was cognitively intact, able to direct their own care, had diagnoses including morbid obesity (a serious health condition characterized by excessive body weight that significantly impacts daily functions such as breathing and mobility), diabetes, and chronic pressure ulcer, and required extensive assistance with activities of daily living (ADLs) such as bathing and toileting.Review of care plan dated 11/04/2024, documented Resident 2 had bathing schedule twice of a week. In an interview with Resident 2 on 11/03/2025 at 2:46pm, Resident 2 stated they had missed many showers over the past few months because of the bath aides being used as regular aides rather than providing bathing. When asked if they had communicated with the facility regarding their showers, Resident 2 stated, they hadn't talked to anyone about it because it doesn't do any good. Review of Resident 2's record, showed bathing and resident refusal of bathing was documented on the nursing assistant documentation, and the resident received three showers in August, 08/13/2025, 08/24/2025, 08/27/2025, documented a 10-day span between bathing from 09/27/2025 to 10/08/2025. <Resident 3>Review of the annual assessment dated [DATE] documented Resident 3 admitted to the facility on [DATE], was cognitively intact and able to direct their own care, had diagnoses including morbid obesity and diabetes, and required supervision assistance for most ADLs such as transferring, toileting, and bathing. Review of care plan dated 12/03/2025, documented Resident 3 had a bathing schedule of two times a week on Thursday and Sunday evenings.In an interview with Resident 3 on 11/03/2025 at 2:24pm, Resident 3 stated they had not been getting bathed regularly for 2 months because the bath aides were being used as regular aides instead of providing bathing. Review of Resident 3's record including nursing assistant documentation and nursing progress notes, between the dates of 08/01/2025 and 12/03/2025, showed bathing and resident refusal of bathing was documented on the nursing assistant documentation, and it was documented the resident was bathed and/or offered bathing three times in the month of October 2025, 10/03/2025, 10/12/2025, 10/26/2025. Further review showed Resident 3 bathed three times in the month of September 2025, 09/14/2025, 09/17/2025, 09/28/2025, and two refusals to be bathed was documented on 09/15/2025, and 09/27/2025. Additionally, no documentation for bathing was documented between 08/27/2025 and 09/14/2025 and no documentation of bathing being offered during that time was noted. (same)<Resident 4>Review of the quarterly assessment dated [DATE], documented Resident 4 admitted to the facility on [DATE], was cognitively intact and able to direct their own care, had diagnoses including Chronic Obstructive Pulmonary disease, chronic pain, and required maximum assistance for bathing. In an interview with Resident 4 on 11/03/2025 at 2:41pm, Resident 4 stated they used to get bathed twice weekly but now they were lucky if they got bathed one time per week. Review of Resident 4's record including nursing assistant documentation and nursing progress notes, between dates of 08/01/2025 and 12/03/2025, showed bathing and resident refusal of bathing was documented on the nursing assistant documentation and it was documented that they bathed five times in September 2025, 09/02/2925, 09/10/2025, 09/14/2025, 09/17/2025 09/27/2025, and four times in August 2025, 08/13/2025, 08/24/2025, 08/27/2025, and 08/31/2025.In an interview on 11/21/2025 at 1:30pm, Staff B, Director of Nursing, stated all the residents had missed some showers at the beginning of November 2025, because the bath aide hours had been decreased due to a low census of residents in the facility at that time. Interviews with DON and Admin, usually done at the end of our investigation.In an interview on 12/03/2025 at 1:23pm, Staff D, Nurse Manager, stated all residents were scheduled to be bathed twice weekly and occasionally the bath aides would be pulled to floor. They stated there was a two-week period in November 2025 when some bathing was missed due to scheduling. Reference: WAC- 388-97-1060(2)(b)

Based on interview and record review the facility failed to ensure accepted standards of clinical practice were met for care of a peripherally inserted central catheter (PICC) line (a long thin tube inserted through a vein in the arm and passed through to the larger veins near the heart) for 1 of 1 sampled resident (Resident 1). This failure placed residents at risk for potential delay in the administration of necessary intravenous (IV), administered through a vein, medications, and a decreased quality of life.Findings included .Review of the nurse practice act for Washington State Dated 2024, documented that a registered nurse (RN) working under the direction of a physician may perform patient treatments, whether or not the severing or penetrating of tissues is involved and whether or not a degree of independent judgment and skill is required.Review of the admission assessment dated [DATE], documented Resident 1 was admitted on [DATE], had diagnoses including pyogenic arthritis (a serious joint infection caused primarily by bacteria) of the right knee joint, and chronic pain. Additionally, the admission assessment documented Resident 1 was cognitively intact, able to direct their own care, required maximum assistance for activities of daily living (ADLs) such as moving in bed, transferring from bed to chair, and toileting.Review of progress note dated 09/04/2025, by Staff C, Registered Nurse (RN), documented Resident 1's PICC line was found leaking and Staff C removed the PICC line. The progress notes further showed no documentation of provider notification or the provider order prior to removing the PICC line.In an an interview on 12/20/2025 at 12:03pm, Staff C stated on 09/04/2025 they checked Resident 1's PICC line and found it was leaking, and they were unable to push fluid through it with a syringe, so they pulled the PICC line out of Resident 1's arm. Staff C stated they did not notify the physician or obtain an order prior to pulling out the PICC line. They stated they did not know, at the time, they needed to notify the physician and obtain an order before pulling the PICC line. In an interview on12/02/2025 at 1:27pm Staff B, Director of Nursing, stated according to the facility policy, physician notification of any changes to a resident's PICC line was required, and a physician order had to be obtained prior to removing a PICC line.Reference: WAC 388-97-1620(2)(b)(ii)

<Second Floor Dining Room> Observations of the meal showed the following on 06/09/2025: At 12:01 PM, Staff D, Speech Therapist, touched the back of a female resident seated at a dining room (DR) table. Staff D completed HH then grabbed a pair of gloves and put them on. Staff D approached another female resident, touched their wheelchair (WC) with the gloved hand, walked to the serving area to get a bowl of soup, and brought it to the female resident. Staff D then touched another resident's WC with the same gloves on, went to get ketchup at the serving area. Staff D returned to the resident with the same gloved hands, opened the burger bun, poured the ketchup on the burger, and moved it closer to the resident. At 12:05 PM, Staff D went to get a plate of food with the same gloved hands and brought it to Resident 183, touched the table surface, then the resident's right chest, and then the table surface again with gloved hands. A staff approached Staff D with a plate, Staff D touched the plate of food and gave instructions to the staff. Staff D then assisted a male resident in their WC out of the DR with the same gloved hands. At 12:10 PM, Staff D returned to the DR, put on gloves, went to talk to a male resident, got a cola for another male resident, opened the cola can, touched their pants at the hip area, then sat down on the resident's walker seat. Staff D then returned to Resident 183, placed the same gloved hands on the table surface where Resident 183 was seated at. Staff D then stepped away and went to a male resident who requested a baked apple for dessert. En route to getting the male resident the baked apple, Staff D went to Resident 71, adjusted their napkin, and went to the serving cart to ask for the baked apple. Staff D took the baked apple and brought it to the male resident. With the same gloved hands, Staff D then went to another male resident and touched their WC with their left hand. Staff D then touched their own front thighs and was called by another male resident who also requested a baked apple. Staff D went to the serving area, obtained the baked apple, and brought the baked apple to the male resident with the same gloved hands. Staff D then announced, I have to go now downstairs, removed their gloves, and exited the DR. The above findings were shared in an interview with Staff F, Infection Preventionist, on 06/16/2025 at 11:03 AM. Staff F stated, You need to take gloves off and wash your hands when making in-between contact with residents and anything that's a personal surface. Reference WAC 388-97-1100 (3), -2980. Based on observation, interview and record review, the facility failed to ensure the staff performed hand hygiene (HH) and changed gloves when required for 2 of the 2 dining rooms observed. This failure placed the residents at risk for foodborne illnesses. Findings included . <First Floor Dining Room> Observations of the meal showed the following on 06/09/2025: - At 12:31 PM, Staff U, Nursing Assistant (NA), touched a resident's arm, then proceeded to touch a sink faucet. Staff U opened the refrigerator door, retrieved a can of soda, opened it, then poured it into a cup. Without performing hand hygiene, Staff U held onto the cup at the rim where the resident's mouth would touch, and gave it to a resident who proceeded to drink from the cup. In an interview on 06/09/2025 at 12:40 PM, when asked when they should perform hand hygiene during meal service, Staff U stated, when changing glove and after providing care for a resident. Staff U stated they did not realize they hadn't performed hand hygiene, and when asked if they should have performed hand hygiene, the staff stated they definitely should have. Observations of the meal showed the following on 06/16/2025: - At 11:45 AM, Staff V, NA, touched a resident's wheelchair handle with gloved hands, then opened the refrigerator and removed juice and two cans of soda. Staff V then poured the juice into a cup and without changing gloves or performing hand hygiene picked up the cup by the rim where the resident's mouth would touch and placed it in front of a resident. Staff V then proceeded to open the cans of soda pop for two different residents and place them in front of the residents. Staff V, still wearing the same gloves, removed a straw from its wrapper, touching it where it would come in contact with the resident's mouth and placed it in front of a resident, then, without changing gloves or performing hand hygiene, picked up two cups by the rims, where a resident's mouth would touch, and filled the cups with ice and placed them in front of residents. Staff V, still wearing the same gloves, then proceeded to touch a tabletop, assisted a resident to put on a clothing protector, then touched a wheelchair handle of another resident, then without changing gloves or performing hand hygiene prepared a drink and gave it to a resident. In an interview on 06/16/2025 at 11:54 AM when asked when glove change and hand hygiene should be performed when working the dining room, Staff V stated between touching residents, when starting meal trays, and if touched a dirty surface. When asked why they did not perform hand hygiene and glove changes at the appropriate times they stated it was because they were only serving drinks and only touching the bottom of the cups. When Staff V was informed they were observed touching the rims of cups and touching the straw they stated they should have performed hand hygiene and glove changes, and stated it was important to prevent cross contamination.

Based on observation, interview, and record review, the facility failed to ensure signage was placed to inform the staff of residents (Resident 7, 77, 180, 182, 183, and 191) who required Enhanced Barrier Precautions (EBP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, germs that are resistant to many antibiotics]). Additionally, the facility failed to ensure hand hygiene was implemented as required during medication administration. These failures placed the residents at risk for the spread of infections, illnesses and unintended health consequences. Findings included . According to a 06/28/2024 Centers for Disease Control article, EBP are used in conjunction with standard precautions and expanded the use of putting on gown and gloves during high-contact resident care activities (e.g., dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care and assisting with toileting) for residents known to be colonized or infected with a MDRO when Contact Precautions did not otherwise apply, as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). <Resident 183> Review of the medical record showed Resident 183 admitted to the facility on [DATE] after they experienced a stroke. The medical record showed Resident 183 admitted with the use of an indwelling urinary catheter that helped empty their bladder. An observation on 06/09/2025 at 10:09 AM showed Resident 183 sitting in a wheelchair and the tubing of the urinary catheter drained to a collection bag and secured to the wheelchair. No EBP signage was observed to instruct the staff of the required PPE after four days of admission. <Resident 77> Review of the progress notes showed Resident 77 admitted to the facility on [DATE] with a feeding tube (a flexible tube used to provide liquid nutrition, fluids, and medications directly to the stomach or small intestine when someone is unable to eat or drink adequately). The medical record showed the staff used the feeding tube to provide continuous nutrition, hydration and administer medication to the resident. An observation on 06/09/2025 at 12:34 PM showed Resident 77 in bed. A dressing was observed to the left side of their stomach and a feeding tube coming out of it and connected to a bag of nutrition formula run by a pump on a pole. No EBP signage was observed to instruct the staff of the required PPE after six days of admission. <Resident 7> Review of the medical record showed Resident 7 admitted to the facility on [DATE] with orders to administer antibiotics ([NAME]) intravenously (IV, by vein). The medical record showed the staff currently administered two [NAME] by IV. An observation on 06/09/2025 at 9:49 AM showed Resident 7 sitting in a wheelchair in their room with an IV line to their right inner arm. No EBP signage was observed to instruct the staff of the required PPE after 31 days of admission. <Resident 180> Review of the medical record showed Resident 180 was admitted to the facility on [DATE] with orders to administer an ABT by IV. The medical record showed the staff currently administered an ABT by IV. An observation on 06/09/2025 at 9:28 AM showed Resident 180 sitting in a wheelchair in their room with an IV line to their right arm. No EBP signage was observed to instruct the staff of the required PPE after seven days of admission. <Resident 191> Review of the medical record showed Resident 191 admitted to the facility on [DATE] with IV [NAME] for a bloodstream infection. The medical record showed the staff currently administered the [NAME] three times a day. An observation on 06/10/2025 at 1:25 PM showed Resident 191 sitting in a recliner. Staff D, Speech Therapist, sat directly on the resident's bed with no gown on and wore a surgical mask required by the facility for a COVID-19 (a contagious disease) outbreak. Staff D talked with the resident during their visit. An IV pole was observed with a pump and an IV bag connected to it. No EBP signage was observed to instruct the staff of the required PPE. Another observation on 06/11/2025 at 9:10 AM showed no EBP signage in use after nine days of admission. <Resident 182> Review of a medical record showed Resident 182 admitted to the facility on [DATE] with IV ABT. An observation on 06/09/2025 at 10:21 AM showed Resident 182 in bed. An IV line was observed to their right arm. No EBP signage was observed to instruct the staff of the required PPE after five days of admission. In an interview on 06/12/2025 at 8:44 AM, Staff G, Nursing Assistant, stated that they knew when a resident required EBP by, We have it [signage] posted right outside their door. The above findings were shared with Staff E, Nurse Manager, in an interview and observation on 06/12/2025 at 9:25 AM. Staff E stated that they informed the staff of the requirement for EBP via use of a laminated sign placed outside and by the resident's door on admission. Staff E stated any resident with wounds, IV lines, urinary catheters and feeding tubes required EBP signage. Staff E stated that the staff should wear a gown if they sat on the bed of a resident who met the criteria for EBP. Staff E acknowledged Resident 191 still did not have the signage to show certain cares required EBP and should have been in place eight days ago upon admission to the facility. Staff E stated that when a resident was admitted to the facility, the Admissions Nurse placed EBP signage as required and the reason the signage was not up for the above residents during the observations of 06/09/2025 was because the Admissions Nurse, just took a week's vacation and it [the admission process] was very broken. The above findings were shared with Staff F, Infection Preventionist, on 06/16/2025 at 11:05 AM. No further information was provided. <Hand Hygiene during Medication Administration> On 06/16/2025 at 8:39 AM, observed the administration of medications for Resident 283. Staff P, Nursing Technician, placed their pills into a medication cup and the pain ointment into another cup at the medication cart. Staff P then entered the resident's room, placed the pill cup on the bedside table and watched as the resident took the pills. Staff P put on gloves and applied the ointment, then discarded the gloves. They did not use hand sanitizer after removing the gloves or upon entering or leaving the resident's room. Staff P then went to the medication cart, documented the medications on the computer and began preparing medications for the next resident, without performing hand hygiene. During a concurrent interview, Staff P stated they should use hand sanitizer whenever entering or leaving a resident room, and after removing their gloves. They acknowledged they had forgotten to do so. During an interview on 06/18/2025 at 3:17 PM, informed Staff A, Administrator and Staff B, Director of Nursing of observations during medication pass with Staff P. Staff B stated they expected staff to perform hand hygiene after removing gloves and between each resident. Reference WAC 388-97-1320 (2)(b); -1320 (1)(c).

Based on observation, interview, and record review, the facility failed to ensure the development of adequate baseline care plans within the required timeframe to ensure continuity of care for 4 of 7 sampled residents (Resident 183, 180, 52 and 17) recently admitted to the facility. This failure placed the residents at risk for unmet needs and possible complications. Findings included . <Resident 183> Review of the medical record showed Resident 183 was admitted to the facility on [DATE] with diagnoses that included a recent stroke that affected the right side of their body, diabetes, chronic kidney disease, and heart failure [where the heart can't pump enough blood to meet the body's needs]. An observation on 06/09/2025 at 10:04 AM showed Resident 183 in their room sitting in a wheelchair (WC) with their representative present. The resident's right arm was elevated with a stack of towels about 4 inches thick. On their wardrobe door was signage that instructed the staff to keep their arm elevated 30 degrees while in bed and WC. Resident 183's hand was slightly swollen or puffy. A black forearm/hand brace was observed on the bedside table and the resident's representative stated the resident did not like to wear it. An observation on 06/11/2025 at 10:21 AM showed Resident 183 in their room, seated in a WC, and their representative present. The resident had their right forearm supported on a stack of washcloths, with fingers curled around the washcloths. Observed on the right forearm was a black brace. Resident 183's hand was slightly swollen or puffy. An observation on 06/13/2025 at 10:22 AM showed Resident 183 seated in a WC in their room, watching the television. A stack of towels supported the right forearm which had a black brace applied. The resident's hand was less swollen. Review of the June 2025 Medication Administration Record (MAR) showed Resident 183 received Torsemide (a water pill, used to remove excess water and salt from the body through increased urine production; helps to lower blood pressure and reduce fluid buildup in the body and commonly used to treat conditions like high blood pressure, heart failure, and swelling). Review of the June 2025 Treatment Administration Record (TAR) showed a 06/05/2025 order (the day of Resident 183's admission) that instructed the nurses to, Monitor skin under brace to R [right] wrist. Notify provider if any breakdown is noted. In an interview on 06/13/2025 at 9:54 AM, Staff M, Nursing Assistant, said Resident 183 wore a brace to their right hand because it was softer than a cast, kept their hand in place and from hurting, and the caregivers applied the brace. Staff M said the resident wore the brace whenever they were up and came off at bedtime, That's what I know at least off hand. Staff M said they found specifics about the brace management in the Kardex, an abbreviated form of a care plan for nursing assistants. In an interview on 06/13/2025 at 10:43 AM, Staff L, Licensed Practical Nurse, said, Resident 183 wore the brace because, That's [their] weak side so were keeping the fingers open and preventing a contracture [a condition where muscles, tendons, or skin shorten and tighten, restricting joint movement and causing stiffness]. Staff L stated the nurses or nursing assistants could apply the brace and would know for how long the brace should be on by verifying its order in the TAR. Staff L said if the order was in the TAR, then it would become consistent with the brace application and helped identify concerns, like refusals. Staff L confirmed there were no orders in the TAR to show who was responsible for brace application and how long to keep the brace on once applied. Review of Resident 183's medical record and Kardex showed no indication of the presence of a brace to the right wrist, its purpose, who was responsible for ensuring it was applied, and for how long the brace should be left on the resident's wrist. Additionally, it did not identify or address the primary physical problems and functional limitations associated with heart failure, the resident's goals or desired response, and interventions to help achieve those goals. The above findings were shared with Staff E, Nurse Manager, on 06/13/2025 at 2:34 PM. Staff E acknowledged Resident 183's baseline care plan should have but did not adequately address potential resident response to the diagnosis of heart failure. Staff E stated Resident 183 wore the brace to the right wrist, for comfort and based off of the patient's wishes, and could be applied by the nurses and aides, the resident, and the resident's spouse. Staff E acknowledged the baseline care plan did not show the potential resident response to the brace, the intent of the brace, the resident goals for the brace, and interventions to achieve those goals. Staff E stated the use of the brace should have reflected on the care plan, when it was given to the resident. <Resident 180> Review of the medical record showed Resident 180 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, heart failure, ventricular fibrillation (a life-threatening heart rhythm where the heart quivers irregularly instead of beating effectively), and the presence of a defibrillator (a small battery-powered device placed in the chest that detects and stops irregular heartbeats). The medical record showed orders for the staff to administer Eliquis, an anticoagulant (blood thinner), twice a day for DVT (deep venous thrombosis, a blood clot that forms in a deep vein, most commonly in the legs) prevention. Review of Resident 180's medical record and Kardex showed no care plan that identified or addressed the primary physical problems and functional limitations associated with the treatment of DVT prevention or ventricular fibrillation, to include the presence of a defibrillator, the resident's goals or desired response, and interventions to help achieve those goals. The above findings were shared with Staff E on 06/13/2025 at 2:16 PM. Staff E reviewed Resident 180's care plan and confirmed, I don't see this on here but normally it would be. <Resident 52> According to a comprehensive admission assessment, dated 02/06/2025, Resident 52 was admitted on [DATE] with end-stage renal disease (the kidneys can no longer meet the body's needs) which required dialysis (a medical procedure that uses a machine to filter wastes and fluids from the blood). Review of Resident 52's electronic medical record (EMR) showed the following dialysis-related orders: - on 01/30/2025, dialysis scheduled to occur on Monday, Wednesday and Friday. Details of the order included details of the transport company, pick-up and drop-off times, and the name of the kidney center with their address and phone number. - on 01/30/2025, orders instructed the nursing staff to complete the dialysis communication sheet prior to dialysis, send the form with the resident to dialysis, and complete the form upon the resident's return to the facility. - on 03/01/2025, orders instricted the nurses to monitor the Permcath (a small flexible tube inserted in the right upper chest that facilitated dialysis treatment) every shift. A review of the 03/01/2025 care plan documented a focus of end-stage renal disease. Interventions included to elevate feet, give medications as ordered and monitor for signs of complications. There was no documentation in the care plan that the resident received dialysis services, their dialysis schedule or the name and contact information of the dialysis center, as required. <Resident 17> According to a comprehensive admission assessment dated [DATE], Resident 17 was admitted on [DATE] with diagnoses of a hip fracture and irritable bowel syndrome (IBS, a bowel disorder, symptoms included abdominal pain, bloating and changes in the consistency of bowel movements) with constipation (hard, dry or difficult to pass stools). The resident was alert and able to make their needs known. During an interview on 06/10/2025 at 10:23 AM, Resident 17 stated that they occasionally had abdominal discomfort, and were unsure of the cause. They further reported problems with hard bowel movements, which changed to diarrhea after taking suppositories and enemas. A review of the medical record showed Resident 17 received both scheduled and as needed medications to regulate their bowels. From 05/18/2025 through 06/16/2025, the resident had four formed/normal stools, fourteen diarrhea/loose stools and five constipated/hard stools. A review the 05/09/2025 care plan showed no mention of the presence of an actively treated diagnosis of IBS, any focus on monitoring their bowels, the resident's goals or desired response, and interventions to help achieve those goals. During an interview on 06/18/2025 at 10:08 AM, Staff L, Licensed Practical Nurse (LPN), stated that staff monitored Resident 17's bowel habits and they could give medications for either constipation or diarrhea. They stated that IBS and symptoms should be on their care plan and expressed surprise that it was not. During an interview on 06/18/2025 at 2:50 PM, Staff O, Nurse Manager, reviewed the care plans for Resident 17 and Resident 52. They acknowledged that information on Resident 17's IBS and Resident 52's dialysis treatment should have been on their care plans and were not. Reference WAC 388-97-1020(3) .

