Every finding on record at The Oaks at Lakewood

Based on interview and record review, the facility failed to ensure substantial injuries/injuries of unknown sources were reported to the State Agency Reporting Hotline for 2 of 3 sampled residents (Residents 7 and 9) when reviewed for abuse. This failure placed residents at risk for potential abuse/neglect and a diminished quality of life. Findings included .Resident 7 Review of the electronic health record (EHR) showed Resident 7 was re-admitted to the facility on [DATE] with diagnoses to include dementia (a decline in mental abilities such as memory, thinking, and reasoning), diabetes (too much sugar in the blood), and muscle weakness. Resident 7 was sometimes able to make needs known. Review of Resident 7's EHR showed a Change of Condition form completed on 09/25/2025 related to Resident 7's complaint of pain/discomfort in the right upper shoulder with slight swelling noted. Review of the September 2025 accident and incident log showed an entry dated 09/29/2025 related to Resident 7's 09/25/2025 incident of Other. The log entry indicated the incident was not reported to the State Agency Reporting Hotline. Review of Resident 7's progress note dated 09/25/2025 showed X-ray results received and reviewed with the provider who recommended to send the resident to the emergency room (ER) for further evaluation. Resident 7 was transported to the ER via ambulance. Review of the radiology report dated 09/25/2025 of Resident 7's x-ray results showed, Acute impacted right humeral neck fracture, (a fresh, sudden break in the top part of the right arm bone near the shoulder, where the broken pieces of bone have been jammed together). Review of the facility investigation dated 09/25/2025 showed Resident 7's fracture of the right arm/shoulder area was reasonably related to a previous fall of which the resident had refused to get an X-ray at that time and was assessed, treated for pain, monitored, and family and provider notified. Review showed the facility had ruled out any abuse/neglect; however, it did not show the incident was reported to the State Agency Reporting Hotline. During an interview on 01/29/2026 at 9:11 AM, Staff B, Director of Nursing Services (DNS), stated injuries of unknown sources should be reported to the State Agency Reporting Hotline within two hours. The DNS stated Resident 7's 09/25/2025 injury of unknown source/fracture was not reported and should have been. During an interview on 01/29/2026 at 9:40 AM, after reviewing Resident 7's investigation dated 09/25/2025, Staff A, Administrator, stated Resident 7 had an injury of unknown source that was not reported to the State Agency Reporting Hotline. Staff A stated injuries of unknown source should be reported within two hours. Resident 9 Review of the EHR showed Resident 9 admitted to the facility on [DATE] with diagnoses to include dementia, congestive heart failure (when the heart is unable to pump blood efficiently) and muscle weakness. Resident 9 was able to make needs known. Review of Resident 9's EHR showed a Change of Condition form completed on 11/05/2025. related to an abrasion in the right groin area. An additional Change of Condition form was completed on 11/09/2025 related to an abrasion in the left lateral groin area. Review of the November 2025 accident and incident log showed an entry dated 11/13/2025 related to Resident 9's 11/09/2025 abrasion. The log entry indicated the incident was not reported to the State Agency Reporting Hotline. There was no entry logged related to Resident 9's 11/05/2025 abrasion. Review of the facility investigation dated 11/05/2025 showed Resident 9 was noted with a scratch on the right inner thigh. Resident 9 was unable to recall how the scratch occurred due to poor cognition. Review of the facility investigation dated 11/09/2025 showed Resident 9 was noted with a scratch to the left groin area during personal care. During an interview on 01/28/2026 at 2:36 PM, Staff G, Resident Care Manager (RCM), stated they completed the investigations and concluded the 11/05/2025 and 11/09/2025 abrasions were reasonably related to a fungal infection. Staff G stated during the process of investigation they determined the incidents were not reportable. During an interview on 01/28/2026 at 2:52 PM, Staff B, DNS, stated Resident 9 had cognitive impairment and could not reliably report how the injuries occurred. Staff B stated both incidents were an injury of unknown origin and should have been documented on the incident log and reported to the State Agency Reporting Hotline. Reference WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 2 of 18 sampled residents (Residents 11 and 5) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life. Findings included.Resident 11 Review of the electronic health record (EHR) showed Resident 11 readmitted to the facility on [DATE] with diagnoses of depression and schizophrenia (disorder that disrupts how a person thinks, feels, and behaves, causing them to interpret reality abnormally). Resident 11 was able to make needs known. Review showed Resident 11 had a pre-admission screening and resident review (PASSAR, a mental health assessment) level II evaluation completed on 03/24/2022 and a behavior health (BH) PASSAR notice of determination completed on 10/03/2024. Review of Resident 11's annual minimum data set assessment (MDS), dated [DATE], showed section A1500 was coded No for being considered by the State level II PASSAR process to have serious mental illness and/or intellectual disability or a related condition. During an interview on 01/28/2026 at 10:02 AM, Staff D, Minimum Data Set/Licensed Practical Nurse (MDS/LPN), stated Resident 11's section A1500 of their annual MDS dated [DATE] was coded No and should have been coded Yes because the resident had a PASSAR level II evaluation and a PASSAR notice of determination. During an interview on 01/28/2026 at 10:26 AM, Staff B, Director of Nursing (DNS), stated Resident 11's annual MDS dated [DATE] was not coded accurately for having a level II PASSAR and this did not meet their expectations. Resident 5 Resident 5 admitted to the facility on [DATE] with diagnoses to include stroke, diabetes (excessive blood sugar) and dementia (loss of cognitive functioning). Resident 5 was able to make needs known. Review of the annual MDS dated [DATE] and quarterly MDS dated [DATE] showed Resident 5 had a decline in bed mobility and toilet transfers. The 10/06/2025 MDS showed Resident 5 was assessed as independent, and the 01/05/2026 MDS showed Resident 5 was assessed to require substantial/maximal assistance. During an interview on 01/29/2026 at 8:28 AM, Staff F, Restorative Nursing Assistant, stated Resident 5 consistently participated in restorative services a minimum of three times per week. Staff F stated Resident 5 was able to transfer and ambulate in their room without the assistance of staff. Review of Resident 5's 10/24/2025 care plan showed an intervention Ambulate resident using FWW [front wheel walker] supervision touching assist with w/c [wheelchair] follow 50-80 ft or as tolerated. three-six times/week. Review showed Resident 5 participated in restorative three times per week during the month of January 2026. During an interview on 01/29/2026 at 8:37 AM, Staff D, MDS/LPN, stated Resident 5's MDS was inaccurate and did not meet expectation. Reference WAC 388-97-1000(1)(a)(b)(4)(a)

Based on observation, interview, and record review, the facility failed to ensure the required nursing staff posting accurately reflected the actual staff numbers and actual hours worked for 5 of 7 sampled days (01/22/2026, 01/23/2026, 01/24/2026, 01/25/2026 and 01/26/2026) when reviewed for sufficient staffing. This failure caused the facility's staffing information to not be readily available to residents, and prevented the residents, family members and visitors from knowing the facility's actual number of available nursing staff.Findings included. Observation on 01/26/2026 at 9:13 AM showed the Licensed and Unlicensed Daily Staff document posted was dated 01/22/2026. The scheduled staff and scheduled staff hours were completed; however, the actual staff and actual staff hours were blank. During an interview on 01/27/2026 at 8:54 AM, Staff E, Staffing Coordinator, provided the Licensed and Unlicensed Daily Staff documents dated 01/23/2026, 01/24/2026 and 01/25/2026. Review of these three days showed the actual staff and actual staff hours were blank. Staff D stated the form should have been completed daily to accurately reflect the actual number of staff and hours worked. During an interview on 01/28/2026 at 2:30 PM, Staff A, Administrator, stated the expectation was the Licensed and Unlicensed Daily Staff posting was completed thoroughly each day. Reference WAC 388-97-1620(2)(b)(i)