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 77) reviewed for tube feeding (TF, the delivery of nutrients through a tube directly inserted into the stomach) received their nutrition according to provider orders. This failure placed the resident at risk of nutritional complications, dehydration, or fluid overload. Findings included . Review of a 06/02/2025 admission assessment showed Resident 77 was admitted to the facility on [DATE] with diagnoses that included a progressive neurological condition and severe malnutrition. The staff assessed the resident as cognitively intact and depended on TF for nutrition. An observation on 06/11/2025 at 12:50 PM showed Resident 77 in bed with the head of the bed up. A dressing was observed to their left abdomen and TF tubing extending out. A pole was observed with a pump for the delivery of enteral nutrition. Resident 77 was unable to be interviewed secondary to their desire to conserve physical energy. Review of the May 2025 Medication Administration Record (MAR) showed a 05/28/2025 order that instructed the nurses to administer Jevita [sic, a nutrition formula] 1.2 at 50 cc (cubic centimeter, a measurement) every hour and continuously, for a total administration of 1,200 cc in a 24-hour period, or 400 cc every eight-hour shift. The nurses documented the amount administered on their shift as 50/hr on 05/29/2025, 05/30/2025, and 05/31/2025, not showing the approximate or complete amount of nutrition provided each shift. Review of the June 2025 MAR showed an order that instructed the nurses to administer Jevity 1.2 at 60 ml (milliliter, a measurement also equivalent to a cc) every hour and continuously, totaling 1,440 cc in a 24-hour period, or 480 cc every eight-hour shift. On 06/02/2025, 06/03/3025 and 06/04/2025, the nurses showed no documentation of how much enteral nutrition was provided to Resident 77. Review of the June 2025 MAR showed an order dated 06/03/2025 that instructed the nurses to administer FiberSource (a nutrition formula) 1.2 at 60 cc/hr in a 24-hour period for a total of 1,440 cc, or 480 cc every eight-hour shift. The MAR showed the nurses documented 60 or 60cc instead of the expected or approximate amount of 480 cc per shift from 06/03/2025 to 06/10/2025. Review of the June 2025 MAR showed an order dated 06/10/2025 that instructed the nurses to provide Resident 77 IsoSource (a nutrition formula) at 50 cc/hr continuously, for a total of 1,200 cc in a 24-hour period, or 400 cc every eight-hour shift. Review of the MAR showed the nurses administered nutrition more than what was ordered by the physician on: 06/10/2025 Night Shift - 795 cc, an excess of 395 cc 06/11/2025 Day Shift - 890 cc, an excess of 490 cc 06/11/2025 Afternoon Shift - 1202 cc, an excess of 802 cc 06/12/2025 Day Shift - 600 cc, an excess of 200 cc 06/12/2025 Evening Shift - 600 cc, an excess of 200 cc The above findings were shared with Staff N, Registered Dietitian, on 06/13/2025 at 10:57 AM. Staff N stated the facility ensured a resident with orders for enteral nutrition received the prescribed rate by review of documentation in the MAR. Staff N acknowledged the medical record did not show the staff consistently provided Resident 77 with the prescribed rate of enteral nutrition daily and stated, It would be good to have the total amount [administered]. Looks like there is some miscommunication as to what is supposed to be in the MAR. I don't have an answer for you on that. Am not sure what was going on there. Reference: WAC 388-97-1060 (3)(f). .

Based on observation, interview, and record review, the facility failed to ensure the medical record showed an accurate account of a resident's fluid intake while on a fluid restriction for 1 of 3 sampled residents (Resident 180) reviewed for nutrition and hydration. This failure placed the resident at risk of dehydration, fluid overload, and rehospitalization. Findings included . Review of the medical record showed Resident 180 was admitted to the facility on [DATE] after being hospitalized for an episode of congestive heart failure [CHF, where the heart can't pump enough blood to meet the body's needs] and septic shock [a severe medical condition characterized by dangerously low blood pressure and organ failure, resulting from the body's overwhelming response to an infection] secondary to cellulitis [a bacterial infection of the skin and underlying tissues]. The medical record showed that at the hospital, almost 4.8 liters (a measurement and over a gallon) of fluid were removed. The resident received a diuretic, or water pill (a medication that helped the body get rid of excess water and salt through increased urination). An observation on 06/09/2025 at 9:25 AM showed laminated signage with a blue drop of water on Resident 180's room door. The signage showed, Day 450, Eve [Evening] 450 and NOC [Night] 100. Entry into the resident's room showed Resident 180 sitting in a wheelchair (WC) in their room next to their bed. When asked, Resident 180 stated they were no longer on fluid restriction and the reason it was started was because, lungs were failing. The resident said they now had a water pitcher brought to them by the staff, which started two days ago, and refreshed with ice whenever they asked for it. On 06/10/2025 at 10:31 AM, a water pitcher was observed on Resident 180's bedside table. Resident 180 was not in their room. On 06/12/2025 at 10:10 AM, a clear plastic glass filled partially with water and a water pitcher sat on the over-the-bed table. Resident 180 sat in their WC and stated the staff brought them the water pitcher, Every time I ask. It's the first one for today, and I didn't ask for it. It's fresh today. It's got ice in there. A bottle of Boost [oral nutrition] supplement also sat on the over-the-bed table to which the resident said they received, Every meal. The amount in the bottle was 237 milliliters (mL, a measurement). On 06/13/2025 at 10:31 AM, the laminated signage with the blue drop of water and integers by shift remained on Resident 180's door. Review of 06/02/2025 hospital transfer documents showed orders for a salt-restricted diet with a fluid restriction of 2000 ml. Review of the facility provider orders showed no instruction to the nurses Resident 180 was on a fluid restriction. Review of the care plan and Kardex (abbreviated care instructions for nursing assistants derived from the general care plan) showed it informed the staff Resident 180 was on a Fluid restriction of 2000mL per day. The care plan or Kardex showed no clarity to how much fluid was allowed per shift, specifically the amount sent with meal trays by the kitchen department and how much the staff was allowed to give the resident between meals and per shift apart from the meal trays. Review of the medical record showed no documentation the staff monitored or reconciled Resident 180's fluid intake between shifts to ensure they maintained the ordered fluid restriction. In an interview on 06/13/2025 at 10:08 AM, Staff M, Nursing Assistant, stated they knew a resident was on fluid restriction by the water drop signage on doors and by checking the Kardex. Staff M stated they documented fluids in the electronic medical record (EMR) under the Tasks section and included fluids from a water pitcher, at mealtimes and in between meals. Staff M stated the nurses were responsible for documenting how much of the Boost supplement a resident drank. Staff M stated that a water pitcher held 800 to 1000 mL, and they would calculate how much the resident drank at the end of the shift by pouring out and deducting the remaining water from the 800 to 1000 mL adding, I can do an estimate of what was consumed. In an interview on 06/13/2025 at 10:33 AM, Staff L, Licensed Practical Nurse, stated a resident ran the risk of becoming dehydrated, constipated, or running a low blood pressure when on a fluid restriction. Staff L was asked what the facility process was to ensure the staff provided fluids that did not exceed fluid restriction and stated, I believe kitchen gives a certain amount on each tray and there is usually a little sign on the door [of what] nursing gives. Staff L explained that the nursing assistants did not give the resident fluids apart from what was sent on the meal trays and were responsible for documenting that amount under the Tasks section of the EMR. Staff L stated that residents on fluid restriction are generally not provided water pitchers but if they really want one we will fill it with what they can have for their shift. Staff L stated that before the end of their shift, they checked the amount of fluid a resident consumed, tallied and then documented it either in the Medication Administration Record (MAR) or the progress notes. Staff L stated they believed Resident 180 was on a fluid restriction secondary to CHF. Staff L confirmed nurses were responsible for including the amount of Boost supplement consumed and counted it towards the fluid restriction. Staff L stated a provider order showed how much fluid the kitchen department would send at meal trays and how much the staff could give per shift so that the fluid restriction would not be exceeded. Staff L checked Resident 180's medical record and could not find an order for the fluid restriction and added, [The resident] does have heart failure and kidney disease, especially [now] that he also has IV [by vein] fluids. That's something that needs to be clarified. Staff L acknowledged there was no documentation in the medical record that showed how much fluid the nurses gave Resident 180 shift by shift, or the nurses reviewed and tallied the entire daily amount of fluid to ensure Resident 180 met the fluid restriction ordered at the time of admission to the facility and mentioned in the care plan. The above findings were shared with Staff N, Registered Dietitian, on 06/13/2025 at 11:18 AM. Staff N stated they expected fluid restriction to show in the provider order. Staff N reviewed Resident 180's medical record and confirmed, I don't see that order in, and we would want to see and delegate who's responsible for how much to give per shift. Staff N reviewed Resident 180's meal tray slip delivered with each meal, which would include the type of diet, allergies, preferences, and fluid restriction. Staff N confirmed it did not show instructions to the kitchen staff on Resident 180's fluid restriction and stated, I'm not sure what happened. Reference WAC 388-97-1060 (3)(i). .

Based on interview and observation, the facility failed to ensure medications carts were locked/secured in the absence of a nurse, expired medications were discarded timely, and injectable medications were dated/timed when opened. These failures placed the residents at risk of unauthorized access to medications and their potential adverse effects, theft or diversion of medications, and decreased potency and safety of the medications. Findings included . <Unsecured Medication Cart> An observation on the second floor on 06/09/2025 at 9:06 AM showed an unlocked and unattended medication cart stationed at the beginning of Unit B - Transitional Care Unit. In this continuous observation, Staff C, Licensed Practical Nurse (LPN) approached the medication cart. At 9:30 AM, the medication cart was again observed unlocked and unattended, and Staff C was coming from Unit B, Long Term Care Unit. Staff C acknowledged the medication cart was opened and that it should have been locked, and stated it should be secured, When we are away. <Expired Medications> On 06/18/2025 at 01:45 PM, during an inspection of medication cart 2 on the first floor, an eight-ounce bottle of Hibiclens (a skin cleanser that helps reduce bacteria) with an expiration date of 11/2024 was observed in the cart with other medications and supplies. Staff S, LPN, acknowledged the expiration date and stated the Hibiclens should have been discarded. Staff S stated all the medication cart nurses are responsible for checking for and disposing of expired medications and supplies in the medication carts. <Injectable Medications> On 06/18/2025 at 1:10 PM, during an inspection of the second floor medication room, an open, undated bottle of Tubersol solution (used to help diagnose tuberculosis infection) was observed in the medication refrigerator. Staff O, Nurse Manager, acknowledged the Tubersol was opened and undated and stated it should have been disposed of because it expired 30 days after being opened and there was no way to know when it was opened. In an interview on 06/18/2025 at 02:16 PM , Staff B, Director of Nursing, stated Tubersol was only good for 30 days after being opened and if it was not dated when opened it should be thrown away. Reference WAC 388-97-1300 (2), -2340. .

Based on interview and record review, the facility failed to ensure controlled medications were adequately accounted for, following accepted standards of practice in 3 of 3 controlled medication ledgers reviewed. This failure placed residents at risk of misappropriation of controlled substances and a decreased quality of care. Findings included . According to the 2025 article titled Narcotic Drugs: Handling and Documentation, Controlled Drug Policy and Procedure, written by [NAME], a nationally recognized Registered Nurse (RN) and online educator, for the publication RN.org, the traditional method of accounting for narcotic medications in long-term care facilities included an end-of-shift narcotics count with the oncoming nurse counting the medications, the outgoing nurse verifying the count, and both nurses signing off in the ledger that the count was correct. <Controlled Substance Ledger Books> Record reviews and interviews of the controlled substance ledger books showed the following: - On 06/18/2025 at 1:35 PM, the ledger showed that 37 out of 75 signature lines were blank from 05/24/2025 through 06/18/2025 for Medication Cart 1 on the first floor. In an interview at that time, Staff R, Licensed Practical Nurse (LPN), confirmed the signatures were missing. - On 06/18/2025 at 01:45 PM, the ledger showed that 93 out of 189 signature lines were blank from 05/17/2025 through 06/18/2025 for Medication Cart 1 on the second floor. In an interview at that time, Staff S, LPN, confirmed the signatures were missing. - On 06/18/2025 at 01:55 PM, the ledger showed that 93 out of 189 signature lines from 03/17/2025 through 06/18/2025 for Medication Cart 2 on the second floor. In an interview at that time, Staff T, RN, confirmed the signatures were missing and acknowledged the facility process to account for controlled substances was the same as described in the 2025 article referenced above. In an interview on 06/18/2025 at 2:16 PM, Staff B, Director of Nursing, acknowledged the inconsistent accounting of controlled substances. Reference WAC: 388-97-1620(2)(b)(i)(ii),(6)(b)(i)

Based on interview and record review, the facility failed to utilize their grievance process to ensure concerns and grievances expressed by members of the Resident Council were responded to and/or followed up in a timely manner for 2 of 7 sampled residents (Residents 35 and 59) reviewed for Resident Council. This failure placed the residents at risk for a diminished quality of life and loss of self-worth. Findings included . The facility Grievance policy, last reviewed 12/20/2023, documented the grievance process was available to be utilized by residents to express concerns with their care and treatment as well as other general concerns. The policy documented the facility's Grievance Official would evaluate, investigate, and take actions to resolve the concerns. In addition, the policy documented the Grievance Official would respond to the individual who expressed the concern within three working days of the concern being expressed, complete the grievance resolution forms, and follow up with the individual to inform what steps were taken to address and/or correct the concern. <Resident Council Minutes> Review of the January 2025 through April 2025 Resident Council minutes showed the following: - On 01/28/2025, Resident 35 stated their shower drained slowly after bathing and Resident 59 stated towels were not picked up after they showered, it sometimes took days and there had been times when they had placed the towels outside in the hallway by their room door in order to have them picked up. In addition, the meeting minutes documented many of the residents in attendance stated their bed linens were not being changed timely. - On 02/25/2025, no documentation was found in the meeting minutes that showed the concerns that were expressed in the 01/28/2025 meeting as stated above had been addressed and/or followed up on by the Grievance Official. - The 03/25/2025 meeting minutes were not provided, the documentation received only included the meeting agenda and the attendance roster of staff and residents. - On 04/29/2025, Resident 59 stated the issue with bath towels not being picked up and bed linens not being changed timely was still a problem. No documentation was found in the meeting minutes that showed the issue was addressed, what actions were taken, or what if any, follow-up occurred. Review of the facility's grievance log and grievance binder from January 2025 through April 2025, found no entries were made related to the above concerns that were expressed in the Resident Council meetings, nor were any grievance forms completed as per the facility's grievance policy. During an interview on 06/13/2025 from 3:16 PM through 3:42 PM, Staff Q, Activity Director, stated the Grievance Official was Staff A, Administrator, until about a month ago, and now it was Staff K, Social Services. After reviewing the Resident Council meeting minutes and a discussion about the grievance process and concerns that residents voiced during Resident Council had not been addressed and/or followed-up timely, Staff Q stated the grievance forms were filled out by the Grievance Official. When asked if the grievance forms were completed for issues expressed during Resident Council meetings, Staff Q stated they had not been, but using them would make it easier and helpful to ensure concerns were addressed and followed-up on. In an interview on 06/13/2025 at 11:54 AM, after discussion about the grievance process, lack of logging grievance concerns in the facility log, and lack of timely follow up for resident's concerns, Staff A acknowledged the facility grievance process was not utilized consistently and addressing and following up on resident's concerns was not timely. Reference WAC 388-97-0920 (1-6)