Based on observation, interview, and record review the facility failed to implement transmission-based precautions (TBP) for 1 of 4 residents (Resident 4) reviewed for TBP, and failed to use gloves when administering an injectable medication for 1 of 4 sampled residents (Resident 54) reviewed for medication administration. This failure placed residents and staff at risk for communicable diseases, poor clinical outcomes, and a diminished quality of life. Findings included . Review of the facility isolation precautions sign titled AEROSOL CONTACT PRECAUTIONS dated 08/09/2023 showed staff were to wash or gel (hand sanitizer) hands, use full PPE (personal protective equipment) which included wearing gloves, a gown, a respirator (N95 mask which filters 95% of particles in the air) and wear eye protection prior to entering the room. It further showed the door should remain closed unless it impacted patient care. Review of the CDC The Basics of Standard Precautions by ([NAME] JD, CDC Guidelines for Isolation Precaution, 2007) states to use gloves when anticipating contact with blood or body substances. Resident 4 Review of the electronic health record showed Resident 4 admitted to the facility on [DATE] with diagnoses that included heart failure and dementia (a group of thinking and social symptoms that interferes with daily functioning) and showed that Resident 4 had tested positive for Covid-19 (a highly contagious respiratory virus) on 10/07/2024. Observation on 10/16/2024 at 9:52 AM, showed Resident 4 laid in bed in their room. There was a sign for aerosol contact precautions posted outside the door. Staff G, Certified Nursing Assistant, entered the room without putting on a gown, eye protection, N-95 mask or gloves. Staff G exited the room and assisted a housekeeper staff by opening the door and the housekeeping cart kept the door open. Housekeeping staff then entered the room without putting on the required PPE. Observation on 10/16/2024 at 9:55 AM, showed Staff K, Maintenance Supervisor, entered the room without putting on the required PPE. Observation on 10/16/2024 at 10:00 AM, showed Staff H, Assistant Business Office Manager, entered Resident 4's room without putting on PPE. During an interview on 10/16/2024 at 10:05 AM, the assigned licensed nurse (unidentified) stated Resident 4 still required isolation precautions for Covid-19. During an interview on 10/21/2024 at 10:48 AM, Staff J, Infection Preventionist/Staff Development, stated it was their expectation that staff performed hand hygiene, put on an isolation gown, gloves, N95 mask, and eye protection when entering the room of a Covid-19 positive patient. Additionally, the door to the room should remain closed. Resident 54 Resident 54 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/25/2024, showed Resident 54 was able to make needs known. During an observation of medication administration on 10/21/2024 at 10:44 AM, Staff E, Licensed Practical Nurse (LPN) followed by Staff F, LPN administered 2 different insulins to different areas on Resident 54's abdominal wall without using gloves. During an interview on 10/21/2024 at 10:50 AM, when asked about injection practices, Staff E, LPN, stated they usually use gloves prior to administration of injectables. During an interview on 10/22/2024 at 1:49 PM, Staff B, Director of Nursing Services, stated not following the posted isolation precautions and standards of medication administration practice did not meet their expectations. Reference WAC 388-97-1320(2)(b)

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment/services to prevent new ulcers for 1 of 3 sampled residents (Resident 7) reviewed for pressure ulcers. This failure placed the resident at risk for decreased comfort, infection, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 7 admitted to the facility on [DATE] with diagnoses to include chronic pain, diabetes and was a high risk for pressure injuries. Review of the Care Plan initiated on 05/03/2021 showed an intervention of Offload heels with pillows related to decreased mobility. Observations on 10/16/2024 at 1:58 PM, 10/17/2024 at 10:40 AM, 10/18/2024 at 9:03 AM and 10/21/2024 at 9:26 AM showed Resident 7 lying in bed without their heels offloaded. During an interview on 10/21/2024 at 9:38 AM, Staff M, Resident Care Manager/ Licensed Practical Nurse stated Resident 7's heels should have been floated while in bed. During an interview on 10/22/2024 at 2:30 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that staff followed the care plan to offload Resident 7's heels as the resident allowed. Reference WAC 388-91-1060(3)(b)

Based on interview and record review, the facility failed to ensure that pain medications were provided as the provider ordered for 1 of 2 sampled residents (Resident 69) reviewed for pain management. This failure placed the resident at risk of receiving incorrect pain medication, sedation, and a diminished quality of life. Findings included . Resident 69 admitted to the facility on [DATE] with diagnoses of fracture of the left femur (thigh bone) and dementia (group of symptoms affecting memory, thinking and social abilities). Resident 69 required substantial max assistance with most activities of daily living. Review of Resident 69's orders showed an order dated 09/03/2024 for Roxicodone 5 milligrams (a controlled drug used to treat pain) to be given one tablet by mouth every four hours as needed for moderate to severe pain seven-ten (pain scale from 0-10, with 0 being an absence of pain and 10 being severe pain). Review of Resident 69's orders showed an order dated 09/03/2024 for acetaminophen (Tylenol) 650 milligrams one tablet by mouth every six hours as needed for pain level one-10. Review of Resident 69's September 2024 Medication Administration Record (MAR) showed Roxicodone 5 mg was given on 09/23/2024 for a pain level of six, 09/29/2024 for a pain level of three and 09/30/2024 for a pain level of six. Review of Resident 69's October 2024 MAR showed Roxicodone 5 mg was given on 10/04/2024 for a pain level of five and 10/15/2024 for a pain level of six. During an interview on 10/22/2024 at 8:37 AM, Staff P, Resident Care Manager, stated the expectation was that pain medications were given within parameters or for staff to consult the provider to have parameters adjusted. During an interview on 10/22/2024 at 8:43 AM, Staff B, Director of Nursing Services (DNS), stated the expectation was that pain medication be administered as the provider ordered. Staff B, DNS, further stated staff should have given the Tylenol order prior to giving the Roxicodone. Reference WAC 388-97-1060(1)

Based on observation and interview, the facility failed to provide a homelike environment during meal service for 1 or 3 sampled wings (North wing) when reviewed for dinning. This failure placed residents at risk for decreased appetite and a diminished quality of life. Findings included . During an interview on 10/16/2024 at 10:01 AM, Resident 33 stated they were unhappy that housekeeping would clean during mealtimes. Observation on 10/21/2024 at 12:12 PM, showed Staff R, Housekeeping Staff, cleaning resident room [ROOM NUMBER] with a spray while the resident in bed B was eating. Bed A's food was still covered and on the bedside table. During an interview on 10/21/2024 at 12:12 PM, Staff R, stated they were using Lysol to disinfect surfaces. When asked about appropriate times to clean Staff R stated, We are not allowed to clean while residents are eating in their room unless we ask them. During an observation and interview on 10/21/2024 at 12:17 PM, Staff Q, Housekeeping Manager, informed Staff R to stop cleaning the resident room. Staff Q stated staff should not have been cleaning during resident mealtimes because of the chemicals. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS, an assessment tool) accurately reflected the status for 2 of 18 sampled residents (Residents 54 and 17) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Resident 54 Resident 54 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs) and congestive heart failure. Resident 54 was able to make needs known. Review of the admission MDS, dated [DATE], showed the Dental section B marked YES to No natural teeth or tooth fragments. Review of Resident 54's denture consultation dated 01/24/2024 showed the resident had decayed, loose teeth and was missing some upper teeth and all lower teeth. During an interview on 10/22/2024 at 2:06 PM, Staff N, MDS Resource Nurse, stated section B was coded incorrectly as Resident 54 had a partial denture. During an interview on 10/22/2024 at 2:30 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that the MDS assessments were coded accurately. 49926 Resident 17 Resident 17 was admitted to the facility on [DATE] with diagnoses that included Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), depression, Post Traumatic Stress Disorder and chronic pain. The annual MDS, dated [DATE], showed Resident 17 usually understood others. Observation on 10/16/2024 at 1:22 PM, showed Resident 17 in a low bed, yelling at other staff members that entered the room, and did not want to socialize with anyone. Review of the annual MDS, dated [DATE], showed section D0700 as Resident 17, never had social isolation. Section L0200 dental was marked as Resident 17 had no issues with their teeth. Review of Resident 17's care plan showed Focus area for psychosocial well-being related to issues including social isolation. Review of Resident 17's care plan showed an intervention initiated on 11/24/2023 for broken and carious teeth and to encourage oral care. Review of a dental consult from 05/14/2021, showed Resident 17 with multiple decayed, broken and missing teeth. During an interview on 10/22/2024 at 11:43 AM, when asked about MDS coding and practice, Staff C, MDS Nurse stated they followed the Resident Assessment Instrument (RAI) manual. Reference WAC 388-97-1000(1)(b)

Based on interview and record review, the facility failed to ensure 1 of 1 sampled resident (Resident 125) received medications as ordered when out of the building for dialysis (a process of removing waste from the blood) when reviewed for dialysis. This failure placed the resident at risk of reduced medication effectiveness, increased pain, increased depression, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 125 admitted to the facility on [DATE] with diagnoses of dependence on renal dialysis and end stage renal disease (the failure of the kidneys). Resident 125 was unable to make needs known. Review of the provider's orders showed Resident 125 was out of the facility at 7:00 AM on Tuesday, Thursday and Saturday for dialysis. Review of the August 2024 medication administration record showed Resident 125 was not provided any morning medications on Tuesdays, Thursdays, and Saturdays. Review showed missing medication included an antidepressant, an antiarrhythmic (medication used to keep heart rhythm normal), an anticoagulant (medication to thin the blood), and a pain medication. During an interview on 10/22/2024 at 2:24 PM, Staff M, Resident Care Manager/Licensed Practical Nurse, stated Resident 125 did not have a provider's order to hold medications on dialysis days. Staff M stated their expectation was that Resident 125 received all ordered medications. Staff M stated Resident 125's lack of ordered medications on dialysis days did not meet expectation. During an interview on 10/22/2024 at 2:49 PM, Staff B, Director of Nursing, stated residents who went to dialysis should have a provider's order to provide or hold medications on dialysis days. Staff B stated their expectation was that staff would get an order to administer the medications upon return from dialysis. Staff B stated Resident 125 not receiving their ordered medication on dialysis days did not meet expectation. Reference WAC 388-97-1900 (1), (6)(a-c)

Based on observation, interview, and record review the facility failed to ensure expired eye drops were removed timely from use in 1 of 3 medication carts (Red Wood) reviewed for medication storage. This failure placed the residents at risk for receiving expired medications, ineffective medications and a diminished quality of life. Findings included . Review of facility provided Medication Storage Guidance, dated 2024, showed latanoprost should be discarded six weeks after opening. Observation of the Red [NAME] medication cart on 10/21/2024 at 12:38 PM with Staff D, Licensed Practical Nurse (LPN), showed Latanoprost eye drops medication with an open date of 08/09/2024. During an interview on 10/22/2024 at 1:31 PM, Staff B, Director of Nursing Services, stated nurses should date eye drops when they are opened and follow the recommendations for expiration dates. Reference WAC 388-97-1300(2)