Based on interview and record review, the facility failed to identify a designated interdisciplinary team member, to act as a liaison for coordinating care and communication with the hospice provider, for 1 of 1 sampled residents (Resident 37), reviewed for hospice services. This failure placed the resident at risk for unmet care needs. Findings included The 05/05/2025 significant change assessment documented Resident 37 was able to make decisions regarding their care, had diagnoses which included malnutrition, asthma, and respiratory failure. In addition, the assessment documented the resident received hospice services. Review of Resident 37's record showed a referral was made on 04/16/2025 for hospice services, and serv ices were started on 05/01/2025. Review of the facility's 05/01/2025 hospice agreement documented the services and responsibilities for care that would be provided by both the facility and the hospice provider; however, the policy did not include and/or document who the designated facility liaison to hospice was that was responsible for collaborating in the development and care of the resident. In an interview on 06/11/2025 at 2:11 PM, Staff A, stated the facility was in the process of updating and renewing contracts due to transitioning to new owners. When asked if the facility had a designated hospice liaison, Staff A stated when hospice services were desired, Staff K, Social Services made the arrangements, but a designated hospice liaison had not been appointed. No associated WAC

Based on interview and record review, the facility failed to ensure informed consents which explained the potential risks and benefits associated with the use of psychotropic medications and/or vaccines were accurately completed, and obtained from the resident or their representative prior to their administration, for 2 of 5 sampled residents (Residents 14 and 3) reviewed for unnecessary medications. In addition, the facility failed to ensure Resident 3 had the cognitive ability to understand the risks prior to signing the informed consent. These failures placed the residents and/or their representatives at risk of not being fully informed of the potential risks and benefits of receiving the medication and/or vaccines. Findings included . <Resident 14> The 04/15/2025 quarterly assessment documented Resident 14 had diagnoses which included depression, a mental health condition characterized by a persistent feeling of sadness that lasted over an extended period. In addition, the assessment documented that the resident received psychotropic medication. Review of the physician orders from 01/01/2025 through 06/11/2025 documented the psychotropic medication, Duloxetine, had been prescribed on 03/01/2024 to treat Resident 14's depression. Review of the Medication Administration Records (MARS) from 03/01/2025 through 06/11/2025 documented Resident 14 had received the medication daily as prescribed. Review of Resident 14's record found an informed consent that included the risks and benefits for the Duloxetine had been signed by the resident on 03/13/2024, 12 days after the resident began taking the medication. In an interview on 06/11/2025 at 12:46 PM, Staff H, Nurse Manager, stated informed consents for psychotropic medications needed to be obtained prior to the first dose of the medication being given. When informed of the Duloxetine consent being completed 12 days after Resident 14 had received the medication, Staff H stated the facility had transitioned to new ownership and a different electronic record system and would check with medical records to see if an earlier consent had been obtained. In a follow-up interview on 06/11/2025 at 1:05 PM, Staff H provided an informed consent for the Duloxetine; however, it was the same consent that was dated 03/13/2024. Staff H acknowledged an informed consent had not been done prior to Resident 14 receiving the medication as was required. <Resident 3> Review of a 05/16/2025 quarterly assessment showed Resident 3 was admitted to the facility on [DATE] with a diagnosis of dementia and bipolar disorder (a mental illness with extreme shifts in mood, energy, and activity levels). The assessment showed Resident 3 had severely impaired cognitive skills for daily decision making, unclear speech, and was sometimes able to be understood by and sometimes able to understand others. Review of the medical record showed Resident 3 had two next of kin as emergency contacts. Additionally, a 02/28/2025 cognition care plan showed the resident was no longer consistently responding to the cognitive assessment, showing signs of severely impaired cognition and the [Spouse] assists with decision making and coordination of care. The care plan informed the staff Resident 3 required supervision/assistance with all decision making. Review of a 09/11/2024 vaccine consent for pneumonia (a contagious respiratory disease) showed the staff provided vaccine information to Resident 3 and the consent was signed by the resident. The consent showed the resident understood the risks and benefits of receiving the vaccine and did not consent to receiving it. Review of 09/23/2024 vaccine consents for influenza and COVID-19 (both contagious respiratory diseases) showed the staff provided vaccine information to Resident 3 and the consents were signed by the resident. The consents showed the resident understood the risks and benefits of receiving the vaccines and consented to receiving them. Review of the June 2025 MAR showed the staff administered to Resident 3, Depakote [an anticonvulsant or seizure medication also used to treat bipolar disorder] twice a day for bipolar disorder. Review of a 09/11/2024 Informed Consent for Use of Psychotropic Medication showed the medication category chosen was Antipsychotic [a class of medications primarily used to manage symptoms of psychosis, such as hallucinations, delusions, and disorganized thinking], to include the possible side effects associated with the use of an antipsychotic. The consent showed Resident 3's legal representative consented to the use of the antipsychotic and educated to the potential side effects associated with that medication category, instead of the anticonvulsant. The above findings were shared with Staff H, Nurse Manager, on 06/13/2025 at 3:34 PM. Staff H confirmed Resident 3 signed the informed consents to the immunizations, acknowledged Resident 3's severely impaired cognition, and stated that the resident was not the appropriate person to make an informed decision about immunizations and the vaccine information should have been reviewed with the next of kin identified in the care plan. Staff H acknowledged the Depakote was placed in the wrong medication category, making the informed consent erroneous in the information provided to Resident 3's representative. Reference WAC 388-97- 0300(3)(a), -0260, -1020(4)(a-b). .

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 2) reviewed for quality of care, received timely notification to the medical provider of a change in condition. This failure placed the resident at risk of delayed access to care, inability to participate in care planning, and diminished quality of life. Findings included . Review of the skilled nursing facility transfer orders dated [DATE] for Resident 2 showed they were discharged from the hospital in stable condition following an episode of respiratory failure. The oxygen therapy orders showed the resident was to receive oxygen at 2-3 liters per min (LPM; a unit of measure) via a nasal cannula (thin flexible tube with prongs that go inside the nostrils), and the resident had adamantly declined non-invasive positive pressure ventilation (respiratory support where air and oxygen is given through a mask under positive pressure). Per Resident 2's Portable Orders for Life-Sustaining Treatment (POLST) dated [DATE], the resident was to receive comfort-focused treatment and was not to be transported to the hospital. Review of the [DATE] progress notes for Resident 2 showed on [DATE] the medical provider saw the resident for complaints of vertigo (sensation of motion or spinning that is often described as dizziness). The resident's heart rate and blood pressure were stable, and the resident had no respiratory symptoms. Per the provider note staff were to monitor the resident's orthostatic blood pressure (test to measure the way blood pressure changes when a person shifts from a lying down or sitting position to standing) once daily and to continue to provide oxygen at 2-4 LPM. Further review of the progress notes showed at 5:30 PM the same day the resident was receiving oxygen via a mask at 8 LPM. There was no information regarding updates to the medical provider on the resident's increased oxygen need. An entry dated [DATE] showed Resident 2 was found unresponsive at 0350, was pronounced deceased at 0352, and the medical provider was aware of the resident's status. In an interview on [DATE] at 4:00 PM Staff B, Resident Care Manager, stated they would expect staff to notify the medical provider of a change in a resident's respiratory status, including increased oxygen need. Staff B reviewed Resident 2's medical record and stated based on their POLST status they would not expect new orders besides increased oxygen and resident monitoring. Staff B was unable to state whether the medical provider was notified of the resident's change in condition on [DATE] after the provider's visit. In an interview on [DATE] at 3:46 PM Staff A, Director of Nursing, stated they spoke with the medical provider group and were not able to find any notifications regarding Resident 2's increased oxygen needs on [DATE]. Per Staff A, the nurse who worked with Resident 2 on [DATE] believed the provider had already been notified of the resident's condition. Staff A stated they would expect staff to notify the provider of the resident's change in condition and obtain any needed orders for additional supportive/comfort care. Reference: (WAC) 388-97-0320 (1)(b)(d)

Based on interview and record review, the facility failed to ensure an allegation of potential misappropriation was reported to the State Agency as required, for one of five sampled residents (Resident 2) reviewed for abuse. This failure placed residents at risk for possible abuse. Findings included . In an interview on 03/29/2024 at 1:18 PM, Resident 2 stated during their admission to the facility they had reported to multiple unidentified nursing assistants and one unidentified charge nurse a complainant about missing property (a notebook) and missing money (stored inside the notebook). The resident stated they were told by the charge nurse that facility administration was aware of the concern and were investigating. Review of the January to April 2024 incident logs showed no entries for Resident 2. In an interview on 04/09/2024, Staff C, Charge Nurse, confirmed Resident 2 had mentioned missing property and money to them, and they had notified the resident that facility administration was investigating the complaint. Staff C stated they were not involved in the investigation and had no further information, but an entry should have been on the incident log. In an interview on 04/09/2024 at 3:52 PM, Staff A, Administrator, stated Resident 2 had submitted a complaint to social services staff about missing items and thought that included a concern about a missing debit card. In an interview on 04/12/2024 at 11:10 AM Staff D, Social Services, confirmed Resident 2 had complained about missing money inside of a book, and after a search facility staff had found and returned the resident's book, but no money was inside of it. Staff D stated missing money complaints should be reported to facility administration, but since the resident did not bring up the missing money again, they thought the complaint had been resolved. In a follow up interview with Staff A at 12:51 PM on 04/15/2024, Staff A confirmed Resident 2's complaint of missing money was not reported as required. Reference: (WAC) 388-97-0640(5)(a)

Based on interview and record review, the facility failed to investigate resident-reported concerns (grievances) and to provide timely follow-up for 1 of 5 sampled residents (Resident 2), reviewed for grievances. This failure placed the resident at risk of having unresolved grievances and a diminished quality of life. Findings included . Review of the policy titled, Safeguarding Residents' Belongings, revised December 2023, showed the facility would promptly respond to and investigate complaints of missing property, and the Administrator or their designee would notify the resident of the results of the investigation and corrective action taken within 10 working days. In an interview on 03/29/2024 at 1:18 PM, Resident 2 stated during their admission to the facility they had reported to multiple unidentified nursing assistants and one unidentified charge nurse a concern about missing property (a notebook) and missing money (stored inside the notebook). The resident stated they were told by the charge nurse that facility administration was aware of the concern and were investigating. Review of the 2024 grievance log and incident logs showed no entries for Resident 2. In an interview on 04/09/2024, Staff C, Charge Nurse, confirmed Resident 2 had mentioned missing property and money to them, and they had notified the resident that facility administration was investigating the complaint. Staff C stated they did not recall the date(s) of the investigation and/or the outcome. In an interview on 04/12/2024 at 11:10 AM Staff D, Social Services, stated resident concerns regarding missing property were typically reported by residents to nursing staff, then submitted on a grievance form. Staff D stated Resident 2's concern regarding their missing book and money was written on a scrap of paper, and upon a search the book had been found. Staff D stated no money was found inside the book and since the resident did not bring up the missing money again, they assumed it had been found. Per Staff D, facility administration was responsible for following up with residents on grievances, but Resident 2's concern had not been properly documented so there was no closure. In an interview on 04/15/2024 at 12:51 PM, Staff A, Administrator, confirmed that resident concerns of missing property or money began as a grievance, then were escalated to the incident log if unable to be found. Staff A stated since the resident and staff did not bring up further concerns with missing property and/or money for Resident 2 they believed the resident's concern had been resolved. Staff A confirmed no documentation regarding the investigation for Resident 2 was available and stated assumptions regarding the outcome should not be made. Reference WAC 388-97-0460

Based on interview and record review, the facility failed to care plan and implement an identified intervention for 1 of 5 sampled residents (Resident 3) reviewed for care planning. This failure placed the resident at risk of unmet needs and diminished quality of life. Findings included . Review of a facility investigation dated 03/15/2024 showed Resident 3 made a statement about trauma from their past that was triggered by cares provided by a (male) nurse the previous night. Per the investigation, the resident's care plan was updated to include female-only care for personal care. Review of Resident 3's care plan, effective 03/11/2024 to 04/20/2024, showed no interventions for female-only care for personal care. The Kardex (summarized version of the care plan) for the same timeframe also showed no interventions for female-only personal care. In an interview on 04/09/2024 at 12:39 PM a representative for Resident 3 stated they were told Resident 3 would have female-only staff provide personal care after 03/15/2024, but the resident continued have male staff provide personal care such as toileting and dressing/undressing for bed. In an interview at 1:14 PM the same day, Staff E, Social Services, confirmed Resident 3 was to have female-only staff provide personal care after 03/15/2024, which was listed in their care plan. After reviewing the care plan and Kardex, Staff E stated there was no intervention listed on either for female-only care. Per Staff E, the care plan and Kardex was the method of communicating interventions (such as female-only care) to staff members. In an interview at 4:10 PM the same day, Staff A, Administrator stated identified interventions for resident care should be added to the care plan. Reference: (WAC) 388-97-1020(1), (2)(a)(b)

Based on observation, interview, and record review, the facility failed to thoroughly investigate the cause(s) of falls and assess the need for additional effective interventions for 1 of 3 sampled residents (Resident 1), reviewed for accident hazards. This failed practice placed the resident at risk for additional falls, injury secondary to falls, and diminished quality of life. Findings included . Review of the 03/06/2024 significant change assessment showed Resident 1 was severely cognitively impaired and had a history of falls. Additionally, the resident required moderate staff assistance for transfers, toileting, and walking, and supervision in their wheelchair. Review of Resident 1's care plan for falls, initiated 04/27/2023, showed staff were to offer toileting assistance every two hours and assess for unmet needs, ensure the resident's floor was clean and free of clutter, encourage appropriate footwear, ensure the bed was at an appropriate height to allow for safe transfers, and provide a room in a highly trafficked area to facilitate frequent observation. Review of the March 2024 incident log showed two non-injury falls for Resident 1 were listed on 03/22/2024 and 03/26/2024. In an interview on 03/29/2024 at 3:20 PM a representative for Resident 1 stated on a recent visit with the resident they had noticed a large amount of bruising on the resident's face and was told by the resident that they had a recent fall. The representative stated they were concerned about fall prevention as the resident was high risk to fall and had previously had significant injuries due to falls. Observation at 3:38 PM the same day showed Resident 1 still had a healing bruise next to their right eye. The resident was sitting up in their wheelchair in their room, leaning far forward in their wheelchair attempting to pick up a crumbled-up piece of garbage from the floor next to their garbage can. Review of the March 2024 progress notes for Resident 1 showed the resident was found lying face down on the floor in their room by nursing staff after attempting to self-transfer on 03/13/2024. The note did not contain additional details regarding the fall, including whether care planned interventions to prevent falls were in place at the time. Review of a facility fall report dated 03/22/2024 showed the resident was found on the floor at approximately 7:00PM. Per the note, the resident had no injury other than a healing bruise from a previous fall. Per the report the resident's call light and fluids were in reach but the report did not indicate if the call light was utilized at the time of the fall. Assessment of additional factors that may have contributed to the fall were not included. No new interventions to prevent further falls were listed. Review of a facility fall report dated 03/26/2024 showed the resident had an unwitnessed fall at approximately 3:21 PM that day, after attempting to walk to the bathroom. The report did not show when the resident had last been assisted to the bathroom and/or seen by staff. No new interventions to prevent further falls were listed. In an interview on 03/29/2024 at 3:54 PM, Staff F, Nursing Assistant, stated they tried to encourage Resident 1 to attend activities during the day and they tried to monitor the resident when they were in their room. Staff F stated Resident 1 was care planned for assistance with toileting every two hours, but the resident would try to go the bathroom more frequently than that. Per Staff F, the resident thought they could walk but they were very unsteady. In an interview at 4:35 PM the same day, Staff B, Director of Nursing, stated they were not aware of Resident 1's fall on 03/13/2024 and the fall was not investigated. When asked about root causes for the falls on 03/22/2024 and 03/26/2024 Staff B stated there was no additional information available and the investigation reports should have been reviewed for completeness by the charge nurse on duty at the time. Staff B acknowledged no additional interventions to prevent falls were developed due to the lack of information available regarding the falls. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate licensing necessary to carry out the functions of the nutritional services for 91 residents. Failure to ensure the Registered Dietician (RD) had a license to practice in Washington State placed residents at risk for unmet nutritional needs and possible unintended weight loss or gain. Findings included . On 02/21/2024, a review of the staff credentials showed Staff K, Registered Dietician (RD), had successfully completed requirements for dietetic registration through the Academy of Nutrition and Dietetics Commission on Dietetic Registration, with a certificate valid through 08/31/2024. A copy of Staff K's license to practice in Washington State was also requested and none was provided. A search of the Washington State Department of Health Provider Credential database found no record to show that Staff K had the required Dietician Certification (license) to practice as a dietician in Washington State. In an interview on 02/22/2024 at 11:08 AM, Staff K was asked if they were licensed as a dietician in Washington State. Staff K stated no, and then asked if they needed to be. When informed it was required, Staff K stated they were not aware and would take the necessary steps to get the license. Reference: WAC 388-97-1160(1)

Based on observation, interview, and record review the facility failed to ensure food was prepared in accordance with professional standards for food service safety. Specifically, the facility failed to ensure the kitchen staff with facial hair were wearing beard restraints (nets) to prevent hair from contacting exposed food and clean equipment. Unsafe food handling practices placed the residents at risk of unsanitary food and possible foodborne illness. Findings included . A document from the United States Food & Drug Administration Food Code website titled Food and Drug Administration Food Code 2022, Chapter 2. Management and Personnel Section 2-402 Hair Restraints updated on January 18, 2023, showed that food employees shall wear coverings over their hair and beards to prevent hair from contacting exposed food and clean equipment. On 02/13/2024 at 8:49 AM, during a tour of the kitchen, Staff J, Cook, was observed chopping fresh fruit. Staff J had a full beard of short hair, without a beard net in place. On 02/22/2024 at 10:24 AM, during a second visit to the kitchen, Staff L, Cook, had a goatee (facial hair on chin) and was observed combining a flour-like mix with water in a large metal bowl without a beard net in place. During an interview on 02/22/2024 at 10:28 AM Staff L acknowledged they should wear a beard nets while preparing food in the kitchen. Staff L stated they would put on a beard net. During an interview on 02/22/2024 at 11:00 AM Staff K, Registered Dietician, acknowledged staff with facial hair are required to wear a beard net. Reference: WAC 388-97-1100 (3)

Based on observation and interview, the facility failed to provide a dignified dining service for 1 of 1 sampled resident (341). Specifically, Resident 341 was referred to as a feeder on their printed meal ticket. This failure placed the resident at risk for psychosocial harm and decreased quality of life. Findings included . On 02/21/2024 at 12:02 PM, Resident 341 was served lunch in the 2nd floor dining room. A meal ticket listed the Resident name, diet, and assistance level as 1:1 Feeder. The meal ticket was placed face-up on the table in front of the resident, and visible to residents, staff and visitors. On 02/21/2024 between 12:15 PM and 12:37 PM, Resident 341 ate their meal without staff assistance, and at 12:57 PM, had finished eating and left the dining room independently in their wheelchair. During an interview on 02/22/2024 at 10:31 AM, Staff Q, Nursing Assistant, stated they knew what level of assistance a resident needed at meals by reading the meal ticket. Staff Q stated if they needed to communicate the level of assistance a resident needed with eating or drinking, they would describe the type of help needed, and they would not call a resident a feeder. During an interview on 02/22/2024 at 11:00 AM, Staff K, Registered Dietician, stated meal tickets were used to communicate the residents' diet, allergies, and level of assistance to the kitchen and staff. Staff K stated they completed the meal ticket information, and they used the term feeder and one to one assistance interchangeably to describe a resident that needs assistance with eating. Staff K acknowledged the term feeder could be a dignity issue. Reference: WAC 388-97-0108(1-4)