Based on observation, interview, and record review the facility failed to schedule a dental appointment for 1 of 3 sampled residents (Resident 53) reviewed for dental services. This failure placed the resident at risk for unmet dental needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 53 admitted to the facility on [DATE] with diagnoses to include chronic kidney disease and chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs that restricts airflow). Resident 53 was able to make needs known. Observation and interview on 10/16/2024 at 9:53 AM, showed Resident 53 lying in bed watching television. Resident 53 had no upper or lower teeth and stated that their dentures no longer fit due to weight loss. Review of the Care Plan dated 08/21/2024 showed a Focus area Has oral/dental health problems related to edentulous (no natural teeth). The Intervention showed Coordinate arrangements for dental care/transportation as needed/as ordered. During an interview on 10/18/2024 at 11:40 AM, Staff L, Social Services Director (SSD), stated the dentist was at the facility on 09/16/2024 and Resident 53 should have been seen at that time due to dental issues. Staff L stated Resident 53 was added to the list on 09/23/2024 to be seen in December which was the next time the dentist would be in the facility. Documentation received on 10/23/2024 at 5:13 PM from Staff B, Director of Nursing Services (DNS), stated the facility was unaware Resident 53 had requested to see the dentist until 10/14/2024. Reference WAC: 388-97-1060 (2)(c), (3)(j)(vii)

Based on observation, interview, and record review the facility failed to schedule a dental appointment for 1 of 3 sampled residents (Resident 54) reviewed for dental services. This failure placed the resident at risk for unmet dental needs and a diminished quality of life. Findings included . Resident 54 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs) and congestive heart failure. Resident 54 was able to make needs known. Observation and interview on 10/16/2024 at 9:13 AM, showed Resident 54 had missing upper teeth and no bottom teeth. Resident 54 stated they had an upper partial but had not yet put it in for the day. Review of a dental report from Smile Seattle Dentures dated 01/2024 showed a recommendation for new denture (upper and lower) and hygiene cleaning. Review of the Electronic Health Record (EHR) shows a referral dated 03/04/2024 for updated x-rays and extraction of all upper teeth. Review of the EHR shows communication on 07/18/2024 that Resident 54 did not want extractions only a bottom denture. Documentation showed Smile Denture would contact the Resident's family to discuss options. During an interview on 10/18/2024 at 11:54 AM, Staff L, Social Services Director (SSD), stated they were unaware if dental staff discussed any options with Resident 54 or their family as they did not have additional communication related to the resident. Staff L stated Resident 54 would be seen the next time the Denturist was in the facility. During an interview on 10/22/2024 at 11:33 AM, Staff A, Administrator (ADM), stated Resident 54 was on the list to be seen in September 2024 however they were out of the facility. Reference WAC: 388-97-1060(2)(c),(3)(j)(vii)

Based on observation, interview, and record review, the facility failed to offer a timely care conference to 1 of 3 sampled residents (Resident 36) and failed to revise a plan of care for 1 of 3 sampled residents (Resident 60) when reviewed for care plan revision. This failure placed residents at risk of not having input into their plan of care, inaccurate plans of care, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 36 admitted to the facility on [DATE] with a diagnosis of dementia ( loss of memory, language, problem-solving and other thinking abilities). Resident 36 was unable to make needs known and had a power of attorney (POA). During an interview on 10/16/2024 at 1:17 PM, Resident 36's POA stated they had not been contacted to conduct a care conference since December 2023. Review of the Care Plan Review assessments showed Resident 36 last had a care conference on 12/06/2023. During an interview on 10/18/2024 at 12:30 PM, Staff L, Social Services Director, stated the facility held care conferences on admission, quarterly, and as needed and were recorded on the Care Plan Review assessment. Staff L stated Resident 36 last had a care conference on 12/06/2023 and the lack of care conference did not meet expectation. During an interview on 10/18/2024 at 1:10 PM, Staff A, Administrator, stated care conferences should occur at admission, quarterly, and as needed. Staff A stated Resident 36's lack of care conference since 12/06/2024 did not meet expectation. 49926 Resident 60 Resident 60 was admitted to the facility on [DATE] with diagnoses that included stroke, heart failure and dementia. The five-day Minimum Data Set (MDS) an assessment tool, dated 09/21/2024, showed Resident 60 was not able to make needs known. Observation on 10/16/2024 at 11:05AM, showed Resident 60 pulling at covers in the bed, uncovering them self, lifting their leg and pulling on their brief with grimacing face. During an interview on 10/18/2024 at 1:21 PM, Collateral Contact (CC1), stated Resident 60 had never taken a shower, Resident 60 was afraid of the water going over their head and only took baths. Review of Resident 60 care plan Focus area ADL Self Care performance initiated 09/15/2024, showed an intervention of Bathing (SHOWER/BATHE SELF) (Specify:Irequier,The Resident requires, assistance Dependent on staff for bathing/showering 2X/XK). There were no specific directions for Resident 60 about a bath as a preference over shower due to fear of water over their head. During an interview on 10/22/2024 at 1:38 PM, Staff B, (DNS) stated the expectation was for residents and their decision makers to be interviewed about their choices, the care plan be updated/revised to reflect the residents preference. Reference WAC 388-97-1020(2)(c)(d)

Based on observation, interview, and record review, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for 1 of 2 sampled dependent residents (Resident 4) reviewed for ADL care. This failure placed the resident at risk for poor nutrition, weight loss, and a diminished quality of life. Findings Included . Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, dementia ( loss of memory, language, problem-solving and other thinking abilities) and severe malnutrition (condition when someone doesn't have enough nutrients to meet their needs). The admission Minimum Data Set (MDS) an assessment tool, dated 05/13/2024, showed Resident 4 was usually able to understand others. Observation on 10/17/2024 at 9:42 AM, showed Resident 4 lying in bed, they appeared very frail and weak. Observation and interview on 10/21/2024 at 1:02 PM, showed Resident 4 in bed with the head of the bed slightly up and the bedside table nearby with the lunch tray on top. Resident 4 stated, I can't eat, I can't see what is on my plate, I can't get myself up. Surveyor called upon Staff D, (Licensed Practical Nurse) who assisted Resident 4 to sit up and have lunch in bed. Resident 4 stated the food was cold. Review of Resident 4's Electronic Health Record showed Focus ADL Self Care Performance Deficit, initiated on 05/07/2024, with intervention set up-part/moderate assist. Set up tray and encourage meal intake. During an interview on 10/22/2024 at 1:51 PM, Staff B, (DNS) when asked about the process of following the care plan related to assistance with meals stated the expectation was for residents to be set up with their trays and be assisted to eat their meals. Reference WAC 388-97-1060(2)(c)

Based on observation, interview, and record review, the facility failed to follow providers orders for 1 of 5 sampled residents (Resident 125) when reviewed for unnecessary medications and failed to safely administer insulin for 1 of 4 sampled residents (Resident 54) reviewed for medication administration. These failures placed residents at risk of discomfort, pain, infection, and a diminished quality of life. Findings included . Resident 125 Review of the electronic health record (EHR) showed Resident 125 admitted to the facility on [DATE] with diagnoses of dependence on renal dialysis (a process of removing waste for the blood) and end stage renal disease (the failure of the kidneys). Resident 125 was unable to make needs known. Review of the provider's orders showed Resident 125 received a blood pressure medication which was to not be given if the systolic blood pressure (top number of a blood pressure reading) was greater than 130. Review of the EHR showed Resident 125 had provider's orders for bowel medication to be provided after three days without a bowel movement. Review of a bowel movement tracker for August 2024 showed Resident 125 did not have a bowel movement from 10/09/2024 through 10/13/2024 (five days). Review of the October 2024 medication administration record (MAR) showed Resident 125 was provided the blood pressure medication 15 times and five of the 15 times the resident's systolic blood pressure was greater than 130. Further review showed Resident 125 was not provided bowel medications. During an interview on 10/22/2024 at 2:24 PM, Staff M, Resident Care Manager/Licensed Practical Nurse, stated the expectation was to follow the provider's orders as written when providing medications. Staff M stated Resident 125 was provided blood pressure medication outside of the provider's orders and that did not meet expectation. Staff M stated Resident 125 was not provided the ordered bowel medications and that did not meet expectation. During an interview on 10/22/2024 at 2:49 PM, Staff B, Director of Nursing, stated the expectation was for nurses to follow the provider's orders as written. Staff B stated Resident 125 received blood pressure medication outside of the parameters and lack of bowel medication did not meet expectation. 49926 Resident 54 Review of the facility policy about Injections, Insulin administration dated 06/01/2023, showed Cleanse injection site with alcohol if necessary. Resident 54 was admitted to the facility on [DATE] with diagnoses that included heart failure and diabetes. The quarterly Minimum Data Set (MDS), an assessment tool, dated 09/25/2024, showed Resident 4 was able to make needs known. During an observation of medication administration on 10/21/2024 at 10:44 AM, Staff E, Licensed Practical Nurse (LPN) followed by Staff F, LPN administered 2 different insulins to different areas on Resident 54's abdominal wall without cleaning the skin area. In addition, the nurse did not wear gloves. During an interview on 10/21/2024 at 10:50 AM, when asked about injection practices, Staff E, LPN, stated they usually use alcohol wipes prior to administration. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review the facility failed to ensure a safe environment was maintained related to facility equipment for 1 of 4 sampled residents (Resident 14) reviewed for accident hazards. This failure placed the resident at risk for avoidable injuries and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 14 admitted to the facility on [DATE] with diagnoses to include above the knee amputation and diabetes. Resident 14 was dependent on staff for transfers and able to make needs known. During an interview on 10/17/2024 at 10:57 AM, Resident 14 stated they did not feel comfortable using the sit to stand because the grab bars were loose. Observation on 10/21/2024 at 10:30 AM, showed two Tollos Steady aid Sit to Stand units #73508 and #870353 located on the [NAME] wing with grab bars that easily moved from left to right and appeared loose. During an observation and interview on 10/21/2024 at 10:36 AM, Staff K, Maintenance Supervisor, stated they were made aware of the moveable grab bars in February 2024 when a Certified Nursing Assistant brought it to their attention. Staff K stated they attempted to tighten the bolts however when tightened the Sit to Stand would not raise properly. Review of the Tollos Steady aid manual copyrighted 2014 stated Ensure there are no loose bolts or nuts, and the actuator does not wobble, squeak, vibrate or make unusual noise. During an interview on 10/22/2024 at 11:27 AM, Staff A, Administrator, stated the expectation was that preventative maintenance was conducted and if there were concerns an outside representative should have been contacted for assistance. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 3 sampled residents (Resident 54) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Resident 54 admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs) and congestive heart failure. Review of Resident 54's admission Minimum Data Set assessment (MDS) dated [DATE] showed the resident received 02 therapy. Observations on 10/16/2024 at 9:17 AM, showed Resident 54 received O2 set to between 4 and 5 liters (L) per minute via a nasal canula (devise to deliver O2 through a tube into the nose) that was connected to an O2 concentrator. Observations on 10/18/2024 and 10/21/204 showed Resident 54 received O2 set to between 4 and 5 liters (L) per minute via a nasal canula. Review of Resident 54's Care Plan showed an intervention for oxygen settings at 3 L continuously. During an interview and observation on 10/21/2024 at 9:07 AM, Staff E, Licensed Practical Nurse (LPN), observed Resident 54's O2 and stated it was set at 5 L. Staff E stated the resident would get anxious and increase their oxygen, which they had done the previous week. Staff E asked Resident 54 if they had increased the oxygen which they denied. Staff E stated the O2 should have been set at 3 L. During an interview on 10/22/2024 at 1:28 PM, Staff O, Assistant Director of Nursing (ADON), stated the expectation was that staff follow the providers order and check the O2 setting every shift. Reference WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to explain the arbitration agreement in a manner that residents understood for 3 of 3 residents (Residents 13, 24 and 11) reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a trial without consent, lack of adequate resolution of violations of rights, and a diminished quality of life. Findings included . Resident 13 Review of Resident 13's arbitration agreement on 12/08/2023 showed that the resident signed the arbitration agreement. During an interview on 12/08/2023 at 11:25 AM, Resident 13 stated that they did not recall signing an arbitration agreement and that they would not want to give up their right to a trial. Resident 13 further stated that they did not know that they had signed an arbitration agreement with the facility at admission. Resident 24 Review of Resident 24's arbitration agreement on 12/08/2023 showed that the resident signed the arbitration agreement. During an interview on 12/08/2023 at 11:38 AM, Resident 24 stated that they did not know what an arbitration agreement was and did not know if they wanted to sign one because they did not understand what it was. Resident 11 Review of Resident 11's arbitration agreement on 12/08/2023 showed that the resident signed the arbitration agreement. During an interview on 12/08/2023 at 11:48 AM, Resident 11 stated that they did not recall signing an arbitration agreement and the agreement was never explained to them. Resident 11 further stated that they were presented numerous papers to sign on admission and they were unsure what they signed. During an interview on 12/08/2023 at 10:30 AM, Staff E, Director of Admissions, stated that the facility explained the arbitration agreement on admission, but was unsure how it was explained to the residents. Staff E further stated that the arbitration agreement did not restrict resident's ability to request a court trial. Staff E further stated that a family member could sign the arbitration agreement in lieu of a resident without a power of attorney in effect. Staff E stated that they ensured residents were cognitively capable to sign the document by speaking with them. During an interview on 12/08/2023 at 12:00 PM, Staff A, Administrator, stated that arbitration agreements were presented to residents on admission and that the process of signing admission documents could be a blur due to the amount of information presented. Staff A further stated that if a resident was not cognitively able to sign the arbitration agreement, then they would refer to family to sign. No Reference WAC

Based on interview and record review, the facility failed to provide services to improve hearing for 2 of 3 residents (Residents 13 and 33) reviewed for communication/sensory. This failure placed residents at risk of not being able to communicate, inability to participate in activities, feelings of isolation, and a diminished quality of life. Findings included . Resident 13 During an interview on 12/04/2023 at 12:56 PM, Resident 13 stated that they had previously used hearing aids which were lost, was deaf in one ear and had difficulty hearing with the other. Review of Resident 13's diagnosis list on 12/07/2023 showed unspecified hearing loss of the left ear. Review of a physician's progress note dated 11/09/2023 showed that Resident 13 had hearing loss with right greater than left, required new hearing aids, and requested a referral to audiology for assessment and treatment. During an interview on 12/07/2023 at 11:14 AM, Staff D, Assistant Director of Nursing (ADON), stated that Resident 13 had a hearing deficit, was referred to audiology for assessment and treatment, and that this appointment had not been scheduled. Staff D further stated that Resident 13's provision of care to improve hearing did not meet expectation. Resident 33 During an interview on 12/04/2023 at 11:16 AM, Resident 33 stated that they had difficulty hearing and did not have hearing aids. Review of Resident 33's 11/17/2023 initiated care plan showed a focus area for risk of communication problem related to hearing deficit/hard of hearing. Review of a 02/13/2023 progress note showed that Resident 33 had difficulty hearing. Review of Resident 33's 03/13/2023 quarterly MDS showed minimal difficulty hearing with no appliance. During an interview on 12/07/2023 at 11:14 AM, Staff D, ADON, stated that it was difficult to tell whether Resident 33 had a hearing deficit due to other diagnoses and that further assessment was needed to understand the resident's ability to hear. During an interview on 12/07/2023 at 1:38 PM, Staff B, Director of Nursing Services, stated that the expectation was for residents with hearing difficulties to be assessed and treated. Staff B further stated that Resident 13 should have been referred for audiology and that the lack of referral did not meet expectation. Staff B stated that Resident 33 should have been assessed to better understand their hearing ability and that this lack of assessment did not meet expectation. Reference WAC 388-97-1060(3)(a)

Based on interview and record review, the facility failed to provide a written bed-hold notice, at the time of transfer to the hospital, for 3 of 4 residents (Residents 22, 55 and 67) reviewed for hospitalization . This failure placed the residents at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 22 Review of Resident 22's medical record on 12/05/2023 showed that resident was transferred from the facility to the hospital on 10/30/2023 with a readmittance date of 11/04/2023. Review of Resident 22's medical record on 12/05/2022 showed no documentation that a written bed hold notice was provided to the resident and/or their responsible party for the transfer to the hospital. Resident 55 Review of Resident 55's medical record on 12/05/2023 showed that Resident 55 was transferred from the facility to the hospital on 10/11/2023 with a readmittance date of 10/13/2023. Review of Resident 55's medical record showed no documentation that a bed hold was offered and/or the bed hold notice had been provided to the resident or responsible party. Resident 67 Review of Resident 67's medical record on 12/05/2023 showed that Resident 67 was transferred from the facility to the hospital on 10/27/2023. Review of Resident 67's medical record on 12/05/2023 showed no documentation that a bed hold was provided to Resident 65 and/or their responsible party for the transfer to the hospital. Further review of the medical record showed the first contact made with the responsible party about a bed hold was on 11/02/2023. During an interview on 12/06/2023 at 1:08 PM, Staff E, Director of Admissions, stated that nursing staff was now responsible for bed holds as of the last 60 days. Staff E further stated that written notices had not been provided to the resident/responsible party; however, it was available if they wanted a copy. During an interview on 12/06/2023 at 1:25 PM, Staff M, Licensed Practical Nurse (LPN), stated that the nurse who discharged the resident was responsible for completing the bed hold. Staff M stated that the notice should be completed and uploaded to the resident's medical record. Staff M further stated that they did not know if the resident/responsible party was supposed to receive a copy of the written notice. During an interview on 12/08/2023 at 9:21 AM, Staff B, Director of Nursing services (DNS), stated that nursing had recently taken over the bed hold process and that they were working on getting all staff on the same page. Staff B also stated that the resident's should have been offered a bed hold and provided a written notice; however, they were not. Reference WAC 388-97-0120 (4)