Based on observation, interview, and record review, the facility failed to provide the identified transfer assistance required to prevent injury for one of five sample residents (1), reviewed for accidents and supervision. This failure resulted in actual harm to Resident 1, who sustained a fracture and pain during a transfer without utilization of a two-person assist and appropriate equipment, as required. Findings included . Per the 11/24/2022 quarterly assessment, Resident 1 required extensive assistance of one staff for transfers, was not steady, and had no falls since admission to the facility. Review of a 01/03/2023 provider progress note showed Resident 1 had an assisted fall the previous day while transferring from the toilet to their wheelchair via Lumex (a non-mechanical stand assist transfer aid designed for residents who have the strength and stability to lift and support themselves). The resident reported their legs just sometimes give out. Per the care plan initiated 05/11/2021, new interventions were implemented on 01/03/2023 and 01/04/2023 for physical therapy to evaluate the resident's transfer status, and for extensive assistance of two staff for transfers via Hoyer (a mechanical lift used to transfer residents with increased assistance needs due to mobility challenges and weakness). Review of an 01/23/2023 incident investigation showed Staff E, Nursing Assistant (NA), used the Lumex to transfer Resident 1 into a shower around 9:45 AM that day without incident, despite the resident stating it won't work. After the shower Staff E used the Lumex to transfer the resident back to bed and was unable to properly seat the resident on the edge of the bed. Staff E requested assistance; Staff D, Registered Nurse, entered the room and found Resident 1 sliding off the edge of the bed with the Lumex in front of them and reporting they were not able to stand back up. Per the investigation, Staff D and E were unable to successfully assist Resident 1 into bed with the Lumex, so they placed a pillow under the resident and asked for additional staff assistance. Staff F, NA, entered the room and found Resident 1 sitting halfway on the edge of the bed and sliding down, while still holding the grab bar on the Lumex, which caused their buttocks to be lower than their knees, while their feet were sliding off the foot platform. Staff F repositioned the resident's feet onto the platform, then Staff E and F grabbed the resident under the arms and assisted them into a standing position and back into the bed. Per the investigation, at 12:30 PM that day, Resident 1's wife reported to staff that the resident's left leg was swollen and painful. An x-ray was completed on 01/24/2023, and found the resident had a new fracture to the lower left leg. In an interview on 03/10/2023 at 2:43 PM Staff E, NA, stated prior to the incident on 01/23/2023 staff were notified of resident care needs, such as their transfer status, from a care guide (a brief version of the care plan) that was kept at the nurse's station; however Staff E did not look at the care guide for Resident 1, prior to transferring the resident into and out of the shower that day. Staff E stated when previously working with the resident, the resident used the Lumex, and they were not told about the updates to the resident's status. Staff E confirmed being the only staff member present when they transferred the resident out of the shower to the bed with the Lumex, and stated the resident said their leg wasn't working right, but they did not know what happened to cause the resident to slide off the edge of the bed. On 03/09/2023 at 2:28 PM Staff D stated they were aware Resident 1 was care planned for use of the Hoyer when the incident occurred on 01/23/2023, due to weakness and a prior fall, but when entering the room to assist Staff E, the resident was already sliding off the edge of the bed and on the Lumex. Staff D stated they attempted to push the Lumex back to assist the resident onto the bed, and when that was unsuccessful, locked the brakes until another staff member came to assist. In an interview on 03/10/2023 at 3:39 PM, Staff C, Physical Therapist, stated the resident was initially seen for therapy for a left upper leg fracture in 2021, and had progressed to standing and walking prior to the fall on 01/02/02023. After the fall, physical therapy started working with the resident again on strengthening, and nursing staff were to use the Hoyer for Resident 1's transfers until therapy staff had cleared the resident to begin using the Lumex again. Staff C stated nursing staff had not yet been cleared to use the Lumex with the resident when the incident occurred on 01/23/2023, due to the resident's continued weakness. Observation at 4:33 PM on 03/09/2023 showed Resident 1 was sitting up in a wheelchair in their room with their left leg wrapped in a thick brace and elevated on the wheelchair leg rest. The resident did not wake up despite attempts to rouse them. In an interview on 03/10/2023 at 10:34 AM a representative for Resident 1 stated they visited the resident on 01/23/2023 and the resident immediately told them that staff had pushed on their left leg during a transfer, which was surprising because staff should have known to be careful, due to the resident's prior injury. Per the representative, there was obvious swelling below the knee, and the resident reported severe pain at the time. The representative also stated Resident 1 had been sleeping in their wheelchair a lot lately as it was less painful for them than the bed. The representative stated the resident was experiencing pain and discomfort at night, due to an inability to move their leg to reposition themselves and the heavy/bulky brace, which they were not allowed to remove. Per the representative, the resident had seen an orthopedic doctor after the fracture was identified, and on their last visit on 03/01/2023, the physician notified the resident and their representative that the fracture was stable, not healing but not getting worse, and would need to be evaluated monthly for the next three months, to determine a plan of care. On 03/10/2023 at 3:10 PM, Staff B, Resident Care Manager, stated Resident 1's care guide identified they were to be using the Hoyer after their fall in the beginning of January 2023, and the facility's investigation revealed staff were not checking the care guides at the nurse's station prior to providing care. Per Staff B, the facility's investigation concluded that the stress placed on the resident's leg while attempting to reposition them up into the bed via the Lumex (to prevent them from falling) on 01/23/2023 caused the lower leg fracture. Staff B confirmed Resident 1 was to wear the brace on the left leg at all times, and continue monthly follow up visits with the orthopedic doctor for the next three months, as the resident was not a surgical candidate (to repair the fracture) due to their overall medical status. At 3:55 PM the same day, Staff A, Director of Nursing, confirmed the facility's investigation found the root cause of Resident 1's injury to be a transfer that was not done according to the resident's identified care needs. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide the necessary behavioral healthcare to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 sample residents (1), reviewed for care and services. Specifically, Resident 1 was checked for toileting needs in an undignified manner, was upset and afraid the identified person (Staff A) was going to return, and did not receive any follow-up by the facility related to the incident, or the resident's expression of distress. This failure caused the resident actual psychosocial harm. Findings included: A review of the record showed Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the record, the resident used a walker and wheelchair for ambulation. The 03/02/2022 care plan showed the resident had an identified activity of daily living self-care deficit. Interventions included toileting the resident with limited assistance of one staff. The care plan was not updated following a concern Resident 1 had regarding being touched inappropriately by a nursing assistant (NA) - see below. On 03/05/2022 at 1:57 PM, Staff B, Licensed Practical Nurse Supervisor documented in a progress note that the resident reported they were uncomfortable with the night shift Nursing Assistant (NA, later identified as Staff A). Per Resident 1, the NAC entered the resident's room, asking if the resident was wet and needed changed. The resident stated they were not fully awake, and the NA continued to take the covers off, and touched the resident's brief with their hand. Per the record, the resident stated they believed it was not sexual in nature, but very inappropriate. A 03/30/2022 Resident Concern/Grievance Form showed the administration received an email survey alert that Resident 1 had a staff concern. When called on 04/08/2022 at 8:53 AM, Resident 1 reported the incident occurred on 03/05/2022 at 3:00 AM. The resident stated a caregiver went in their room to assist them with going to the bathroom, pulled back their covers and put hands on their crotch area asking, Are you wet? The form showed the caregiver did not inform the resident what they were doing. The resident stated they felt very uncomfortable afterwards, that it was not sexual in nature, and was a training issue. The resident requested they be informed that the agency NA would not be back, and have follow up by management. Per interview, the concern was not resolved; the resident had not heard from management while still in the facility. An investigation statement by Staff F, Risk Manager, showed on 03/30/2022 at 3:15 PM, they called Resident 1 regarding their survey results post discharge. Per the document, Resident 1 stated they spoke with their home health case worker about the incident, how they felt they were assaulted, and were told to make a criminal report (which was done on 03/26/2022). The resident reported the incident to Staff B, Licensed Practical Nurse Supervisor, and was told someone would follow up. Resident 1 reported on 03/05/2022 at 3:00 AM they had to go to the bathroom and put on their light. Staff A came in, grabbed their crotch and said, Why, are you wet? The resident told the nursing assistant to get out of the room, pulled the covers over their head, and cried for three hours. Staff B asked the resident what they wanted done, and Resident 1 stated they did not want that NA in their room again, or they would leave the facility. Per the above interview with the resident, no facility staff ever came back and confirmed that with them, and throughout the rest of their stay they did not know if Staff A was going to come back. The resident stated they tried to never ring their call bell at night, and would go nine hours in pain. The resident reported that they had some really bad days since they had gotten home, and reported being previously sexually assaulted, so the incident brought back many bad memories, and they screamed and cried at times. An investigation statement by Staff G, Administrator, showed that on 03/30/2022 at 4:30 PM, they called Resident 1 to acknowledge the resident's concerns. The resident expressed that not knowing if the aide was in the building or not was upsetting. Staff G apologized that no one followed up with the resident on that day, to let them know the nursing assistant was not on site anymore. An investigation statement by Staff D, Director of Nursing Services on 03/31/2022, showed that on 03/05/2022 at 10:30 AM, they received a call from Staff B notifying them of Resident 1's complaint (i.e., Staff A had physically touched the resident's brief to see if it was wet rather than ask the resident, who was alert and oriented). Per the statement this upset the resident, and they requested the NA be better trained before performing care. Staff A was out of the facility, their agency was contacted, and their return to work at the facility was denied until the agency could get them more training. Staff B called again at 12:40 PM, stated there was no concern of a sexual assault, and stated the resident felt it was just a training problem. Staff B felt the situation was resolved to the resident's satisfaction. When interviewed on 04/07/2022 at 11:57 AM, the home health agency Physical Therapist (PT) stated on their third visit to the resident's home, the resident told them about the NA grabbing their brief. Resident 1 reported to them that they were afraid for the rest of the night, and reported it when morning came. The resident was told someone would follow up with them and no one did. The PT reported the resident was sullen, and shared that they had been abused as a child and this had triggered them. When interviewed on 04/08/2022 at 8:53 AM, Resident 1 stated after the NA had grabbed their brief, they told the NA to get out of their room, pulled the covers over their head and cried for hours. They called their nephew to come in and stay with them, then reported the incident to Staff B. Resident 1 was not told until after they returned a survey weeks later regarding their stay that the NA had not been back to the facility. Then they received a call from the facility, and that was the first time anyone had talked to them after the event was reported to Staff B. The resident stated they had been afraid their whole stay the NA was going to come back, and the resident had family with them most of the time after that. The resident stated they had good days and bad days since then and had been continuing to rely on family for support. When interviewed on 04/14/2022 at 1:53 PM Staff C, Social Worker, stated they practiced using a trauma informed care model. Per Staff C, the model took into consideration any life situations a resident has had that might impact their care, and those life events were kept in mind when developing a plan of care. Staff C stated staff would notify them or discuss any concerns that needed follow up in the morning report. Staff C was not told Resident 1 had concerns regarding Staff A, and further stated it was an incident they should have been made aware of. If so, they would have been able to interview the resident and provide frequent check-ins. Per Staff C in general, feelings regarding an event such as this might change as a resident processed what happened. They might cry, withdraw, or not say anything. It could be referred to a counselor, and the resident would decide if they wanted the counselor's services. When interviewed on 04/15/2022 at 9:25 AM Staff B, Licensed Practical Nurse Supervisor stated they spoke with Resident 1 after the incident, then called and updated Staff D, Director of Nursing Services. Staff B assumed the incident would be discussed in the morning report, but did not know if that happened as they were not part of that meeting. Staff B stated normally an incident like that involved the social worker, but it was a weekend, so they handed off their findings to Staff D. Reference: WAC 388-97-0860(1)(a)(b)(2)