Based on observations, interview and record review the facility demonstrated a pattern of inaction and serious disregard for consequences for 1 of 3 Sample Residents (#1) reviewed for post-surgical care. The facility did not have clinical systems in place to manage risk factors, implement proactive measures to avoid complications. The failure included; lack of clear weight bearing orders; absence of ongoing accurate and thorough nursing assessment/monitoring, not identifying risk factors, lack of person centered interdisciplinary team approach to care, and failure to adhere to professional standards. The series of these failures contributed to and resulted in deterioration of the surgical incision, constituting neglect. The complications resulted in hospitalization for infected and re-fractured ankle, and an amputation of the foot. Findings include: Resident #1 admitted to the facility on [DATE] after right ankle surgery with implanted hardware to hold the bones together. At the same time she had a broken right knee requiring immobilization according to hospital records dated 01/10/18. The same records showed a left ankle immobilized with a splint secured with ace wrap. Observations and interviews conducted on 01/25/11 at 11:55 AM and 01/29/18 at 1:59 PM. Resident #1 was in a hospital bed, the left ankle had an [DEVICE] (metal rods outside of the ankle inserted through skin to keep the bones together.) Resident stated I might lose my foot, because there is infection in the bone. Resident said she might have put too much weight on it and broke it again. Resident #1 said she stayed at the facility from 01/11/18 through 01/21/18. Resident said she was unable to get out of the bed by herself. Resident reported having problems receiving help in a timely manner and did not have dignified experience with care. Resident #1 reported diarrhea episodes between 01/15/18 and 01/19/18 and had two incidents where she laid in feces for over an hour and was treated rudely by staff. Resident used toilet paper to clean self after bowel movements. Resident reported she did not receive any assistance with hand hygiene after contact with fecal matter. Resident described feelings of discouragement and hopelessness. Refer to F550 for Resident #1. ORDERS Record review showed on 01/11/18 Resident #1 was non-weight bearing (NWB) to the left lower extremity (LLE) according to admit orders. On 01/16/18 according to a document titled Report of Consultation, read resident may transfer WB (bear weight) on left with a fracture boot. On 02/02/18 at 9:07 AM Staff W was asked to clarify guidance for transfers on the consultation report. Staff W explained resident could use the left foot for balance and transfers without applying full weight. Physical therapy note on 01/16/18 included; fracture boot on and can now bear weight on left for transfers, the same note also stated the resident had NWB (non weight bearing) precautions to the LLE. During an interview, Collateral Contact, V, surgeon on 01/29/18 at 9:37 AM clarified that Resident #1 was NWB to the left foot while in the fracture boot but could place it on the floor for balance and/or transfers purposes and at no time should bear full weight. During the same interview CC V said facility staff informed him that resident's left ankle was bleeding on 01/18/18 and they changed the dressing. CC V stated he gave an order to monitor for bleeding and no weight bearing to the left foot. A date stamped chart note on 01/19/18 at 8:21 AM showed facility received instructions for NWB to LLE and no walking on the left foot and to report continued bleeding to the physician. Review of communication among facility healthcare providers related to transfers and/or weight bearing orders found conflicting information and lack of clarify. The admit orders on 01/11/18 stated NWB to LLE however the Care Plan with initiation date of 01/11/18, showed resident was one person slide board transfer and was weight bearing for transfers on left foot for nursing assistants. Toileting care plan did not provide directions on how to transfer the resident. Therapy notes on 01/19/18 showed Restorative Nursing Assistant (RNA), was instructed on working with Resident #1, with a goal to increase lower extremity strength. No further information was available if RNA and/or therapy were notified about onset of complications (bleeding). It is unknown if therapy and/or restorative staff continued to work with the resident. On 01/29/18 at 1:59 PM during an interview, Resident #1 said on 01/16/18 she had a follow up appointment with the surgeon who changed the left ankle dressing. During the same appointment her left foot was placed in a black boot. Resident was asked if she received education from nursing staff and/or therapy regarding weight bearing restrictions to both legs, she recalled just one therapist. Resident was asked how she used the bathroom resident stated that she pivoted .using my boot from the bed to the commode. Resident said she thought that on 01/17/18 therapy brought a bedside commode and it was placed next to her bed. Resident said it was helpful as she was having diarrhea. In an interview on 02/02/18 at 7:30 AM and at 0907 AM, Staff T and W confirmed resident used a bedside commode. Staff W said the commode was adjusted on 01/18/17. Record review did not find clarifying orders about using bedside commode for toilet transfers. NURSING ASSESSMENT/PROFESSIONAL STANDARDS Nursing progress notes from 01/11/18 through 01/21/18 did not show ongoing, thorough and accurate assessment of the right and left extremity. The clinical evaluation dated 01/11/18 at 9:01 PM marked that resident had no skin alterations. The admission note on 01/11/18 documented resident had diabetic sores on her fingers, however there was no further assessment monitoring, or treatment orders related to documented skin problem. Review of electronic records on 01/25/18 found Resident #1 weekly skin assessment was not complete. The assessment page showed overdue weekly skin check as of 1/16/18. Nursing assessment on 01/12/18 and on 01/13/18 identified resident had a cast to the left lower extremity. The hospital records, interview with Resident #1 on 01/25/18 at 12:25 PM, and interview with Staff T on 02/20/18 at 7:30 AM, revealed Resident #1 did not have a cast at any time. On 01/29/18 at 2:35 PM Staff C, a nurse manager was unable to provide evidence of accurate nursing assessment and reported that resident had a hard cast. Staff C could not provide evidence that nurses conducted ongoing monitoring of the left lower extremity. Staff S, licensed nurse on 01/29/18 at 3:03 PM said she did not find orders for monitoring left ankle. Staff K, licensed nurse on 02/05/18 at 9:25 AM and Staff J, licensed nurse on 02/06/18 at 12:47 Staff J, licensed nurse nursing standards include assessing for circulation, cessation and movement when caring for ankle surgeries. Progress notes between 01/11/18 and 01/21/18 did not find relevant nursing assessment on 24 out of 31 shifts for monitoring the left and the right lower extremities. There was no assessment describing support devices used to both extremities and whether the positioning was correct. There was no ongoing assessment that described skin conditions under the devices and distally. The nursing assessment was not conducted in accordance with professional standards as referenced in Perry and Potter, Clinical Nursing Skills & Technique, 8th ed., 2014. The assessment did not contain description of neurovascular status (nerves and blood vessels), and ongoing monitoring of sensation, circulation and movement of the left extremity. Without conducting a thorough assessment the nurses cannot obtain baseline data, and identify risk factors such as [MEDICAL CONDITION] (nerve disease), and identify early signs of skin or musculoskeletal complications and cannot implement interventions and/or anticipate potential complications. After Resident #1 developed bleeding to the left ankle on 01/18/18, the physician orders [REDACTED]. The facility failed to monitor resident closely after a change of condition. On 01/25/11 at 11:55 AM Resident #1 reported staff did not look at her left foot dressing or wraps. Resident said the ankle started bleeding on 01/18/18. Resident reported that Staff P, a licensed nurse changed the dressing once, and no one else looked at it until 01/21/18. On 01/21/18 a visitor discovered Resident #1's dressing and the boot was saturated with blood. Nursing documentation dated 01/21/18 at 6:13 PM described left boot taken out .there was foul smell coming out of her wound .dressing with dark drainage .swollen .dark purple and green bruising noted . ankle has screw out .drainage coming out from wound .MD notified orders to send to ER. CC V, surgeon on 01/29/18 at 9:37 AM during an interview said he expected to be notified right away of ongoing bleeding and/or changes in sensation. CC V said he looked at Resident #1's left ankle on 01/16/18 and it was straight and the sutures were intact without signs of no infection. During the same interview, CC V stated he gave directions to facility staff to watch for bleeding on 01/19/18 at 8:21 AM. CC V stated if he was notified earlier about any changes he could have taken the resident to the operating room sooner. CC V said when Resident #1 was in the operating room on 01/21/18 the bone and screws protruded through the skin and the ankle was deformed. The incision was grossly infected. On 1/21/18 at 6:55 PM hospital progress note included patient seen trauma to left ankle, lateral dislocation of the ankle joint and now there is necrosis and hardware protruding from the site hematoma from secondary trauma . assessment open tibia fracture left ankle trimalleolar re-fracture. TIMELY RISK IDENTIFICATION At the time of admission Resident #1 had known risk factors including inability to move without assistance due to broken left ankle and fractured right knee, [DIAGNOSES REDACTED]. MAR (Medication Administration Record) showed Resident #1 did not receive strong pain medication or narcotics until 01/20/18. The lack of pain after a surgical procedure is indicative of possible problems with sensation. On 01/20/18, resident's pain level was a 7 and after resident received narcotic medication the pain level decreased to a 6. There was no evidence this change was identified by nursing and was reported to the physician. Staff B, Director of Nursing provided a timeline to surveyors on 02/05/18, regarding the left foot. This document showed that on 1/19/18 a nurse noted screw protruding out of skin, however no action was taken at that time. INFECTION Resident admitted on [DATE] without signs of infection to the left ankle as noted in the hospital notes on 01/10/18. Resident #1 had diarrhea between 01/15/18 and 01/19/18. Resident independently cleaned herself but did not receive assistance with hand hygiene. On 01/21/18 Resident #1's surgical incision had signs of infection as documented in the nursing notes. On 1/21/18 at 6:09 PM blood and wound cultures from left foot were obtained on 1/21/18 at 9:13 PM showed growth of [MEDICATION NAME] cloacae (bacterium part of the gut flora that can be transmitted through contaminated hands) from both sources. The resident was diagnosed with [REDACTED]. Refer to F635 Refer to F609 Refer to F610 WAC 388-97-0640 (1)