Based on interview and record review, the facility failed to ensure 1 of 3 sample residents (1), reviewed for medication administration, was free from significant medication errors. Failure to transcribe the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included: Per the admission record, Resident 1 admitted to the facility on [DATE] following a hospital stay, where they received treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record also showed the resident had diabetes mellitus, (a condition caused by the pancreas being unable to produce enough insulin), and used a CGM (a system which used a tiny sensor wire inserted just under the skin to monitor blood sugar levels in the body), and an insulin pump to provide insulin, to manage the resident's diabetes. Review of the admission medication orders showed insulin was ordered, which included the rates and time intervals that the insulin was administered by the pump, and showed if the resident was unable to manage the pump, nursing staff were to remove the pump, and administer 26 units of long-acting insulin daily, and give a sliding scale dosage of short-acting insulin, based on the amount of carbohydrates the resident consumed at the meal and snack time. A telephone order dated the day of admission (08/18/2021) showed the physician was called to obtain instructions for the nursing staff when the resident's blood sugar levels were low, but no orders were found that instructed nursing staff on how or when to monitor the resident's blood sugar levels, or how to care for and maintain the CGM system and insulin pump. Review of the August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, no information was found in either the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 08/24/2021 diabetic care plan showed the interventions that were implemented were the standard generic interventions for a resident who did not utilize a CGM system, and were not specific to Resident 1's diabetic care needs. No interventions were found that informed nursing staff the resident utilized a CGM system or an insulin pump, nor did it include instructions on when or how to obtain the resident's blood sugars, how to maintain or care for the CGM system, how often to change the sensor, or what to do if there were problems with either the CGM or the pump. An 08/18/2021 admission progress note at 12:00 PM showed the resident had a CGM and an insulin pump, that the resident entered the amount of carbohydrates consumed into a cell phone, and then the insulin pump delivered the amount of insulin needed. From 08/18/2021 through 08/20/2021, documentation showed the resident communicated with the nursing staff the blood sugar levels and any signs and symptoms of high or low levels. However, those readings were not recorded in the record. On 08/21/2021 at 11:31 PM, a progress note showed the resident was complaining of not feeling well, groggy and numbness in her upper extremities (all can be symptoms of high and low blood sugar), and was sent to the hospital for evaluation. No documentation was found that showed the resident's blood sugar had been taken, or that the facility staff had disconnnected the pump and given insulin as ordered by the physician, since the resident may have not been able to manage reading their blood sugars and/or giving themselves insulin via the pump. The resident returned to the facility early morning on 08/22/2021 with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The blood sugar reading at that time was 138 (normal blood sugar range is 70 to 140). No documentation of the resident's blood sugar was found again until a progress note on 08/23/2021 at 8:54 PM, which showed the resident had been acting strange all day, was unable to hold a cup of water, and had not eaten dinner. The resident's blood sugar was checked by the nurse, found to be 138, and the provider was notified of the resident's condition. On 08/24/2021 at 12:33 AM, a progress note showed the resident's blood sugar was 170 via the CGM, the resident had not felt well all day, their speech trailed off, the resident did not open their eyes, and the dinner tray was sitting at the bedside untouched. At 2:00 PM, another progress note showed Resident 1 was dazed and confused, and unable to manage the monitoring of the blood sugars and the insulin pump. The note further showed the morning blood sugar level was 308, and the physician was notified, but there was no documentation or orders to show the resident had received any insulin for the high value of 308, nor was there any documentation of the blood sugar being retaken. A provider note at 2:11 PM the same day (08/24/2021) showed the resident was evaluated due to having strange behaviors over the past 2 days. Per the note, the resident's August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . No documentation was found to show the resident's blood sugar was being monitored until 8:36 PM at which time it was 307, and the resident was sent to the hospital for evaluation at the request of the family. On 08/25/2021 at 7:41 AM, a progress note from Staff C, Physician's Assistant, showed the resident had been admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 12/14/2021 at 9:40 AM, Staff A, Interim Administrator, was asked for the facility policy and procedure for monitoring blood sugars, and management and maintenance of insulin pumps (for residents who had CGM systems and insulin pumps). At noon on 12/14/2021, Staff D, Nurse Education Manager, provided paperwork that showed the licensed nursing staff had received training on the use of insulin pumps, but stated the facility did not have a policy or procedure for managing pumps or a CGM system. Staff D confirmed there were no residents in the facility currently with an insulin pump, and stated that the facility only accepted residents with them if they were self-managed. When informed no documentation was found that showed the resident's blood sugar and insulin were being monitored or assessed to ensure the resident was managing everything correctly, Staff D stated the resident self-managed the blood sugar levels and insulin administration. Staff D further stated if the resident was unable to manage the insulin pump or monitor blood sugar levels, the licensed nursing staff should shut the pump off, and blood sugar monitoring and insulin should be administered per the doctor's orders. In an interview on 01/07/2022 at 2:35 PM, Staff E, Licensed Practical Nurse, was asked how admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders were then checked by the medication nurse, to ensure accuracy. Staff E further stated they had not worked with Resident 1, but because it was rare to have a resident with a insulin pump, if they had been assigned to the resident, they would have made sure the orders were clearly understood, such as how and when to check the blood sugar levels, when to change the sensor, and how to change the insulin cartridge in the pump. In an interview on 01/07/2022 at 2:45 PM, Staff F, Charge Nurse, confirmed the process for processing admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing Resident 1's record, Staff F confirmed the orders for insulin had not been transcribed on admission, there were no orders for checking the blood sugar, the CGM sensor, or the insulin pump. Staff F stated when insulin orders were entered into the electronic record, the program prompted the nurse to enter the times/frequency for the blood sugar checks. However, the insulin orders were not transcribed, therefore, blood sugar checks were also not transcribed. During an interview on 01/07/2022 at 3:13 PM, Staff B, Director of Nursing, acknowledged the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the discussion about Resident 1, the surveyor expressed that failure to process the insulin orders, to monitor and assess the blood sugar levels, and to ensure the resident to was able to self-manage the CGM sensor and insulin pump resulted in harm to Resident 1, who required hospitalization for ketoacidosis. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to provide adequate supervision to prevent a fall for one of three sample residents (#1), reviewed for falls. This failure led to actual harm for Resident #1, who fell from a raised bed while unsupervised, and sustained a fracture. Findings included . According to the 02/11/2021 assessment, Resident #1 was admitted with [DIAGNOSES REDACTED]. The resident had memory impairments, difficulty making her needs known, and required extensive assistance with activities of daily living. Review of the resident's 01/29/2021 updated care plan showed the resident was at risk for falls due to weakness. The care plan showed the resident's bed was to be at the lowest position, fall mats on the floor, and staff were to frequently check the resident. A facility 03/17/2021 investigation showed the resident was receiving care with the bed raised about 2.5 feet off the floor. Per the investigation, as care began, Resident #1 started to become combative and scratched Staff A, Nursing Assistant. Staff A stepped away from the resident's bedside, and went to the door to ask for help. When Staff A was at the door she heard a thump, and turned around to see Resident #1 on the floor, laying on her right side. The resident was assessed for injury after the fall, range of motion was normal, and the resident had no complaints or signs of pain. The resident had an x-ray ordered the next morning, due to her history of fractures. On 03/18/2021, the resident's x-ray showed a [MEDICAL CONDITION], and she was transported to the hospital. During an interview on 03/31/2021 at 3:05 PM, Staff B, Director of Nursing, confirmed Resident #1's bed should have been lowered when Staff A left the bedside to get help. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure two of four sample residents (#1, 8), reviewed for resident-to-resident altercations, was free from physical abuse/assault. This failure resulted in actual harm to Resident #1, who sustained two small lacerations to his right forearm, and who had lingering emotional distress from the incident. This failure also placed these and other residents at risk for physical abuse/assault from two residents who reacted with physical aggression (#2, 9). Findings included . According to the facility policy titled, Abuse and Neglect Guidelines, dated (MONTH) (YEAR), each resident has the right to be free from physical and mental abuse and/or assault. The guidelines showed residents were not to be subjected to abuse by anyone, including other residents. In addition, the guidelines showed the facility was responsible to identify residents with a personal history which placed them at risk for abusing other residents, in addition to monitoring for changes that would trigger abusive behavior. Per the policy, the facility definition showed that abuse meant the willful infliction of injury .with resulting physical harm, pain, or mental anguish, and physical assault meant an intent to cause physical harm or injury to another person .any unlawful touching of another person .or, an action that causes a person fear of imminent harm. RESIDENTS #1 AND #2: Per the most recent quarterly assessment, dated 10/14/19, Resident #1 had [DIAGNOSES REDACTED]. The assessment further showed Resident #1 was cognitively intact for daily decision-making, used a wheelchair for mobility, and had no behaviors. According to Resident #2's most recent quarterly assessment, dated 10/24/19, she had [DIAGNOSES REDACTED]. The assessment showed that Resident #2 was moderately impaired in cognition, ambulated independently using a walker, and had delusions (a belief or altered reality that is persistently held, despite evidence to the contrary). According to the facility incident report, dated 11/11/19 at 11:35 AM, Resident #1 was sitting in the dining room, with the remote to the television on the table where he was sitting. Per the report, Resident #2 came over and took the remote, went back to her table, and started doing a crossword puzzle (not paying attention to the television). Resident #1 then went over to her table, picked up the remote, and went back to his table. The report showed Resident #2 then came after him, grabbed his arms to retake the remote, pushed his arms down by his wheelchair wheels, and then pushed him up against the wall behind him. As a result, Resident #1 received two lacerations to the arm. Resident #1 started yelling leave me alone, you're hurting me, you're hurting me! The incident report showed Resident #2 responded by saying, No, give them to me right now! (referrring to the remote control). Staff entered the room, and Resident #2 went back to her table. The residents were separated, and Resident #2 was moved from the first floor to the third floor, for closer supervision. In an interview with Resident #1 on 12/11/19 at 7:45 AM, he was asked about the events that occurred that day in the dining room. He stated he was in the dining room, and she (Resident #2) was at a table working crossword puzzles or something. He stated he went to get the remote to turn on the television. He was asked if he had told Resident #2 that he was taking the remote, and stated yes. He then stated that after he took the remote, she came over screaming at me and slammed right into me with her walker. Resident #1 demonstrated how she came at him with her arms open, grabbed his arm, and dug her fingernails into his right forearm. Observation of the resident's right forearm showed two areas approximately the size of a dime or less, in the middle portion of the forearm. The wounds had healed, but there were residual scars. Resident #1 stated that his arm bled pretty badly, and he screamed for help from staff. Resident #1 was asked if he and Resident #2 had any previous encounters, and stated yes. He stated that her room used to be across from his on the first floor, and she would come into his room all the time uninvited, and it disturbed him. He was asked if the staff were aware of her coming into his room, uninvited. He stated, yes, they knew about it. Resident #1 was asked how all this made him feel. He stated, looking at the wounds on his arm, I will have these scars for the rest of my life to remind me of it (the incident). He continued by stating that Resident #2 still made him feel very uncomfortable when they were in the same room, such as during activities, and he would leave and not participate to avoid her. In an interview with Resident #2 on 12/11/19 at 9:05 AM, she was seated in her room on the third floor, by herself. She was dressed, alert, and had clear speech, but had difficulty making herself understood, due to the inability to maintain consistent thought during the interview. She was asked why she was moved to the third floor, and stated she liked it there, but then stated the surveyor would know better than she did as to why she moved. Resident #2 was asked about why she was moved in her own words. She stated was playing cards with another guy, and he (Resident #1) came over and grabbed the remote. She stated he did not even ask her. She was asked if she was upset by this. She stated no, but that she did go and grabbed them back. She was then asked if she had pushed him or caused him any injury. She stated no, she did not push him, and did not know about any injury. In an interview on 12/11/91 at 12:30 PM, Staff C, Unit Manager, confirmed that the resident-to-resident altercation was substantiated as abuse. Staff C stated that the investigation showed that Resident #2 did cause the skin injury, and that Resident #1 was very shook up by the incident. Staff C was asked if there had been prior incidents between the two residents. Staff C stated that Resident #2 had a history of [REDACTED].#1's room, uninvited. He would slam the door, but there had not been any negative physical interactions between them, prior to this incident. Staff C stated that Resident #2 would get into other people's personal space because she wanted to help, and that redirection was a challenge. RESIDENTS #8 AND #9: According to the quarterly assessment, dated 11/21/19, Resident #8 had [DIAGNOSES REDACTED]. The assessment also showed Resident #8 was severely impaired in cognition and had no behaviors. Per the 11/21/19 quarterly assessment, Resident #9 had [DIAGNOSES REDACTED]. The assessment showed the resident was moderately impaired in cognition, and had physical behaviors that impacted others (and intruded on the privacy of others). Per the 11/20/19 facility incident investigation report, an incident was witnessed by Staff G, Social Services. The report showed that Staff G was walking down the hallway, when she observed Resident #9, who was seated in her wheelchair near the front desk, propel her wheelchair towards Resident #8, also seated in a wheelchair reading the newspaper, and with no warning or reason, reached over and aggressively pinched Resident #8's breast and side. Per the report, Resident #8 recoiled, and attempted to swat Resident #9's hand away in defense. As Staff G stood between the residents, Resident #9 was asked to stop her behavior, but she continued to reach around and grab Resident #8. After Staff G called for assistance, the residents were immediately separated. Per the investigation report, the root cause analysis showed that both residents had [DIAGNOSES REDACTED]. In an interview on 12/10/19 at 2:12 PM, Resident #8 was asked if she remembered the incident. She stated, Oh, yes I do, very well. I don't know why she did it, I was just reading the paper. She was able to demonstrate to the surveyor where she was pinched. During random observations of Resident #8 during the survey, there were no signs or symptoms of psychosocial harm. In an interview on 12/11/19 at 8:30 AM, Resident #9 was seated in her wheelchair, in front of the medication cart. She was asked if she remembered the incident, and stated she did not remember anything. She was asked if there had been an incident recently where she might have pinched another resident, and she stated no. In an interview on 12/11/19 at 11:23 AM, Staff C, Unit Manager, confirmed the resident-to-resident altercation was abuse, as it had been witnessed by staff. She stated that Resident #9 was cognitively intact, but would deny the incident occurred when asked. Staff C was asked if she was aware of any past history of behaviors for Resident #9, prior to admission, and stated yes. Staff C stated recently the resident had increased physical behaviors with staff, such as striking out and attempting to trip staff. She confirmed this was an out of the blue altercation with Resident #8, as she had not had any physical behavior with other residents, prior to this altercation. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure nursing staff provided pain medication and/or treatment in a timely manner to one of two sample residents (#199), reviewed for pain management. This failed practice resulted in harm to Resident #199, who experienced increased pain and emotional distress, due to a delay in receiving pain medication and treatment, upon his request. Findings included . Per the facility's entry tracking record, Resident #199 admitted to the facility on [DATE] following an acute hospital stay. Per the facility's progress notes dated 02/17/19, the resident was admitted following surgery to repair a fractured right hip, which he sustained as the result of a fall at home. In addition, the progress notes showed the resident's right shoulder had been dislocated (an injury in which your upper arm bone pops out of the cup-shaped socket that's part of your shoulder blade) in the fall, but was placed back into its socket (reset) in the hospital. In an interview on 02/19/19 at 7:37 AM, when asked how his care had been at the facility, the resident stated, to be honest, not good at all. He stated that it had taken 20-30 minutes for his call light to be answered on several occasions . He further stated that he had pressed his call light to ask for medication for pain relief at around 6 AM this morning, and had just received the medication a few minutes prior to the surveyor entering the room at 7:37 AM, or about an hour and a half after he requested it. The resident stated that he was in significant pain, about an 8 or 9 (on a pain scale of 0 - 10, with 0 being no pain, and 10 being severe pain), because his right shoulder had popped back out of socket following lunch on 02/18/19. Upon observation, the resident's right shoulder appeared crooked and lay below the level of his left shoulder. In addition, the resident's right arm was hanging motionless by his side. The resident stated that he had very little movement in his right arm at this point, due to it being dislocated. When asked if the staff had taken measures to ensure he received immediate treatment for [REDACTED]. No order was obtained for an immobilizer (a device to provide stability), until a determination was made related to the need for additional treatment. Review of the facility's call light response log for 02/19/19, showed the resident had pressed his call light to request medication for his pain at 5:38 AM. Per the record, the resident had narcotic pain medication ordered to be given twice daily, and every four hours as needed. A review of the medication administration record (MAR) for 02/19/19, showed the resident had not received the requested medication until 7:15 AM, or more than an hour and a half after he requested it. The MAR showed the last dose of the scheduled narcotic had been given the prior evening. A follow-up interview was completed with the resident on 02/19/19 at 11:57 AM. The resident stated that his arm really hurt, about a nine or 10. The resident further stated that he had been seen by Staff S, Nurse Practitioner, who told him he was prescribing an anti-[MEDICAL CONDITION], and told the resident we should wait and see if it worked. The resident stated that he had told Staff S his shoulder had a tendency to dislocate, but he could usually manipulate his arm back into the socket. The resident further stated that he had told Staff S he hadn't been able to do that this time, and was in significant pain. The resident also stated that when he had asked Staff S about going to the emergency room to get his shoulder reset, Staff S stated that he didn't think it would help, and the resident needed to wait and see if the new medication reduced the swelling. Staff S was unavailable for interview. A nursing progress noted dated 02/20/19 at 3:04 PM, showed the x-ray taken of the resident's right shoulder on 02/18/19 confirmed it was dislocated. The note also showed the resident stated on 02/20/19 at 11:50 AM, that his right shoulder pain was a nine out of 10 on the pain scale, was given as needed (PRN) pain medication (the effectiveness was not documented on the MAR), and requested to be transported to the emergency room to get his shoulder reset. The resident was sent by ambulance to the emergency room at 12:10 PM, or two days after his shoulder was dislocated at the facility. Additional review of the MAR showed the resident had requested PRN medications, for increased pain, six times between 02/18/19 and 02/20/19, before he was transported to the emergency room . In a follow up interview on 02/21/19 at 8:14 AM, the resident stated that the hospital gave him different medications, reset his shoulder, and placed a sling on him that kept his arm up and against his body. He stated that his pain had decreased significantly with treatment. He stated that facility staff still had not wanted to send him to the emergency room , even after he requested it, so he demanded to go yesterday (02/20/19). In an interview on 02/21/19 at 12:55 PM, Staff E, Resident Care Manager, stated that Staff S had spoken to the resident and offered to send him to the ER, but the resident and his wife had declined to have the resident sent out. In a follow up interview on 02/21/19 at 1:08 PM, the resident and his wife both stated that the facility had not offered to send him out, and in fact, when they had requested to go to the emergency room to have the resident's shoulder reset, the nursing staff said they had to get Staff S's permission to send the resident out. There was no documentation present in the resident's clinical record that showed a discussion was had with the resident related to going out to the emergency room , and/or the resident's refusal to go. In an interview on 02/21/19 at 1:35 PM, Staff A, Administrator, stated that the resident should have been sent to the emergency room immediately related to his change of condition (shoulder dislocation and pain) and because he and his wife had requested it. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure two of three sample residents (#39, 27), reviewed for mobility, received care and services to maximize their range of motion and mobility. This failure placed the residents at risk for decreased ability to freely move their joints, pain related to debility, and/or increased weakness, and caused harm to Resident #27, who experienced a decline in his ability to maneuver his left hand. Findings included . 1. According to Resident #27's assessment dated [DATE], he had short and long term memory problems, and required assistance with his activities of daily living, which included bed mobility, transferring, toileting and hygiene. The assessment showed he had no functional limitations in his upper or lower extremities. During an observation and interview on 02/12/19 at 10:19 AM, Resident #27 was seated in a wheelchair in his room. His left hand was flexed downward at the wrist joint at rest, and his fingers were turned inward. He did not have a splint on his wrist or any palm protector device to keep his fingers from staying in a fist position. When asked at that time whether he could extend his wrist and fingers, the resident attempted to, and could not. When asked whether he had anyone helping him to exercise his joints in his hand and wrist, he said, No, but it needs it. In an interview on 02/20/19 at 9:32 AM with Resident #27's representative, when asked whether the resident had stiffness in his left hand and difficulty extending his wrist or hands when he arrived at the facility, the representative said she did not remember him having it before, but he did now. When asked whether the facility was providing any exercises for that wrist and hand, or a splint, she said she was not aware of the facility providing that. Review of the restorative documentation for Resident #27 showed he received restorative therapy, which included active range of motion, until 11/06/18 (a restorative program consists of nursing interventions aimed at assisting the resident to maximize their functioning outside of a formal physical or occupational therapy program). Review of the progress notes for that time period showed no indication of why the program was discontinued. There was documentation that the resident had declined the programs on 11/06/18, but prior days, including 11/01/18, 11/03/18, and 11/04/18, he had accepted active range of motion. In an interview on 02/21/19 at 12:55 PM, Staff J, Restorative Nurse Supervisor, stated there was no note in the record related to the resident's end of restorative services, so she was not able to answer why they ended. In an interview on 02/20/19 at 3:37 PM, Staff I, Resident Care Manager, stated she was not aware of any issue with Resident #27's left hand or wrist. In an observation on 02/20/19 at 3:44 PM, Resident #27's left wrist was flexed downward at rest, and his fingers curved inward to a fist position. Staff I asked Resident #27 to extend his wrist and fingers. The resident was not able to do so. Staff I provided passive range of motion, and was able to get Resident #27's wrist to move from the flexed to neutral position (in line with the forearm). It did not extend upward past the neutral position. Staff I also provided range of motion to the fingers, which she was able to extend almost to a flat position, in line with the hand. During the observation, Staff I stated Resident #27 still used that hand to self propel his wheelchair. The resident was not observed self-propelling his wheelchair during the survey time period. Review of an occupational therapy screening dated 02/20/19 showed New development of wrist drop to left wrist (the wrist is in a flexed downward position). Would benefit from splinting and ROM (range of motion) program. The record showed the resident did not receive routine range of motion services after 11/06/18, and that the resident's left hand and wrist became impaired, whereas they were not when he admitted to the facility. 2. In an initial interview on 02/12/19 at 10:57 AM, Resident #39 stated she should have been exercising with a restorative program three times per week, but it had not been happening routinely. She stated she felt she needed the sessions to get her strength back. In an interview on 02/20/19 at 1:16 PM, Staff J, Restorative Nurse Supervisor, stated all residents on a restorative program should receive it three to six days per week. Review of the restorative documentation for (MONTH) and (MONTH) 2019 on 02/20/19 showed Resident #39 did not get her restorative program from 01/15/19 to 01/24/19 (a nine day gap between sessions), 02/01/19 to 02/07/19 (a six day gap between sessions), and from 02/11/19 to 02/18/19 (a seven day gap between sessions). In further interview on 02/21/19 at 1:01 PM, after reviewing the concerns with lack of consistent implementation of the restorative program for Resident #39, Staff J stated the biggest barrier to providing the programs consistently was that staff in the restorative department were re-assigned to accompany residents on outings, or to assist on the floor. Reference: (WAC) 388-97-1060 (3)(d)

Based on observation, interview and record review, the facility failed to ensure care and services were provided to appropriately monitor and treat a wound for two of four sample residents (#27, 16) reviewed for wounds or skin conditions. This failure placed the residents at risk for worsening wounds or untreated skin conditions, and caused harm to Resident #27, who experienced a worsening wound with infection. Findings included . 1. According to Resident #27's assessment dated [DATE], he had short and long term memory problems, and required assistance with his activities of daily living. His [DIAGNOSES REDACTED]. In an interview on 02/20/19 at 11:26 AM, Staff P, Registered Nurse, stated nurses assigned to the weekly skin checks were expected to document each wound's description and measurements on the form in the computer, every week. Review of the progress notes showed on 10/18/18, the resident experienced pain when his right heel was touched. There was no description of what the resident's heel looked like at that time. The first progress note referring to a wound to the right heel was dated 10/24/18. The note stated the wound was approximately 4.5 centimeters (cm) in diameter, and the dressing was dried to the skin. The note indicated the nurse used normal saline (a cleaning solution) on the dressing to help separate it from the wound. Although the progress notes showed the resident had pain to his right heel on 10/18/18, and first referred to a right heel wound on 10/24/18, review of the Treatment Administration Records (TARs) showed there were no wound care orders in place until 12/25/18. Nursing notes and skin assessments showed the wound dressing was changed intermittently between 10/24/18 and 12/25/18 without an order, and the wound deteriorated as follows: On 10/27/18, a progress note showed the resident complained of pain to the heel earlier in the day, and that the wound dressing was changed. A visual skin inspection associated with a weekly skin check dated 11/06/18 showed the heel wound was 15.0 cm. x 11.0 cm. (much larger than the earlier documented size on 10/24/18). It showed the wound had eschar, (according to the State Operations Manual,Eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like). There was no indication in the note that the provider was notified of a change in the wound's condition. A progress note on 11/10/18 described that the wound dressing was changed, and noted there were no dressing change orders for the resident in the electronic record. An 11/13/18 skin assessment showed the wound was 5.9 cm. x 5.0 cm., and the dressing was changed. The next record that the dressing was changed was 12 days later, on 11/25/18. The nurse documented the right heel dressing had to be removed with normal saline, and that the heel was tender to touch. The 12/04/18 skin assessment showed the dressing was changed on that date (nine days from the previous dressing change). On 12/05/18, the nursing notes showed the dressing was changed. According to the 12/11/18 skin assessment, the dressing was changed, and the wound measured 3.0 cm. x 4.0 cm. A nursing progress note from 12/17/18 showed the right heel wound was 10.0 cm. x 7.0 cm., and had a foul odor. There were no associated notes to state that the provider was notified. The TAR for (MONTH) (YEAR) still reflected there were no orders for wound care to the heel on this date, and nurses were not documenting ongoing wound care. The next note that the dressing was changed, was one week later on 12/24/18. The note showed Resident's heel was gangrenous (gangrene is a condition in which the tissue dies). The note described that the wound had a strong odor, and moderate white drainage. The note showed the provider was notified at that time. Additionally, the nursing notes and skin assessment forms from 10/24/18 to 02/21/19 showed the following gaps between times that the resident's wound was measured and described: 11/13/18-12/04/18, 12/17/18- 01/01/19, 01/01/19-01/22/19, and 02/05/19- 02/21/19. They were not done weekly, to track the condition of the wound regularly. Dates when the skin assessment was declined by the resident, there was no evidence that it was attempted again the next shift, or the next day. Per the documentation it was attempted again the next week, leaving long periods between the wound assessments. Review of a provider note dated 12/25/18, showed he assessed the wound as the dressing was changed, and described it as having a bad odor. The note showed the resident would be given antibiotic medication to be treated for [REDACTED]. An additional provider note, signed 12/30/18, showed the wound was likely vascular in nature (due to changes in blood flow to the area). Review of the Medication Administration Record [REDACTED]. In an observation on 02/20/19 from 2:04 PM to 2:12 PM, Staff P, Registered Nurse, changed Resident #27's dressing to his right heel. When Staff P removed the covering dressing, the wound appeared covered in black eschar, which was separated from the wound borders by a small gap around the circumference. The tissue under the eschar, visible in the gap, appeared covered in thick, opaque drainage. Per Staff P, the area measured 6.0 cm. by 8.0 cm. She stated staff were trying to keep it as dry and clean as possible. During the dressing change, the resident complained of discomfort, which was alleviated after the care was finished. Staff P commented that the wound was not as odorous as it had been over the weekend. In a telephone interview on 02/27/19 at 3:59 PM, Staff I, Resident Care Manager, stated when there was a new wound, the orders for treatment were typically initiated within a day. The resident's wound deteriorated during a period when he did not receive consistent wound care, and did not have active dressing change orders. 2. Per the 11/02/18 assessment, Resident #16 was moderately cognitively impaired for decision making, but was able to make his needs known. On 02/12/19 at 3:01 PM, Resident #16 was observed sitting in a recliner in his room watching television. When asked about his care at the facility, he stated there were some spots on his skin that someone was supposed to look at, but they never did. Several small spot-like [MEDICAL CONDITION] were observed by the resident's left eye, on the top of his head, and on his arms. A provider note on 05/09/18 by Staff T, Nurse Practitioner, documented the lesion on the resident's forehead was assessed and a referral to a dermatologist (a doctor who treats skin conditions) was made, due to the dark coloring and irregular borders of the lesion. A review of the physician orders [REDACTED].#16 to see a dermatologist was made on 05/09/18. Further record review did not show any documentation that an appointment to a dermatologist was made, or that the resident had been to a dermatologist. In an interview on 02/19/19 at 11:29 AM, Staff H, Resident Care Manager, stated documentation from the dermatology appointment should be in the resident's record. When informed that no documentation was found, Staff H, stated she would check with medical records. In a follow-up interview with Resident #16 on 02/19/19 at 1:14 PM, when asked if he had been to a dermatologist, he stated, They were supposed to send me to one quite a while back but nothing ever came of it. He then pointed to the [MEDICAL CONDITION] on his left hand, left eye, and top of his head and stated, It may not be anything, but what the hell are these things? I would like to know. On 02/19/19 at 4:00 PM, Staff LL, Medical Records, provided a copy of an email correspondence dated 06/12/18, showing the dermatology appointment on 06/11/18 for Resident #16 was rescheduled for 07/19/18, due to the resident refusing to go. No additional documentation was found to show whether/not the resident attended the re-scheduled appointment on 07/19/18. On 02/21/19 at 11:42 AM, Staff S, Nurse Practitioner, confirmed there was no further documentation that showed if Resident #16 had gone to the dermatology appointment. Reference: (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to ensure staff provided effective pain management in a timely manner, for one of six sample residents (#1), reviewed for acute pain. This failed practice resulted in actual harm, with the resident experiencing severe pain and emotional distress. Findings included: According to the record, Resident #1 was discharged from the hospital and admitted to the facility on [DATE], to recover from a [MEDICAL CONDITION] syndrome and bacterial pneumonia. The record showed the resident had a sudden onset of acute pain, starting on 01/17/18. Review of Resident #1's most recent comprehensive assessment, dated 01/16/18, showed the resident scored 12 on the Brief Interview for Mental Status (BIMS), and was verbally able to make his needs known. In addition, the assessment revealed the resident did not have any pain or behaviors, such as rejection of care, during the assessment observation period. Review of Resident #1's care plan related to pain management, dated 01/10/18, included the following: Problem: At risk for pain. Goal: Resident will state relief or reduction in pain within one hour of intervention. Interventions: - (Administer) pain medication per MD (Medical Doctor) orders. - Monitor pain intensity following medication treatment. - Reassess pain management efficacy as needed. Review of Resident #1's January 2018 Medication Administration Record [REDACTED]. In an interview on 02/20/18 at 2:17 p.m., Staff B, Licensed Practical Nurse/Resident Care Manager, described the facility process for resident pain management. It included pain assessment, administration of pain medication as ordered and requested by a resident, monitoring, and documentation. Staff C further stated the information required for resident pain management was located in the MAR indicated [REDACTED]. Staff used the pain intensity scale (0-10) for residents able to verbalize pain. Review of the facility pain intensity scale/blue sheet, showed pain was rated from 0 to 10, with 0 being no pain, and 10 being excrutiating pain. Review of a facility investigation showed on 01/17/18 at 11:00 p.m., Resident #1 stated to Staff A, Registered Nurse (RN) he had mid-scapula (upper back) pain. Staff A assessed the resident's blood pressure, heart rate, respirations, and temperature. At 12:30 a.m. on 01/18/18 (an hour and a half after the resident's initial report of pain), Staff A returned with [MEDICATION NAME] (an over-the-counter pain medication), Tums (an antacid), and [MEDICATION NAME] (a medication for anxiety). At approximately 4:00 a.m., Staff A returned to Resident #1's room. The resident stated he was in so much pain, he wanted to harm himself. The investigation did not show any documentation of the 0-10 pain intensity scale being used at 11:00 p.m., 12:30 a.m., or approximately 4:00 a.m. (when the resident expressed severe pain, and wanted to harm himself). In addition, the investigation did not show additional pain medication was provided, after the resident wanted to harm himself, and expressed severe pain. Review of the progress notes showed one note written by Staff A, on the 01/17-18/18 night shift (from 10:00 p.m. to 6:00 a.m.). The note was written on 01/18/18 at 3:31 a.m., and showed Resident #1 was in severe pain, and stated to Staff A, Do you have any string/rope so I can kill myself? The progress notes did not show any additional pain medication was provided, or physician phone contact made. On 01/18/18 at approximately 8:00 a.m., Staff B, LPN/RCM, interviewed Staff A by phone. Staff A stated no additional pain medication was provided to Resident #1 after 12:30 a.m., and stated, Yea, I probably should've called the on-call (doctor) or something else. In an interview on 02/20/18 at 1:36 p.m., Staff C, Director of Nursing (DON), stated, one and a half hours is too long to wait for pain medication (from 11:00 p.m. to 12:30 a.m.). Staff C stated staff were instructed to provide pain medication as ordered, within 15 minutes of request from a resident. He stated that was our facility goal. At 2:17 p.m. on 02/20/18, Staff B confirmed Staff A did not follow the facility process, related to pain management. Staff B stated the process included aspects of assessment, monitoring, documentation, and administration of ordered pain medications. Resident #1 was unavailable for interview. Reference: (WAC): 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (#1), reviewed for anticoagulant therapy (the administration of medication to prevent blood clots) was adequately monitored for therapeutic dosing, while receiving a high risk medication. This failure resulted in harm for Resident #1, who experienced a gastrointestinal (GI) bleed, and hospitalization . Findings include: Resident #1 was admitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. The resident's plan of care, dated 03/03/17, identified a potential for bleeding, related to taking a blood thinner ([MEDICATION NAME]). Staff were directed to monitor the resident's laboratory values, including the INR (INR stands for international normalized ratio - the PT/INR test is usually done when taking a blood thinning medicine, such as [MEDICATION NAME]), and to monitor for signs and symptoms of bleeding. Per review of admission orders [REDACTED]. The PT/INR lab test determined the effectiveness of the [MEDICATION NAME], so the medication could then be adjusted, according to the results. A facility investigation, dated 03/09/17, indicated Staff B, a registered nurse, processed the admission orders [REDACTED]. Per review of the Medication Administration Record [REDACTED]. Progress notes dated 03/06/17 documented the resident went out of the facility for a physician appointment. The resident returned with new orders, and it was noted her INR was 4.3 (a therapeutic level is between 2.0 - 3.0). The resident's [MEDICATION NAME] was held. On 03/07/17 at 4:15 a.m., progress notes documented the resident had a large melenic stool (dark, tarry stools that usually indicate bleeding in the upper part of the digestive system). The resident complained of being dizzy when moving, and her blood pressure was 90/30 (normal range is 120/80). The resident was sent to the hospital. Hospital notes were obtained and reviewed. On arrival to the hospital on [DATE], the resident was described as pale. She verbalized she needed to have a bowel movement, and then became unresponsive. It was noted the resident had a large volume of melenic stool. The resident's INR was 5.5, and she received 2 units of blood. The resident received Vitamin K (used to reverse the effects of [MEDICATION NAME]), related to a life-threatening [MEDICAL CONDITION], and was admitted to the Intensive Care Unit (ICU). During an interview on 04/04/17 at 10:15 a.m., Staff C, director of nursing, stated if a resident was admitted with [MEDICATION NAME] orders, staff were to follow the admission orders [REDACTED].e., periodic PT/INR testing), nursing staff were expected to call and and get orders. Staff C confirmed Staff B had not ordered the INR to be drawn daily for 5 days as ordered, so no INR was drawn until 03/06/17. Staff C indicated the nurse had been terminated, other licensed nursing staff were in-serviced, and nurse managers were doing audits, to determine that physician orders [REDACTED]. Reference: (WAC) 388-97-1060(3)(k)(i).

Based on interview and record review, the facility failed to ensure a registered nurse (Staff B), met the professional standard of coordinating care, by accurately implementing physician orders, for 1 of 5 residents (#1), reviewed for anticoagulant therapy (the administration of medication to prevent blood clots). This failure resulted in actual harm to Resident #1, who experienced a gastrointestinal (GI) bleed. Findings include: According to the Lippincott Manual of Nursing Practice, Tenth Edition (Lippincott, Williams & Wilkins, 2014, page 16), The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practioners are accountable. Resident #1 was admitted from the hospital on [DATE], with [DIAGNOSES REDACTED]. The resident was alert, oriented, and able to make her needs known. The resident's plan of care, dated 03/03/17, identified a potential for bleeding, related to taking a blood thinner ([MEDICATION NAME]). Staff were directed to monitor the resident's laboratory values, including the INR (INR - stands for international normalized ratio. The PT/INR test is usually done when taking a blood thinning medication, such as [MEDICATION NAME]), and to monitor for signs and symptoms of bleeding. Per review of admission orders [REDACTED]. The PT/INR lab test determined the effectiveness of the [MEDICATION NAME], so the medication could then be adjusted, according to the results. A facility investigation, dated 03/09/17, indicated Staff B, a registered nurse, processed the admission orders [REDACTED]. The INR on 03/06/17 was 4.1 (a therapeutic level is between 2.0 - 3.0), and per the record, the resident was sent to the hospital on [DATE], with a GI bleed. Although Resident #1 had orders to have daily INR levels to be drawn for 5 days, Staff B did not implement the orders as written, or act within professional standards of practice. The resident was sent to the hospital the morning of 03/07/17, after having melenic stools (dark, tarry stool that usually indicates bleeding in the upper part of the digestive system). (See F 329 for additional information). Reference: (WAC) 388-97-1620(2)(b)(i)(ii), (6)(b)(i).

Based on observation, interview, and record review, the facility failed to maintain a safe environment to prevent accident hazards, for 1 resident (#1), in a sample of 4. This resulted in actual harm for the resident, who wandered into an unsecured construction area, fell , and suffered a brain bleed and a large cut to her head, requiring hospitalization . The facility failed to take immediate corrective actions to prevent a similar accident, and protect other vulnerable residents from harm. In addition, the facility failed to protect residents from hazardous objects, that were left in an unsecured construction area. An immediate jeopardy was identified on 02/28/17 at 3:55 p.m. Findings include: Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. According to her care plan on that date, she ambulated with a walker and stand by assistance. According to the record, she was able to bear weight, but was weak, and was at high risk to fall. It also documented she was very forgetful at times, and had wandered into other resident rooms. According to a facility investigation dated 02/23/17, on the night of 02/22/17, Resident #1 was found lying on the ground near a piece of equipment, at the far end of a construction area, at 12:30 a.m. The investigation indicated she was last seen at 10:00 p.m., in her room. When staff found the resident, it was reported she was bluish-gray, both from dust and cold temperatures. The construction area had holes in walls, which were open to the outside. The resident was found with a large gash on the back of her head, and multiple small skin tears and bruising, around both hands. According to Staff C's statement, there were multiple objects on the floor around her, including: a chemical spray bottle, extension cords, plastic tubing, and plastic tarps. She was sent to the hospital for evaluation, and admitted with [DIAGNOSES REDACTED]. Per the hospital Emergency Department record, dated 02/22/17, Resident #1 was found in a construction zone; it was unclear how long she had been exposed to cold temperatures, but she had signs of trauma. The facility investigation determined Resident #1 had exited her room, taken the elevator up to the main level, opened an unlocked door to the construction area, and tripped over equipment. The investigation also determined the door to the construction area was left unlocked by staff , because a hall light switch was located behind the door (and they failed to relock the door after accessing the switch). Per the investigation, to prevent further incidents, the facility installed an alarm on the door leading to the construction area, and moved the hall light switch, to be accessible to staff without having to unlock and/or access the construction area. During observations on 02/28/17 at 9:20 a.m., the door leading to the main construction area was labeled, and the alarm was visible; however, the door was unlocked, and the alarm was not on. In the same general area, a door (to Room 221) was marked work in progress; a padlock was visible, but not locked. The surveyor was able to open the door, and observed metal framed-in rooms, buckets of building material, and cords on the floor. No workers were present. At 9:48 a.m., the same day, Room 220 was observed unlocked and unattended. The room had a large ladder leaning against the wall, a spray bottle of chemicals (unlabeled), and what appeared to be extra furniture, stacked in the room. At 9:50 a.m., Staff A was alerted to the unlocked areas. He said the main construction door was unlocked and unalarmed during the day, because workers were present. He confirmed Rooms 220 and 221 should have been locked for resident safety. During a tour of the Garden level at 11:20 a.m., Rooms 109, 115, 116 (normally resident rooms) were marked work in progress. The rooms were unlocked, and unattended. The rooms contained power tools, long metal pipes, multiple cords, ladders, and plastic (covering the walls and furniture). Staff A confirmed the rooms should not be left unattended, because there was no way to lock them. According to Staff A, the facility had 3 residents who were known wanderers - two resided on the Garden level and one on the main level. The facility was aware of the safety hazards related to the construction, however, they failed to ensure residents were consistently safe, by leaving doors to construction areas unlocked and unattended. This resulted in a serious injury requiring hospitalization for one resident, and placed other residents at risk for accidents/injury.

Based on observation, interview, and record review, the facility was not administered in a manner to ensure the safety and well-being of residents, during a multi-phase construction project. As a result, 1 of 4 sample residents (#1) fell in the unsupervised construction area, causing serious injuries which required hospitalization . In addition, because of inadeqate corrective action and monitoring, other residents were placed at risk, secondary to having multiple unsecured areas, with numerous accident hazards. Findings include: The facility began a multi-phase construction project in 2016. A plan was developed, prior to the project start, to protect the safety of residents, residing in the the facility during the construction. A review of the Functional Program, dated 5/5/16, included measures such as: - During each phase of construction, a temporary wall will be constructed, to block off the areas of construction from the rest of the facility. - All individualized care plans and safety measures will be implemented and signed off by nursing care manager, to ensure safety and comfort for the residents. - Prior to, during, and after each phase, team leaders from both the construction side and the management side will meet to discuss all possible impacts to patients and staff, and will implement any necessay plans to ensure safety to everyone. Per observation, interview, and record review, on 02/28/17 and 03/01/17, the items mentioned in the plan were found not to have been done. (See F-323 for more detailed information).