Based on observation, record review and interview, the facility failed to provide adequate supervision and to provide assistive devices to prevent actual and /or potential injuries for 3 of 7 Residents (discharged Resident #1, and current Residents #2 & #3) reviewed for injuries that occurred during care. This failure resulted in harm for Resident #1 due to injuries sustained during a fall out of bed when the care plan was not followed. Resident #2 was harmed due to burns received from a hair dryer. Resident #3 was harmed due to lack of arm support during a transfer. Resident #3 was also placed at risk for injury during a transfer where the care plan was not followed. Findings included: 1. Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident was out of the facility in the hospital during the survey observation period. Review of a care plan revised on 07/13/17 showed the resident had self-care deficits due to fatigue, limited mobility and MS disease process. Bed mobility required two staff participation to reposition and turn in bed. Review of the resident's Kardex (computerized care plan for direct caregivers) dated 07/13/17 showed the resident required two staff for bed mobility. Review of a facility incident investigation dated 08/15/17 showed Staff Q, Certified Nursing Assistant, CNA, was providing care with Resident #1 turned away from him on the bed. The resident began flailing and jerked away from Staff Q and fell off the opposite side of the bed at approximately 8:45 PM. Review of nursing progress notes dated 08/15/17 showed Resident #1 was face down on the floor complaining of pain in both knees. Nursing assessment noted abrasions on both knees and a developing hematoma (collection of blood under the skin) on the right forehead. The resident was transferred to the emergency room for further evaluation. Review of the emergency room orthopedic consult note dated 08/15/17 showed X-rays and CT scan confirmed minimally displaced bilateral patellar (knee cap) fractures. Review of the hospital history and physical notes dated 08/15/17 showed a [DIAGNOSES REDACTED]. During review of the investigation with Staff A, Administrator and Staff B, Director of Nursing, DNS on 08/29/17 at 12:15 PM, Staff B stated that it absolutely should not have happened. 2. Resident #2 was admitted [DATE] with medical [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (automated assessment tool), MDS, dated [DATE] showed the resident had functional limitations on both upper and lower extremities. The assessment noted the need for extensive staff assistance for personal hygiene. The resident's BIMS score (Brief Interview for Mental Status) was 15 (a score of 13 -15 meant the resident was cognitively intact). Review of a facility investigation dated 07/28/17 showed Resident #2 stated he was blowing my hair, he asked me to hold the dryer so he could get my brush. I didn't feel anything then I saw the marks. Staff O, Certified Nursing Assistant, (CNA) was the care provider during the above incident. Review of Staff O's witness statement showed he handed the dryer to the resident; the resident put the dryer on his chest. Staff O was not aware of the placement of the dryer since he was brushing the resident's hair. When the resident said it was hot he removed the hair dryer and told the nurse. Nursing assessment following the incident showed Resident #2 had two burns from the hair dryer to his chest area, 7.5 cm (centimeters) long by 2 cm wide and 4 cm long by 2.5 cm wide; edges red, middle white without blistering. Review of a physician order [REDACTED]. During interview on 08/29/17 at 11:50 AM, Resident #2 stated that he got the burns on his chest from a hair dryer. He said Staff O was helping him do his hair after a shower. He was looking for my hair brush and handed me the dryer. I didn't feel anything at first, then my skin was burning. I said turn it off and he did. The resident said he didn't have full feeling on the skin on his chest and stomach. Observations of the resident's chest during interview showed two slightly red, scabbed areas on lower left chest approximately 5.0 cm by 2.0 cm and 3.0 cm by 2.0 cm. The resident stated that the nurses were still treating the burns twice a day with Silvadene and gauze. 3. Resident #3 was admitted on [DATE] with medical [DIAGNOSES REDACTED]. Review of the Resident's Admission Minimum Data Set, MDS (nursing assessment tool) dated 08/08/17, Section G, Functional Status, showed the resident required extensive assistance of two staff for transfer, toileting and bed mobility. The resident was not steady during surface to surface transfers, (for example from bed to wheel chair and wheel chair to toilet) and when moving from sitting to standing position. Review of a facility investigation dated 08/13/17 showed Resident #3 injured his wrist during a transfer into his wheel chair. Resident #3 reported Staff R, Certified Nursing Assistant, CNA, let his arm and hand go during transfer and when he sat down in his wheel chair, his hand was mal-positioned between the armrest of the wheel chair and his thigh. The resident said he had pain but did not report it until the following day. Initial x-ray on 08/14/17 showed a hairline fracture of the distal ulna (long bone in the forearm). An emergency room follow up visit on 08/15/17 showed a [DIAGNOSES REDACTED]. 4. On 08/30/17 at 3:45 PM, Resident #3 was transferred from his wheel chair to bed by Staff J, CNA. Staff J stated that the resident was a one person stand-pivot transfer with gait belt according to the Kardex (computerized care plan for direct care providers). Resident #3 held his left arm with his right hand during the transfer. The transfer was completed rapidly. The resident made it to the edge of the bed, seated in a slanted position on his left buttock. Staff J completed the transfer without further incident. Review of the Kardex and comprehensive care plan revised on 08/17/17 showed Resident #3 required two staff assist with transfers using a gait belt. The above transfer on 08/30/17 by one staff placed the resident at risk for injury. During a previous observation of a transfer on 08/29/17 at 11:45 AM by Staff L, Certified Nursing Assistant, CNA, and Staff M, Certified Nursing Assistant, CNA, Resident #3 stated that sometimes he was transferred by one staff, but it was hard. Staff L, CNA, said it was ok to do the transfer with one person if you could not find a second person. The Administrator, Staff A and Director of Nursing , Staff B, were informed of the above observations during a status meeting at 2:15 PM on 08/30/17. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure pain medications administered provided adequate pain management for 8 of 8 Sample Residents (#s 1, 2, 3, 4, 5, 6, 7 and 8) who were prescribed narcotic pain medications. These failures had the potential to place all residents at risk for ineffective pain control and resulted in harm for Resident # 5, Resident #6 and Resident #7 who experienced unrelieved, uncontrolled pain. Failures resulted in Immediate Jeopardy identified on 05/08/17 and placed all residents at risk for not having adequate pain management due to inadequate narcotic pain medication management and administration. The facility removed the Immediate Jeopardy on 05/17/17 through facility wide audits, staff training and policy changes. Findings included . On 05/8/17 at 12:35 PM Staff C and Staff F, nursing supervisors reported that the facility identified eight residents had narcotic medications substituted with non-narcotic medications. Both staff reported a total of 12 bubble packs (flexible plastic or cardboard like sheeting containing numerous small air pockets with medication pills inside each bubble) were labeled as narcotics, but the actual pills were not narcotics when the facility's consulting pharmacist identified mislabeled bubble packs. Staff F explained the facility made copies of bubble packs with questionable medications inside and returned medications to the pharmacy for replacement. According to a facility undated investigation completed on 05/17/17, it showed it remained unclear how many doses of mislabeled medications were administered to residents. RESIDENT #6 Resident #6 admitted to the facility from a trauma center on 04/18/17. During an interview on 05/17/17 at 4:15 PM, Resident #6 stated he had been hit by a car and spent 3 weeks in the hospital prior to admitting to the facility. Resident #6 stated he had multiple fractures and has pain in his shoulders, neck, spine, ribs, and down his arms, extending to his fingers. Review of Resident #6's medical record showed a physician's orders [REDACTED]. During an interview on 05/08/17 at 5:00 PM, Staff F, RN, RCM, stated Resident #6 had been hit by a car and has had increased pain. Staff F, RN, RCM, stated Resident #6 was not getting pain relief when he was given his prescribed [MEDICATION NAME] (a narcotic pain reliever). Staff F, RN, RCM, stated, she could not figure out why Resident #6 had got more pain relief from taking an over the counter pain reliever, such as Tylenol, than he did from taking the narcotic pain reliever. Staff F, RN, RCM, explained that a staff member from the pharmacy had completed an audit of medication carts and identified that Resident #6's package of pills labeled [MEDICATION NAME] actually contained [MEDICATION NAME] (a prescription medication used to treat allergies and motion sickness). During an interview on 05/12/17 at 10:55 AM, Resident #6 stated the first couple of days after he admitted to the facility his pain medications were effective at relieving his pain, then it changed. Resident #6 stated his pills looked the same, but tasted different. Resident #6 stated the pills did not give him any pain relief. Resident #6 stated he would lay in bed watching the clock, waiting for it to be time to get another pain pill, hoping the nurse would give him a pill before he had to work with the therapist. Additionally, Resident #6 stated he was dying, and just tried to get used to being in pain. Review of the narcotic log showed when Resident #6 first arrived at the facility his pain medications were supplied from the emergency kit. The second day in the facility Resident #6 received packaged pain medication from the pharmacy. Resident #6 experienced increase pain as a result of not receiving prescribed pain medications. RESIDENT #7 Resident #7 admitted to the facility 08/22/17 with [DIAGNOSES REDACTED]. Review of Resident #7's medical record showed a pain assessment dated [DATE], which showed Resident #7 had pain related to diabetic [MEDICAL CONDITION] and history of right and left [MEDICAL CONDITION]. During an interview on 05/09/17 at 3:30 PM, Staff F, RN, RCM, stated Resident #7 had chronic pain related to having fractures in both her right and left hips. Review of Resident #7's medical record revealed a physician's orders [REDACTED]. During an interview on 05/12/17 at 1:00 PM, Resident #7 stated she had told the nurses her pain pills were not working. Resident #7 stated prior to the medication discrepancy she only took half of her pain pill and her pain level remained three to four on the one to ten pain scale. Then she noticed her pain levels worsening. Resident #7 stated she started taking two whole pain pills, and her pain level never went below and eight, and had increased to 13 on a one to ten scale. Review of the April 2017 Medication Administration Record showed staff asked Resident #7 three times daily to rate her pain using a one to ten scale. Pain ratings were documented as zero on all three shifts for the first six days of April. On 04/07/17 Resident #7 rated her pain as seven during the evening and at night. Resident #7 continued to report pain 15 of the next 21 days, until the wrong medication was identified. During an interview on 05/09/17 at 3:30 PM, Staff C, RN, MDS, stated the pharmacist identified the package of pills labeled [MEDICATION NAME] was did not actually contain [MEDICATION NAME]. Staff C, RN, MDS, stated the pharmacist did not report what the medication was, but confirmed it was not as labeled. Review of the narcotic log, page 4, showed between 04/08/17 and 04/27/17, one pill from the package had been removed and administered every day, indicating Resident #7 received the wrong medication for twenty days. There was no evidence Resident #7 had received the pain medication prescribed by the physician. When asked if there were any other pain relief measures put in place during the timeframe that she had increased pain, Resident #7 stated staff had her try putting a pillow between her knees. Resident #7 stated the pillow was not effective for relieving pain. RESIDENT #5 During an interview on 05/12/17 at 1:50 PM, Resident #5 stated she has continuous pain that throbs, and shoots down her right leg due to a right hip and right upper leg fractures. Resident #5 stated recently her pain level had increased from a seven out of ten rating to a ten out of ten all the time. Review of Resident #5's medical record revealed a pain assessment dated [DATE] which showed Resident #5 rated her pain as eight out of ten in severity. Resident #5 described the pain as aching and throbbing, which had affected her sleep, ability to participate in activities and mood/emotions. Further review of the assessment showed Resident #5 had medical [DIAGNOSES REDACTED]. During an interview on 05/12/17 at 2:00 PM, Staff G, LPN, stated Resident #5 did have recent complaints of increased pain levels. Staff G stated, at the time she did not know why Resident #5 was experiencing more pain. Review on an undated facility investigation showed pharmacy staff identified Resident #5's package of [MEDICATION NAME] actually contained the medication [MEDICATION NAME], used to treat nausea. During an interview on 05/17/17 at 4:00 PM, Resident #5 stated she was told by staff that she had not had her prescribed pain medication for ten days. Resident #5 stated she had used opiate pain medications to relieve her pain. Resident #5 stated she felt like she was going through with drawls from the medication. Resident #5 stated, she was nauseated, ached all over, clammy, shaking, was irritable and hurt like hell. Resident #5 stated she knew the staff were concerned, but they didn't live it, they have no idea what I felt. During an interview on 05/17/17 at 4:00 PM, Staff K stated that during the timeframe when the medication discrepancies were identified, Resident #5 had shown symptoms which may have been sign of withdrawls from the opiate medication. Staff K stated Resident #5 had experienced nausea, shaking and was irritable. During an interview on 05/17/17 at 5:46 PM, Staff Q, Medical Director, stated signs and symptoms of withdrawls can occur after stopping opiate medications. Staff Q, Medical Director, stated the symptoms can start within one to two days. RESIDENT #3 Re-admit to facility 06/24/16 [DIAGNOSES REDACTED]. Pain assessment dated [DATE], showed pain management interventions are necessary for Resident #3's care. During an interview on 5/10/17 at 11:15 AM, Resident #3 stated he had pain in his hand. Review of Resident #3's medical record showed a physician's orders [REDACTED].