Based on observation, interview, and record review, the facility failed to provide care and services to prevent, monitor, or heal pressure ulcers for 2 of 4 residents (#72, 256), reviewed for pressure ulcers. Failure to ensure skin was assessed thoroughly and periodically, and effective interventions were in place before the pressure ulcers developed, caused actual harm to Resident #72, who developed 2 pressure ulcers, and placed both residents at risk for worsening skin conditions. Findings include: 1. According to the comprehensive assessment pertaining to her 12/30/16 admission, Resident #72 had [DIAGNOSES REDACTED]. She required extensive assistance with activities of daily living, including bed mobility and transfers, and did not have any unhealed pressure ulcers. The admission head to toe skin assessment, dated 12/30/16 identified redness to the resident's buttocks area, with no open areas. The assessment noted no skin breakdown to the resident's heels. Review of the nursing progress notes during that time revealed no accompanying description of the resident's skin (in particular the area of redness), upon admission. In an interview on 02/13/17 at 10:59 a.m., Staff E, resident care manager, was asked whether the redness to Resident #72's skin, initially identifed on admission, was described anywhere in the nurses' notes. After review, she confirmed it was not. Resident #72's initial, undated care plan, identified she was at risk for alteration in skin integrity, related to factors including: having a surgical wound, incontinence, immobility, and pain. The interventions listed included: educating the resident on repositioning, pressure reducing materials for her bed and chair, elevating the heels off of the bed surface, repositioning the resident in the bed, and weekly skin checks. Review of the Weekly Pressure Ulcer Progress Report, dated 01/05/17, revealed the resident had 3 wounds on her buttocks/coccyx (tailbone area). The notation included measurements of the areas, but did not describe what they looked like, or what type of wounds they were. Review of the nursing progress notes for that date (or any previous dates) also revealed no wound descriptions. Additionally, the record did not indicate what, if any, additional interventions would be implemented to prevent worsening of the wounds. Review of the Treatment Administration Record for January 2017 revealed inconsistent skin monitoring. The weekly skin checks were completed for 2 of 5 weeks, rather than weekly, as ordered. In an interview on 02/13/17 at 10:59 a.m., Staff E was asked about the expectation for nurses to document skin assessments. She stated they should be done weekly, but they had not been done consistently. When asked how nurses should respond when the resident refused a skin assessment, or the assessment was not done for any reason, she stated it should be passed on to the next shift, and the resident should be re-approached. Review of the facility incident reporting log revealed skin related entries for Resident #72. An investigation for an 01/11/17 entry, documented staff noted irritation . at gluteal cleft (the groove between the buttocks) area while changing brief . Area is reddened, but blanchable (indicating the skin did not stay red when pressure was applied, then released) . The form stated the resident would receive a healing air mattress. The investigation attributed the skin issue to the resident's resistance to repositioning, because of her [MEDICAL CONDITION]. A second investigation report, dated 02/06/17, identified a heel pressure ulcer was noted on 01/19/17. Over two weeks had passed between the time the pressure ulcer was identified, and when the investigation was completed. Again, the investigation attributed the pressure ulcer to Resident #72's immobility and resistance to floating heels or repositioning. A revision to the care plan, dated 02/08/17, instructed staff to apply a pressure reducing boot to her left heel. Review of progress notes, from 12/30/16 through 02/07/17, revealed no mention of the resident resisting repositioning or heel floating. The record did not show any education had been provided to the resident regarding the importance of repositioning, elevating her heels, or any alternative approaches. A progress note, dated 02/07/17, indicated the resident's wound to her coccyx had grown, and was worse than before. In an interview on 02/07/17 at 3:54 p.m., Staff E described Resident #72's coccyx pressure ulcer as unstageable because of a layer of slough over the wound (slough is dead tissue covering the wound bed) and her heel pressure ulcer as suspected deep tissue injury (meaning the skin is closed, but the underlying tissues were likely damaged due to pressure). In an interview on 02/13/17 at 8:42 a.m., Staff E stated Resident #72 was initilly receiving barrier cream to her buttocks, at the time of admission. After Resident #72's coccyx wound worsened, they implemented the pressure reducing mattress. She further confirmed the boot for the resident's heel was not implemented until after the resident developed the pressure ulcer. The surveyor observed wound care on 02/09/17, from 11:20 a.m. to 11:37 a.m. Initially, the resident was lying in bed on her back, with socks on, and no heel boot. Wound care was provided by Staff I, while a visiting nurse was present to assess the pressure ulcers, and to provide recommendations. During the observation, the visiting nurse stated the coccyx wound would take time to heal, and healing would not begin until the slough area came off. She recommended the treatment to Resident #72's heel be changed to keep it dry, and suggested a boot for the heel, in addition to the pressure relieving mattress. Staff I replied the resident had a boot, but she removed it when they tried to put it on. Resident #72 reported pain to her coccyx area during the dressing change. When the visiting nurse consultant asked about how bad the pain typically was on her bottom, the resident reported it was horrible pain. 2. Per the admission assessment, Resident #256 was admitted to the facility with [DIAGNOSES REDACTED]. The comprehensive admission assessment, dated 01/18/17, indicated the resident was cognitively intact for daily decision-making. She required limited to extensive assistance for activities of daily living, was at risk for developing pressure ulcers, and received oxygen therapy. A handwritten, initial care plan, which was done upon admission, indicated the resident was at risk for alteration in skin integrity. An intervention included to have weekly skin checks. A review of the Weekly Skin Integrity Review form, indicated the resident's skin was initially assessed upon admission. Per review of the record, there were no other skin assessments completed, until the resident discharged from the facility, on 2/10/17. In addition, the January and February 2017 Treatment Administration Records indicated staff were to check the resident's ears twice daily for irritation, and ensure tubing pads were over her ears. In January 2017, this was documented zero times out of 41 opportunities. In February 2017, it was documented 7 times out of 11. A Non-Pressure Skin Condition Record, dated 01/27/17, indicated the resident was observed to have a pressure ulcer on her right ear, which measured 0.5 x 0.5 cm. A nursing progress note, dated 01/27/17 at 3:31 p.m., indicated there was a pressure ulcer behind her right ear, which measured 0.5 cm (centimeters), which was red and non-blanchable (skin that does not lose color when pressed), with a 0.3 cm tan scab over it. Foam ear protectors were placed on the oxygen tubing behind both ears. No drainage was present. The progress note further stated, Will place on alert charting (every shift charting for a specific problem). Nursing progress notes were reviewed, from 1/28/17 through 02/02/17. No documentation on the condition of the resident's right ear wound was found. A nursing progress note, dated 02/02/17, indicated the pressure area was a stage 1 (intact skin) and measured 0.5 cm. From 02/03/17 to 02/07/17, there was no nursing progress notes documenting the status of the pressure ulcer, or evidence the wound had healed. The record did not contain documentation to reflect the physician was notified of the pressure ulcer. In an interview on 02/09/17 at 2:59 p.m., the resident was asked if she had any skin breakdown on her ears. She stated, Yes, I used to, but it's healed now, It was from the oxygen tubing. An observation of the resident's right ear did not show any skin breakdown. In an interview on 02/10/17 at 9:49 a.m., Staff O, registered nurse, was asked if the pressure ulcer to the resident's right ear was documented on the treatment record per the order. She stated no. Staff O was asked if there was any documentation regarding wound status, treatments, or nursing progress notes related to the resident's pressure ulcer. She stated, I don't see anything regarding this in her chart. In an interview on 02/10/17 at 1:44 p.m., Staff G, resident care manager, was asked if the documentation regarding checking her ears for irritation, prior to the resident developing a pressure ulcer, was consistently documented. He stated, No, it wasn't. The facility failed to complete skin assessments consistently, thoroughly, and as per physician orders, for residents who entered the facility with skin alterations (or were identified at risk). Additional preventative interventions were not added, or consistently implemented. As a result, two residents developed new and/or worsening pressure ulcers, which were avoidable.

Based on interview and record review, the facility failed to ensure 1 of 6 sample residents (#1), was not administered a medication that the resident was known to have had an adverse reaction to in the recent past. The failed practice resulted in harm to the resident who suffered a severe allergic reaction requiring hospitalization . Findings include: Resident #1 was alert, able to make her needs known, and had [DIAGNOSES REDACTED]. Per record review, the medication [MEDICATION NAME] was prescribed by a Nurse Practitioner at the facility on 8/5/13 to treat the resident's high blood pressure. On 11/8/13 the medication was discontinued as the resident was noted to have signs/symptoms of [MEDICAL CONDITION] (an allergic reaction causing swelling of the lips, tongue, & throat). The swelling resolved after the medication was stopped. On 12/20/13 a different Nurse Practitioner at the facility wrote an order to start [MEDICATION NAME]. The resident received one dose of the medication on 12/21/13 and on 12/22/13 was noted to have swelling to the left side of her tongue. The physician was consulted and the [MEDICATION NAME] was discontinued. [MEDICATION NAME] medication was administered, but the swelling progressed until the resident's lips and entire tongue were involved. Due to the risk of potentially life threatening airway complications, the resident was transferred to the hospital for further evaluation and treatment. Upon arrival at the hospital, the resident was intubated to protect her airway and placed on a ventilator before being transferred to the Intensive Care Unit. Per hospital records, the resident experienced a severe allergic reaction to [MEDICATION NAME] and should not be given any medications in the same drug classification known as ACE Inhibitors. The facility investigation of the incident determined that when the [MEDICATION NAME] was discontinued on 11/8/13, the licensed nurse failed to add the medication to the, "Allergy and Reactions to Medication" sheet in the medical record, or to notify the pharmacy so the resident's reaction to the medication could be documented in their records. On 11/21/13 an administrative nurse caught the omission and added [MEDICATION NAME] to the, "Allergy and Reaction to Medication" sheet in the medical record, but did not notify the pharmacy. On 12/20/13 the Nurse Practitioner (not an emplyee of the facility), wrote orders for [MEDICATION NAME] after noting the medication was not identified as an allergy on the pharmacy generated physician order [REDACTED]. The licensed nurse who transcribed the order for [MEDICATION NAME] on 12/20/13 and who administered the first dose of the medication on 12/21/13 also failed to check the, "Allergy and Reaction to Medication" sheet in the medical record prior to giving the medication to the resident. The facility investigation determined this potentially life threatening medication error was the result of staffs' failure to document and communicate the medication allergy properly, and staffs' failure to check for drug allergies [REDACTED]. During an interview on 1/7/14 at approximately 12:00 p.m., an administrative nurse stated that after the incident the facility reviewed all resident records, including Resident #1, to make sure the allergy lists were accurate and corrections were made as needed. When Resident #1's record was reviewed the, "Allergy and Reaction to Medication" sheet identified [MEDICATION NAME] as an allergy but did not include the drug classification of ACE Inhibitors. When notified of the over site on 1/8/14 at 8:20 a.m., facility administration updated the medical record immediately to include all ACE Inhibitors.

Based on interview and record review, the facility failed to ensure 3 of 57 sample residents were free of significant medication errors (#208,324,370). Residents #208 and 370 experienced harm. Findings include: 1. Resident #370 was admitted to the facility on [DATE] for strengthening, rehabilitation, and wound care. He had [DIAGNOSES REDACTED]. The resident was seen by a practitioner on 9/3/13 after he was admitted to the facility. The assessment indicated the resident was tired, ached all over, had chronic nausea and found it difficult to eat/no appetite. The resident was interviewable at the time and reported to the practitioner he had pain due to his gout. The resident said the medication [MEDICATION NAME] worked for him in the past. The practitioner ordered [MEDICATION NAME] 10 mg every 6 hours as needed. The [MEDICATION NAME] medication was added to the September 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The following information was reviewed on The Internet Drug Index (RxList). [MEDICATION NAME] is a nonsteriodal anti-[MEDICAL CONDITION] medication indicated for short-term use (up to five days). It is not indicated for minor or chronic painful conditions. The maximum dose in adults is 40 mg, increasing the dose will not provide better efficacy but will increase the risk of developing serious adverse side effects. The side effects of the medication include but are not limited to; renal risk for resident with advanced renal impairment and in residents with volume depletion (dehydration). The facility's progress notes were reviewed from 9/5-10/13, the following information was identified regarding the resident. The resident had a fever, he complained of nausea, had diarrhea, had a poor appetite, had wound drainage, and staff encouraged him to drink fluids. The documentation indicated he was lethargic/sedated at times. The practitioner was notified of his condition, but the [MEDICATION NAME] was not mention. The evening of 9/9/13, the practitioner wrote orders to discontinue the [MEDICATION NAME] and lower the dosage of routine [MEDICATION NAME]. On 9/10/13 the resident was transferred to the hospital emergency room at 1:15 p.m. after the physician assessed him. The resident had an elevated Creatinine level of 5.8 (normal range 0.7-1.3) and was lethargic. The physician documented the resident's laboratory values showed acute [MEDICAL CONDITION], with no previous history of renal problems. The physician identified the resident was on [MEDICATION NAME] 10 mg every 6 hours as needed and as needed [MEDICATION NAME] "which seems to be the obvious culprits (of the acute [MEDICAL CONDITION])". According to the 9/10/13 History and Physical from the hospital, described the resident as somnolent and unable to give a history. The document identified the [MEDICATION NAME] was meant to be 10 mg every 6 hours as needed but was given every 6 hours routinely for five and a half days. The hospital physician, documented the resident had acute [MEDICAL CONDITION] and suspected the cause was the nonsteroidal anti-[MEDICAL CONDITION] medication use ([MEDICATION NAME] and [MEDICATION NAME]) and dehydration. On 9/11/15 at 3:10 p.m., the [MEDICATION NAME] medication card from the pharmacy listed the medication instructions as needed every 6 hours (not routinely). The card was delivered on 9/3/13 and 23 doses of the medication were administered. A practitioner involved with the resident's care was interviewed on 9/12/13 at 9:30 a.m. She stated the resident was admitted to the facility with dehydration, nausea, and poor intake. It was questionable whether he would need to be sent back to the hospital. The practitioner verified [MEDICATION NAME] was a medication that should not be given more than five days routinely. She commented the medication was not the sole cause of the resident's condition. The resident was admitted to the facility on [DATE] and was to receive [MEDICATION NAME] on an as needed basis. The medication was not transcribed onto the medication log accurately. Therefore, the resident received the medication for over five days at the maximum dose recommended. At least 6 different nurses administered the medication on a regular basis from the medication card which had instructions to give the medication as needed. The resident had acute [MEDICAL CONDITION] and was sent to the hospital. Two different physician's identified the resident's medication regime as contributing factors to the resident's condition. 2. Resident #208 had [DIAGNOSES REDACTED]. The resident was taking as needed medication for pain, as well as a [MEDICATION NAME] (narcotic pain medication applied directly to the skin which provides a continuous dose). The physician orders [REDACTED]. Per the May 2013 record, the resident's [MEDICATION NAME] was replaced on 5/14/13. On the morning of 5/16/13, the resident complained of not feeling well, being anxious and nauseated, had tingling of the extremities, and eventually experienced uncontrolled shaking/jerking. She was sent to the emergency room (ER), and was given a medication for the uncontrolled movements (which according to the record was minimally helpful), pain medication, and medication for anxiety. After the resident received the pain/anxiety medications, she stated she felt well (and her symptoms resolved). During the ER stay, the resident discovered that the [MEDICATION NAME] was not on. [DIAGNOSES REDACTED]. The resident experienced probable withdrawal symptoms because she was not receiving the medication for an undetermined period of time. (See F-225 related to lack of investigation of the medication error). 3. Per record review, Resident #324 was admitted for treatment of [REDACTED]. The resident's August 2013 medication orders included intravenous (IV) medications for nausea, itching, and pain. Review of the facility investigation dated 8/21/13 revealed a night shift licensed nurse administered the wrong dose of IV nausea medication. The medication order was for 12.5 milligrams (mg) every 6 hours as needed. If needed, the medication dosage could be repeated 1 time for a total of 25 mg. On 8/21/13 at 5:15 a.m., the licensed nurse gave 50 mg at one time (double the maximum dosage ordered). Per record review, the resident's vital signs were stable and the resident requested IV pain medication 45 minutes later. In an interview on 9/9/13 at 3:30 p.m., the resident stated she was sleeping but staff informed her family member of the medication error when it occurred. In an interview on 9/9/13 at 3:45 p.m., Staff #K stated the medication was dispensed as 50 mg in a 1 milliliter (ml) vial (12.5 mg=.25 ml). The licensed nurse administered the entire ml rather than .25 ml and recognized and reported the error immediately.