#3 had been taking the narcotic pain reliever three times daily for nearly one year. Review of the facility investigation showed Resident #3 had two packages of [MEDICATION NAME] stored in the medication cart. Both packages had been used. Further review of the investigation showed one package of [MEDICATION NAME] did not contain pain medication, but contained [MEDICATION NAME], a medication used to treat acid reflux. The investigations showed the second package of [MEDICATION NAME] in the medication cart, also did not contain [MEDICATION NAME], but contained [MEDICATION NAME], a medication used to treat allergies and nausea instead. Review of Resident #3's medical record showed a progress note dated 04/28/17 that indicated [MEDICATION NAME] had not been given for 8 days. RESIDENT #1 Resident #1 admitted to facility 12/12/15 with [DIAGNOSES REDACTED]. An MDS (Minimum Data Set, a comprehensive assessment tool) dated 03/16/17 indicated the resident had a BIMS (Brief Interview for Mental Status) score of 12, meaning moderate cognitive impairment. According to a facility pain assessment dated [DATE], the resident suffered from chronic back pain and experienced aching and throbbing sensations. The same pain assessment showed the resident felt pain relief from [MEDICATION NAME] (long acting narcotic medication) and [MEDICATION NAME] (short acting narcotic) for breakthrough pain on as needed basis. On 05/12/17 at 10:46 AM Resident #1 was observed in bed in a reclined position. Resident said she received either too much pain medications or not enough. Resident said she had severe pain in her back and legs since [DIAGNOSES REDACTED]. Record review showed in April 2017, Resident #1 had a physician's orders [REDACTED]. A bubble pack that was in use in April 2017 labeled as [MEDICATION NAME] 5 mg tablet was actually [MEDICATION NAME] 12.5 mg (anti- nausea medication) as indicated on the back labels of each individual pill. A second bubble pack with round pills labeled as [MEDICATION NAME] mg was identified and labeled on the back of the bubble pack as [MEDICATION NAME] 10 mg (anti- nausea medication). In April 2017, the resident's Narcotic Log page 13 showed staff administered 24 doses of [MEDICATION NAME] 10 mg. The resident actually received [MEDICATION NAME] 10 mg that was labeled as [MEDICATION NAME] 10 mg, as evidenced by documentation on the medication administration record, narcotic log (page 13) and copy of the bubble pack provided by Staff A on 05/09/17. Review of the narcotic log and Medication Administration Record (MAR) found discrepancies between documented removal of [MEDICATION NAME] and [MEDICATION NAME] on the narcotic log and Medication Administration Record (MAR) On the following dates facility's narcotic log showed multiple narcotic medications were logged as removed but were not documented administered to Resident #1 on the Medication Administration Record (MAR). On 02/24/17 at 05:18 AM, [MEDICATION NAME] 5 mg tablet was removed but not documented on the MAR as administered. On 03/08/17 at 1048 and at 1240 [MEDICATION NAME] 5 mg tablet was removed but not documented as administered. On 03/27/17 at 12:34 PM [MEDICATION NAME] 5 mg tablet was removed but was not documented administered to Resident #1. Review of nursing notes since narcotic discrepancies on 04/28/17, did not find evidence Resident #1 was monitored for potential withdrawal symptoms In an interview on 05/17/17 at 6:00 PM Staff Q, facility Medical Director explained that he expected residents who were affected by mislabeled narcotics to have been monitored for signs of withdrawal symptoms. The symptoms typically were restlessness, increased agitation, nausea, vomiting, and changes of vital signs such as a fast heart rate. RESIDENT #2 Resident #2 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident had acute and chronic pain due to history of multiple joint surgeries according to History and Physical with a date of 10/28/16. Facility's pain assessment dated [DATE] indicated resident experienced pain from the wound and narcotic medication was one of the pain relieve options. Resident was prescribed [MEDICATION NAME] 2 mg (narcotic pain reliever), 1-2 tablets every 6 hours as needed for pain. On 05/12/17 at 12:35 PM Resident #2 was observed in bed. Resident was interviewed about pain management. During an interview resident said she took [MEDICATION NAME] (narcotic medication) for pain from wound on her back and experienced episodes of unrelieved pain and that it hurt like hell. Resident was unable to provide exact dates of when she had severe pain. Facility's undated narcotic discrepancy investigated identified on 04/28/16 Resident #2's bubble pack labeled as [MEDICATION NAME] 2 mg tablets, had remaining 16 tablets of unknown medications when it was identified by the pharmacist on 4/28/17. Another bubble pack containing round pills had a prescription label of [MEDICATION NAME] 2 mg but the back of each pill was labeled as [MEDICATION NAME] 25 mg (blood pressure medication) tablet. Record review showed Resident #2 received 14 mislabeled medications instead of [MEDICATION NAME] 2 mg in April 2017 as identified on the narcotic log, medication administration record and copy of a bubble pack. Reconciliation between the MAR and Narcotic log for April 2017 found multiple narcotic medications were logged as removed but were not documented as administered to the resident on the Medication Administration Record (MAR). On 04/03/17 at 10:15 PM 2 tablets of [MEDICATION NAME] 2 mg was removed but not documented as administered. On 04/09/17 at 4:00 PM two tablets of [MEDICATION NAME] 2 mg or total of 4 mg was removed but the MAR showed only 2 mg was administered. On 04/10/17 at 3:45 PM 2 tablets of [MEDICATION NAME] 2 mg was removed but not documented as administered on the MAR. On 04/12/17 at 6 PM 4 mg of [MEDICATION NAME] was removed but not documented as administered on the MAR. On 04/25/17 at 2:35 PM two tablets of [MEDICATION NAME] 2 mg or total of 4 mg was removed but on the MAR it was documented resident received 2 mg. On 04/28/17 at 6:30 PM a total of 4 mg of [MEDICATION NAME] was removed but on the MAR it was not documented as administered. On 05/3/17 at 1:30 PM 4 mg of [MEDICATION NAME] was removed, the MAR showed the dose was administered at 4:23 PM. On 05/4/17 at 5:00 PM 4 mg of [MEDICATION NAME] was removed but not documented as administered on the MAR. On 05/5/17 at 3:00 PM 4 mg of [MEDICATION NAME] was removed, the MAR showed only 2 mg was administered at 3:14 PM. On 05/07/17 at 2:40 PM 4 mg of [MEDICATION NAME] was removed however the MAR shows resident received 2 mg at 2:33 PM for a pain level of 6 when the directions on the MAR specified to give [MEDICATION NAME] 4 mg for pain level 6-10. 05/08/17 at 9:15 PM 4 mg of [MEDICATION NAME] was removed but staff did not document on the MAR they administered it. Resident #2's pain level was documented the following day as a 10 on 05/09/17. Unrelieved pain can escalate if not controlled timely. RESIDENT #4 Record review and MDS dated [DATE] Resident #4 admitted to facility on 09/02/16 with [DIAGNOSES REDACTED]. The MDS indicated a BIMS of three, meaning severe cognitive impairment. Resident received food, fluids and medications through a tube in the stomach. May 2017 MARs listed resident's diet as NPO (nothing by mouth). On 05/16/17 at 1:10 PM during observation and attempted interview, Resident #4 was in bed with eyes closed. Resident was unable to answer questions. Facility's undated investigation of narcotic discrepancies found Resident #4 had 29 tablets labeled as [MEDICATION NAME] 5 mg were not actual medications and 8 tablets labeled as [MEDICATION NAME] 10 mg were [MEDICATION NAME] (anti- nausea medications). On 05/08/17 at 5:00 PM during an interview, Staff F reported a night nurse found Resident #4's medications labeled as [MEDICATION NAME] were anti- nausea medications instead. Staff F stated that a few weeks ago she gave Resident #4 two [MEDICATION NAME] and said resident did not get relief but it was difficult to tell due to resident behaviors. Resident #4 had orders for [MEDICATION NAME] 5 mg tablet 1 to 2 tablets every 6 hours and [MEDICATION NAME] 5 mg, ½ tablet (2.5 mg) every 4 hours as needed for pain according to the resident's April 2017 MAR. The narcotic log contained a pharmacy label that showed for staff to administer [MEDICATION NAME] 5 mg tablet with instructions to give 2 tabs (10 mg) by mouth every 6 hours, and to give 1/2 of tablet (2.5 mg) by mouth every 4 hours as needed for pain. These two separate orders were combined onto one single narcotic log form. The one narcotic sheet contained two different doses of pain medications. Entries on the narcotic log identified staff removed medications thirty eight individual times between 04/07/17 and 4/20/17 and thirty three times between 03/01/17 and 03/14/17. When staff signed for removal of medications the log did not identify what dose was actually removed and dispensed. The records could not validate what actual dose of [MEDICATION NAME] were administered to Resident #4. During an interview on 05/09/17 at 3:02 PM, when Staff F was informed about the log combining two separate orders for Resident #4, she stated that orders should be separated and nurses needed education. On 05/09/17 at 5:52 PM, Staff K was asked to clarify what doses were actually signed out and administered based on combined orders. Staff K replied that it was unclear and per reasonable deduction thinking it was unknown what medication dose was removed and led to speculation. On 05/12/17 at 6:10 AM Staff L was asked about administering narcotics when the pharmacy label combined different doses of [MEDICATION NAME] on the log and on the bubble pack. For example when nurses documented 1 under the dose on the narcotic log, which dose was signed out and given 2.5 mg or 5 mg of [MEDICATION NAME]. Staff L said I am confused now . I don't know. Review of the narcotic log and medication administration record found discrepancies between documented removal of [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2.5 mg on the narcotic log and Medication Administration Record (MAR). On 03/02/17 at 11:30 PM, two tablets of either 2.5 or 5 mg [MEDICATION NAME] was logged as removed and not documented on the MAR administered to the resident. On 03/06/17 at 230, two doses of [MEDICATION NAME] were removed according to the narcotic log but was not documented as administered on the MAR. This documentation was illegible. On 04/02/17 at 9:56 A.M. nursing notes documented the resident pulled out her gastric tube and was sent to the hospital on [DATE] for replacement. While the resident was without a gastric tube and was not taking anything by mouth (NPO), documentation on the MAR showed staff administered [MEDICATION NAME] 5 mg at 12:00 PM and at 6:00 PM. RESIDENT #8 Resident #8 admitted to the facility on [DATE]. Resident had [DIAGNOSES REDACTED]. Resident had acute and chronic pain described as stabbing, tingling, and throbbing sensations according to facility pain assessment dated [DATE]. The same assessment indicated resident had relieve from narcotic pain medications. Physician orders [REDACTED]. Resident #8 was prescribed [MEDICATION NAME] 20 mg 1 tablet at bedtime. A bubble pack containing round pills had a prescription label identifying medications as [MEDICATION NAME] 20 mg. Pharmacy verification dated 04/28/17 revealed the bubble pack in use had white round pills labeled as [MEDICATION NAME] 20 mg but the medication was an unknown substance when verified by pharmacy. It is unclear what medication staff actually administered to Resident #8 for pain relief. Observations on 05/12/17 at 5:48 AM, and 10:37 AM the resident was in bed with eyes closed. At 11:31 AM the resident stated that sometimes pain medications were helpful and complained about having pain in the knee.