Based on interview and record review, the facility failed to implement it's policy and procedure related to identification and prevention of abuse by protecting 5 of 7 sampled residents (#2, 3, 4, 5, 6) from a pattern of abuse exhibited by Resident #1. Staff knew about Resident #1's inappropriate behavior and touching other resident's private areas, yet neglected to take timely action to protect other vulnerable residents. The facility's lack of recognition resulted in a pattern of harm. Findings include: Resident #1, per record review, had [DIAGNOSES REDACTED]. The resident had memory problems and difficulty with making daily decisions. He was independent with wheelchair mobility and his room was located in an area with cognitively impaired residents. The record showed multiple episodes of Resident #1 seeking out female residents in his vicinity, most of whom were cognitively impaired. The facility did not address his behavior in a timely or effective manner; consequently residents continued to be exposed to his behavior. Five known residents had to deal with Resident #1's behavior before the facility finally implemented stronger interventions of 1:1 monitoring and ultimately discharged the resident. The facility's system for identification and reporting was ineffective. At least 2 staff members (#D, M) had direct observation and 8 staff (#E, F, H, K, N, and P) had knowledge of alleged bothersome comments and inappropriate touching by Resident #1, yet this was not consistently addressed. There were 2 other staff members (#G, L) who were unable to accurately verbalize mandated reporter responsibilities. The facility did not recognize that according to state law sexual abuse includes unwanted or inappropriate touching and that abuse is presumed to cause harm in instances of abuse of a vulnerable adult who is unable to express or demonstrate physical harm, pain, or mental anguish. The failure by multiple staff to identify potential abuse, protect residents, and report allegations of abusive behavior as required demonstrated the facility's Abuse Prevention Program was ineffective. INCIDENT ON 7/22/11 Resident #5, per record review, had [DIAGNOSES REDACTED]. The resident had some memory problems and difficulty with making daily decisions. She required extensive assistance with transfers, ambulating, dressing, bathing, but was independent with personal hygiene and eating. Per review of the facility investigation dated 7/22/11, Resident #5 complained that Resident #1 made "sexual advances" toward her. The investigation stated he asked to lie down in her bed and she told him to go to his own room. Facility staff interviewed Resident #5 and offered her another room, she reported she was not afraid and did not want another room. The facility logged the allegation made by Resident #5 in the incident log, but did not call the state agency. The facility had knowledge Resident #1 had a history of [REDACTED]. Per record review, Resident #1 continued to make statements to Resident #5 such as "you look sexy" and "inappropriate sexual statements" during the evening and night shift. Staff documented they tried to keep Resident #1 away from Resident #5's room. On 9/20/11 at 3:20 p.m., Resident #5 reported Resident #1 wandered into her room and rubbed her arm and asked if he could get into bed with her. She reported Resident #1 exposed his genitals and she told him to get to his own room (she stated she did not share this with staff). Resident #5's affect was flat initially and when questioned her posture tightened and she said with relief, "I'm glad he's gone!" She reported he would touch his privates and call out my name at night. She said she had trouble sleeping at night with him around and felt much better now that he was no longer at the facility. On 9/20/11 at 4:45 p.m., Staff #F reported Resident #5 made allegations continuously regarding Resident #1. She said she didn't call any of the allegations in because she thought they had already been called in and they were continuous. On 9/21/11 at 10:15 a.m., Staff #H reported when Resident #5 made allegations she reported to Staff #B. She said she would call in an allegation if it was brand new or if she believed them. She thought something happened, but she didn't think it was as big as people made it out to be. She stated she never contacted the state agency as required. On 9/21/11 at 11:25 p.m., Staff #C reported Resident #1 was here quite awhile and did fine. She interviewed Resident #5 and she was not afraid and didn't want to move to a different room. She logged the incident, but did not report to the state agency. On 9/21/11 at 4:30 p.m., Staff #K reported she never personally saw Resident #1 touch any of the staff or residents. She said Resident #5 talked about him touching other residents. She reported she didn't call in the allegations because she did not witness them. Her response to an allegation was that she would report it to the supervisor. On 9/23/11 at 5:50 a.m., Staff #N stated she heard Resident #1 make comments to Resident #5, "(Name) You know how to take care of me." She said Resident #5 had trouble sleeping during this time and it started when Resident #1 moved next door to Resident #5. She reported Resident #5 was not afraid, but she was disgusted. She reported if a resident made an allegation she would pass it on to the supervisor and if it wasn't handled she would then call the state agency. On 9/23/11 at 6:30 a.m., Staff #P reported he had never seen Resident #1 inappropriately touch anyone, he just got the stories. The aides told him he would call on the light and make requests to get peri care. He could hear him calling out for Resident #5. He stated he would call out, "Come in here, I've got something for you!" He said he passed it along in report. He was not able to say he would call the state agency if a confused person made an allegation of abuse or neglect. Per additional information received from Staff #A and #B on 9/23/11, the facility reported they did not know Resident#1 exposed himself to Resident #5. They reported Resident #1 was admitted on [DATE] and there were no concerns until 7/22/11. They reported he made an inappropriate remark to a female at another facility, which caused them to get a 1:1 caregiver. This 1:1 caregiver was discontinued early in May 2011. They reported when he was admitted they initiated standard of care monitoring for Resident #1. The facility failed to identify potential abuse and new interventions to prevent inappropriate touching, even though Resident #1 continued to make statements that made Resident #5 uncomfortable. In addition, there was no evaluation of whether Resident #1's room location needed to be changed or may have contributed to Resident #5's distress. The lack of identifying this could be potential abuse and placed other residents at risk. INCIDENT ON 8/11/11 Resident #6, per record review, had [DIAGNOSES REDACTED]. She frequently wandered through the garden level into other resident rooms. She required extensive assistance with activities of daily living (ADL's). Resident #7, per record review, had [DIAGNOSES REDACTED]. She was independent with ADL's. On 9/20/11 at 4:05 p.m., Resident #7 reported she witnessed Resident #1 put his hand on Resident #6's thigh. She stated this occurred before Resident #1 had a 1:1 staff with him. She said she was talking to Staff #D when she observed Resident #1 touch Resident #6's thigh. She said Staff #D saw him and removed Resident #1 away from Resident #6. She stated some of the other residents expressed fear of Resident #1, but she wasn't afraid and didn't think he could help it. She stated they did not put a 1:1 staff member with him until there were a few more complaints of him touching other residents. On 9/20/11 at 4:25 p.m., Staff #D reported she saw Resident #1 touch Resident #6 with his hand inside her pants and go up her leg. She did not call the state agency because she did not want him to be "labeled" and wanted to give him the opportunity to stop. She thought he was confused, but when it continued to happen she reported it to the supervisor and she notified the state agency. After interviews, the resident record was reviewed, Staff #D documented on 8/11/11 she observed Resident #1 touching other female "residents" and staff. She documented that she had a 1:1 conversation with the resident and he was "still doing it." She documented she notified the supervisor and so they could notify the family of both sides. Per record review, the incident was not logged or reported to the state agency and there was no evaluation of whether or not the current plan for safety and supervision was effective for Resident #1. Per review of the nursing notes dated 8/12/11 during the day shift, Staff #I introduced herself to Resident #1 and noted the resident had memory problems. She noted she would explore specific interventions with staff and family to decrease behaviors. Per review of the nursing notes dated 8/13/11, Staff #D documented Resident #1 sought out Resident #6 multiple times. She documented they told the resident to keep his hands to himself (an approach that had not been effective and was not conducive with someone who has memory problems). She documented Resident #1 constantly approached Resident #6 and attempted to touch her thigh. Staff #D documented the resident stated, "She likes to be touched." Staff #D documented the supervisor was aware. Similar behaviors continued and there was still no evaluation to determine whether the current interventions were effective to prevent further sexual behaviors and protect other residents. On 9/20/11 at 4:35 p.m., Staff #E reported Resident #1 gravitated toward Resident #6 and other women in the hall. She reported she didn't witness him touch any other resident, but said people were seeing things. She said she didn't feel like Staff #H was taking the reports seriously, because action was not taken to address the behavior. On 9/21/11 at 11:25 p.m., Staff #C reported when she returned from vacation staff told her Resident #1 touched Resident #6, but that it wasn't in a sexual way the week before. She reported they had an informal meeting because staff were talking about him touching other residents and she wanted to make sure they were treated him with dignity and made sure other residents were safe. On 9/21/11 at 4:00 p.m., Staff #I and J reported Resident #1 only touched Resident #6's knee. They reported there would be no way the resident could have his hand way up to her thigh because the resident had a lap buddy. On 9/22/11 at 2:15 p.m., Staff #B said she saw the information come through report that Resident #1 touched Resident #6. She interviewed the staff and couldn't get anyone to say the resident touched her inappropriately. She found 1 nursing assistant who told her Resident #1 briefly touched Resident #6's knee and it wasn't sexual in nature. She also talked to Resident #1's primary nurse who reported Staff #D had some concerns about some behaviors. She did not investigate any further because the nursing assistant told her it wasn't sexual in nature. She was not aware Resident #7 witnessed the inappropriate touching and did not feel she needed to continue to investigate, despite the inconsistency between the written progress note by the licensed nurse on 8/11/11 and the report by staff. Per additional information received from Staff #A and #B on 9/23/11, the facility reported Staff #B conducted multiple interviews with staff and determined there was no inappropriate resident to resident altercation that took place. Despite a clear description in the facility's policy and procedure for abuse and neglect prevention, the facility failed to identify potential abuse by thoroughly investigating allegation of inappropriate touching. The facility failed to identify previous reports of sexual abuse and act on reports of inappropriate touching. The facility lack of interventions caused harm to Resident #6 due to her inability to express or demonstrate mental anguish. INCIDENT ON 8/24/11 Resident #4, per record review, had [DIAGNOSES REDACTED]. She had memory problems and difficulty with making daily decisions. She required extensive assistance with ADL's, but was independent with walking. Per review of the nursing notes dated 8/24/11, Staff #D, a nurse "caught" Resident #1 touching and rubbing Resident #4's tummy/chest in the large dining room on the garden level. The staff pulled him away from Resident #4 and told him the touching was not appropriate (approach had not been effective in the past). The nurse documented the resident stated, "You caught me!" The nurse documented she notified the supervisor and the supervisor contacted the state agency. The care plan was updated to have the resident in line of sight of staff when out of his bed. Per review of the facility investigation dated 8/24/11 at 6:45 p.m., Resident #1 was observed rubbing Resident #4's abdomen and chest in the dining room. The staff intervened and redirected the resident. The care plan was updated to maintain "line of sight" while the resident is up in his wheel chair. Per review of the nursing notes dated 8/25/11 during the day shift, Staff #H interviewed Resident #1 and he had no recollection of the inappropriate touching. Resident #4 could not recall the event either. The care plan was revised to instruct staff to assist Resident #1 if he had difficulty locating his room and that he would attempt to reach out and touch other residents due to his visual deficits. The facility failed to act on previous reports of inappropriate and unwanted touching by putting interventions into place, and therefore caused Resident #4 harm due to her inability to express or demonstrate mental anguish. FIRST INCIDENT ON 8/25/11 Resident #2, per record review, had [DIAGNOSES REDACTED]. She was dependent on staff for all ADL's. Per review of the facility investigation dated 8/25/11 at 5:30 p.m., Staff #M provided care to Resident #2's roommate with the privacy curtain pulled. She finished care and found Resident #1 just inside the room with his hands under Resident #2's blanket. When Staff #M removed the blanket Resident #1 had his hand between her legs. Staff #M immediately removed the resident from the room and ensured his direct supervision by other staff. Resident #1 was supposed to be in "line of staff sight" and had been in the dining room, but left the dining room without being noticed. On 9/22/11 at 4:00 p.m., Staff #M reported she had been warned to watch for any behaviors with Resident #1 by Staff #K. She provided care for Resident #2's roommate and when finished, she pulled the curtain back and saw Resident #1 with his hands between her inner legs. She removed Resident #1 from the room and reported to the supervisor. She stated she did not call the hotline. She reported she did get some training on mandated reporter responsibilities, but did not remember that she was required to call the state agency. The facility did not ensure that staff followed their plan to provide "line of staff sight" supervision or protect the resident from inappropriate touching. This caused harm for Resident #2 due to her inability to express or demonstrate mental anguish. SECOND INCIDENT ON 8/25/11 Resident #3, per record review, had severe dementia. She had memory problems and difficulty making daily decisions. She was dependent on staff for ADL's. Per review of the facility investigation dated 8/25/11 at 6:40 p.m., Resident #1 approached Resident #3 and held her left hand, massaged her left arm, rubbed her left thigh, and touched between her legs. (This was a little over an hour after the resident was found with his hands between Resident #2's legs and was supposed to be in "line of sight" of staff). On 9/20/11 at 4:35 p.m., Staff #E reported she witnessed Resident #1 touch Resident #3's inner thigh. She stated she was concerned because that day there was a meeting at 2:15 p.m. to make sure they treated Resident #1 with dignity. At the meeting a scenario was outlined showing the potential precursors to the resident's behavior and what to watch for. She said she observed Resident #1 start to pat Resident #3's arm, then her thigh, and then between her legs. She said she pulled Resident #1 away from Resident #3, but not before he touched between her legs. She stated she reported to the supervisor immediately, but she did not call the state agency because she thought the facility was reporting everything to the state agency. The facility failed to have a system in place that identified that inappropriate touching was sexual abuse and failed to ensure there was a plan was in place to protect other vulnerable adults from being inappropriately touched. Despite staff knowledge, preventative measures were not re-evaluated timely. This caused harm to Resident #3 due to her inability to express or demonstrate mental anguish. Per record review, the resident had a 1:1 caregiver on 8/26/11 while out of his bed and was ultimately discharged to another facility.

Based on interview and record review, the facility failed to have qualified staff to provide and supervise care for 1 of 3 (#1) sampled residents in accordance with the resident's plan of care . The facility did not have sufficient staff experienced in long term care that were educated on resident's rights and/or abuse. This resulted in harm for Resident #1 when he was physically restrained during a catheter change. Findings include: See F223 and F282 for additional details Resident #1 had [DIAGNOSES REDACTED]. The resident had an indwelling catheter for [MEDICAL CONDITION]. Per record review, the nursing notes on 1/7/11 at 3:00 p.m., noted that the resident's catheter was changed by staff. The resident was combative during the insertion (no physician ordered as needed medications were given prior to insertion). The resident hit staff, spit on staff, scratched, and kicked. Staff did not utilize the care planned interventions related to the resident's catheter. Instead, 4 facility staff held the resident, covered his mouth with a washcloth, and completed the catheter change. The staff did not leave the room and reapproach the resident at a later time per his plan of care. Per interview on 2/16/11 at 2:00 p.m., Staff #A stated the supervisor called her in to assist in catheterizing Resident # and she was instructed by the nurse to hold the resident's hands and place a washcloth over the residents mouth. Staff #A stated she was just doing what the supervisor instructed her to do and didn't see the situation as abusive. Per interview on 2/16/11 at 2:15 p.m., Staff #B who was involved in the incident stated all her nursing experience had been in an acute care setting and not in long term care so she felt restraining the resident to complete the procedure was fine. She did not feel this was abuse. Per interview at 2:30 p.m., Staff #C stated she was a new nurse and had never worked in long term care. She stated she didn't understand that staff could not restrain the resident in order to finish the procedure. Supervisory staff did not ensure that Resident #1's care was provided in accordance with his plan of care, nor did the staff involved in the incident recognize the resident's right to refuse and the inappropriate use of physical restraints during the procedure constituted abuse. The facility failed to ensure sufficient staff were educated and knowledgeable on residents rights and what constituted abuse. This caused harm for Resident #1 that was physically restrained during an invasive procedure.

Based on interview and record review, it was determined that the facility failed to ensure that its polices and procedures regarding reporting of abuse were implemented. At least 10 staff members had knowledge of an allegation of physical and verbal abuse from one resident (#1) that involved the Administrator of the facility. These 10 staff members failed to immediately report knowledge of the allegation of abuse to their supervisor and to the state abuse hot-line per facility policy and procedure for abuse prevention. This failure by multiple staff to report abusive acts as required demonstrated the facility's Abuse and Neglect Guidelines was ineffective. The failure to ensure that a thorough Abuse Prevention Program was developed and implemented placed all residents in the facility at potential risk of abuse. Findings include: The facility's policy and procedure for abuse and neglect prohibition included a clear description of to whom staff should report abusive incidents. On 12/1/10 staff members were interviewed related to an allegation of abuse made from a resident. There were 10 staff members aware of the allegation. The staff members heard it directly from the resident or from other staff. When asked why they did not report the allegation to their supervisor or call it into the state hot-line, they stated they were afraid of losing their job. They felt intimidated by the Administrator and were fearful of retaliation. Due to the staffs fear of reprisal, the names will remain anonymous. Staff #1 was interviewed and stated he/she overheard the resident explain the verbal altercation incident between him and the administrator to another staff member. The resident was "very upset and not himself." Staff #2 stated the resident said " I feel like I am being targeted with abusive behavior by (name)." The resident "appeared meloncholi...he seemed hurt, sad and bummed out." Staff #2 told staff member #3 about the incident and he/she said to have the resident call the state. Staff #2 stated he/she noticed if anyone tried to go against the Administrator they were gone and felt if he/she said anything he/she "would be gone too". Staff #3 heard about the incident involving the resident and the Administrator. He/She did not report the information any further. Staff #4 stated the resident reported the incident to her the day it occurred. He/she stated "he was very, very, very upset." Staff #4 went to Staff #5 and asked what to do. Staff #5 stated the resident needed to write the information down in a statement and then "we can go from there." Staff #4 did not do anything further with the allegation and neither did Staff #5. Staff #4 stated he/she didn't do anything further because he/she "was afraid of losing my job." Staff #5 was interviewed and stated the resident informed him of the allegation, he/she did not call the allegation into the hotline. Staff #5 stated there was a fear of losing employment if it was reported. Staff #6 stated he/she had heard from another staff member about the allegation on 11/26/10 and the resident told him/her about the incident on 11/29/10. He/She did not know what to do with the information since he/she had not dealt with something like this before. Staff #7 heard about the incident from another staff member. Staff #7 was gong to talk to the resident about it but did not. The information was not reported any further. Staff #8 overheard the actual conversation between the resident and administrator. He/She stated "both parties had raised voices and appeared to be involved in some type of altercation." It was not reported any further. Staff #9 witnessed the resident and the administrator arguing but could not hear the actual conversation. It was not reported any further. Staff #10 stated he/she heard about the confrontation but did not get involved. He/She said he/she tried to avoid the Administrator and stayed to him/herself. The number of staff members who had knowledge of allegations of abusive acts failed to immediately report this knowledge which demonstrated that the facility failed to have an effective abuse prevention program, placed all residents at potential risk of Abuse.

Based on interview and record review, the facility failed to ensure that 1 of 13 residents (#1) were treated with dignity and respect related to a verbal exchange between the resident and administrator that made the resident feel "degraded." This resulted in psychosocial harm. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The resident was alert and oriented and able to make his needs known. The resident was independent with most Activities of Daily Living and independently propelled his wheelchair. During an interview on 11/30/10 at 1:30 p.m., the resident stated he was exiting out of the facility to go to the smoking area. He was stopped outside by the Administrator. He stated he had a clothing protector in his wheelchair which made her "upset." According to the resident, she explained to him "the clothing protector's are not to leave the building, it is dragging in the slush and they are expensive." The resident stated "(Name) then put her hand on my arm, pushed me to the side of the wheelchair and forcefully removed the clothing protector." The resident then stated "(name) saw a cigarette between my legs and picked the cigarette up, shook it at my face and said what do we have here, I told you we don't smoke here." She then proceeded to "throw the cigarette at me, which bounced off my chest." He stated he was then told "we have rules and if you don't like them you can get the hell out...you can just leave." "I felt chastised, like a kid getting in trouble." The resident described feeling "reprimanded, intimidated, chastised, targeted" and worried about "retaliation." The resident stated he was fearful of having to leave the facility. "I think I have been singled out and maybe neglected." The resident stated after the incident he shared the information with several staff members. He was given the Ombudsman phone number and the state hotline and encouraged to call the incident in. Per review of the resident record, there was no documentation related to the allegation the resident had made. However, thru staff interviews the resident was described as being "very friendly, helpful, happy and calm" prior to the incident. After the incident, the behaviors were described as "upset, meloncholi, tearful, and frightened." On 12/1/10 a staff member was interviewed at 5:20 p.m. The staff member was in the parking lot during the alleged incident. The staff member stated she didn't see the interaction of removing the clothing protector but could "hear the resident and the Administrator and they were loud." Per interview on 12/1/10 with staff #11, he/she heard the Administrator say "...I lost my cool." immediately after the incident that occurred on 11/26/10. On 12/3/10 a staff member was interviewed at 10:20 a.m. The staff member was in the lobby during the incident. The staff member could see the Administrator and the resident and could tell there was "arguing." The Administrator was interviewed on 12/2/10 at 10:00 a.m.. She confirmed there was an interaction between her and the resident. However, she stated the conversation was calm on both her part and the resident. She could not recall saying she lost her cool but stated if she had said it it was because "I told the resident I was done... I don't think it was therapeutic for me to say that." Resident #2 was interviewed on 12/3/10 at 8:30 a.m. She stated she often talked with Resident #1 and they would "hang out." She said on the day of the incident he told her what had happened between him and the Administrator. She stated he was "mad when he first talked about the incident and then it turned into stages of grieving." During their conversation, resident #1 started "crying" and told resident #1 he felt "picked on and victimized." The facility failed to ensure the resident was treated in a dignified manner. This placed the resident at risk for psychological harm.

Based on record review and interview the facility failed to ensure a licensed nurse followed the five rights of medication pass for 1 of 3 residents (#1), who received another resident's medications. As a result Resident # 1 suffered negative effects from the medication and was required to be sent to the hospital. Findings include: Resident # 1 had [DIAGNOSES REDACTED]. She had memory and cognitive deficits. Per the resident's record, on 9/18/10 at 06:00 am, staff A had given the resident [MEDICATION NAME] 20 milligrams (a narcotic [MEDICATION NAME] which can cause respiratory depression, and Neurotone 600 milligrams (a [MEDICAL CONDITION] medication that can cause somnolence, and nausea/vomiting). Per the resident 's record there was no physician order for [REDACTED]. Per the facility investigation, Staff A did not follow the 5 rights of medication pass. The facility Medication Administration records had pictures of each resident accompanying their medication sheets. Each resident in the facility had name bands on their wrists to aid staff in identification of the right medication for the right resident. Per an interview on 10/2/10 with Staff B, she confirmed that all residents have identification and that Staff A did not check the identification of Resident # 1 before giving her medication. Failure to correctly identify the residents before administering these medication led to a medication error that caused her to need emergency treatment at the hospital.

Based on record review and interview the facility failed to ensure 1 of 3 residents (#1), who had received another resident's medications was consistently monitored for adverse effects. Resident # 1 had to be sent to the hospital for treatment. Findings include: Resident # 1 had [DIAGNOSES REDACTED]. She had memory and cognitive deficits. Per the resident's record, on 9/18/10 at 06:00 am, staff A had given the resident [MEDICATION NAME] 20 milligrams (a narcotic [MEDICATION NAME] which can cause respiratory depression, and Neurotone 600 milligrams (a [MEDICAL CONDITION] medication that can cause somnolence and nausea/vomiting). Staff B, noted that Staff A had given the wrong medications to the resident at that time and Staff B notified the nursing shift supervisor. Per the nursing notes dated 9/18/10, no time noted, but after the 6 am note, Staff B assessed the resident and the resident "had pinpoint pupils, non reactive to light and glazed. She was increasingly somnolent as the day progressed". Per the facility investigation, at 10:00 am, (4 hours after the resident received the incorrect medications) the physician on call was notified by phone of the medication error. At 10:15 am, physician orders [REDACTED]. Per the resident's record, she did not receive the [MEDICATION NAME]. There was no documentation to show why the [MEDICATION NAME] was not given. Per the same nursing note, "the resident had episodes of vomiting, usually following movement. Continuing to monitor status, ....respirations ranging from 12 to 16 (no previous respiratory rate noted), her skin was pale, dusky, diaphoretic, continue to monitor status frequently". Per the nursing notes, at 2:45 PM, ( over 8 hours after the resident got the wrong medication ) the "resident's oxygen saturation was 78-82% (normal is 95-100%), oxygen was then obtained and administered at 3 liters a minute, the resident was still LETHARGIC AND DIFFICULT TO AWAKEN, TEMPERATURE VERY LOW 94, HEART RATE 88 RESPIRATIONS 28 AND SHALLOW, BLOOD PRESSURE 104/60". Per the nursing note, the nursing supervisor instructed staff to continue to monitor the resident frequently and attempt to arouse and count respirations every 10 minutes and notify if any decrease in respirations or changes in the resident. Per the nursing notes, at 3:30 PM, the on call physician was again notified and an order was received to give the resident [MEDICATION NAME] (a narcotic reversal medication) every 3 minutes up to 5 doses, if her respiratory rate dropped below 8 a minute or oxygen saturation dropped below 88% on 4 liters of oxygen. Per the nursing notes, at 3:45 PM, Staff C notified the supervisor regarding the order for [MEDICATION NAME], the supervisor said she would be there shortly. At 4:15 PM, (45 minutes later, "the resident's oxygen saturation dropped to 74% (no [MEDICATION NAME] given) and her respirations decreased to 8-10 a minute". Staff C called the supervisor again for assistance. At 5:25 PM, and 6:00 PM, the resident received the [MEDICATION NAME]. The resident's physician was notified and an order to transport to the emergency room was obtained. On 10/08/10, and interview with Staff B confirmed that she had not documented any frequent monitoring of the resident or any respiratory/ arousal checks. The facility failed to intervene in a timely manner (1 hour passed before staff gave the [MEDICATION NAME]) by administering a medication for narcotic reversal. The resident required hospitalization .