Based on observation, interview, and record review, the facility failed to ensure accountability of narcotic medications and E Kits and were accurately acquired, received and dispensed and labels matched contents for nine of nine Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7, 8 and 9) reviewed for medication regimens. The facility also failed to obtain pharmacy consultation related to all aspects of medication services, and failed to act upon the recommendations of the consulting pharmacist. These failures placed residents at potential risk for medication errors, misappropriation of medications, and to ensure care related to prescribed medications met their needs. Failure to ensure all aspects of pharmacy services resulted in determination of Immediate Jeopardy on 05/08/17. The Immediate Jeopardy was removed on 05/17/17 after all licensed nursing staff had been educated on new policies and procedures related to receiving medications from the pharmacy, accounting for medications, and medication administration. Findings included . Refer to F 225 for failure to investigate documentated narcotic disrepancies and illegible hand writing to rule out potential diversion activities. Refer to F 309 and F 333 for information related to medication errors and lack of pain management for Resident (#s 1, 2, 3, 4, 5, 6, 7 and 8). PHARMACY RECOMMENDATIONS During an interview on 05/15/17 at 3:15 PM, Staff N, Pharmacist, stated that she visited the facility on a monthly basis. Staff N, Pharmacist, stated that in addition to her monthly visits, a nurse consultant visited the facility and compared the medications in the cart to the medications documented on Medication Administration Records. Staff N, Pharmacist, further stated that she sent a report to the Director of Nursing every month after she visited the facility. The report contained suggestions such as assessments that needed to be done when taking identified medications, medications that required an informed consent, medications that were contraindicated for each resident, required labs, and changes in medications or medication doses that may be necessary. Staff N, further stated that the recommendations sent in February 2017 and March 2017 were not followed through with by the facility. During an interview on 05/17/17 at 3:25 PM, Staff U, Corporate Consulting Nurse, stated that the pharmacist sent recommendations via email to the Director of Nursing (DNS) every month. Staff U, Corporate Consulting Nurse, stated the DNS reviews the recommendations, assigns the nursing tasks, such as consents and assessments to the Resident Care Manager, and then forwards the medication issues to the physician. Staff U, Corporate Consulting Nurse, also stated that the recommendations that the pharmacist sent to the facility in January 2017 and February of 2017 were not acted on. Staff U, Corporate Consulting Nurse, stated many of the March 2017 recommendations also were not acted on. Failure to act on recommendations suggested by the pharmacist placed residents at potential risk for having adverse medication reactions and/or side effects, and delayed identification of the effects of medications due to not performing the required assessments. Additionally, this failure placed residents at potential risk of not being fully informed of all risks and benefits associated with taking the medications. PHARMACY SERVICES During an interview on 05/15/17 at 3:35 PM, Staff N, Pharmacist, stated that she visits the facility quarterly, but does not check the narcotic log to compare what staff documented they administered to the resident as part of their review. During an interview on 05/17/17 at 11:56 AM, Staff V, Pharmacy Nurse Consultant, stated she visits the facility quarterly. Staff V, Pharmacy Nurse Consultant, stated she does not check the narcotic logs for accuracy, unless requested to do so by the facility. Staff V, Pharmacy Nurse Consultant, additionally stated, there had not been a narcotic log audit done in the facility since July 2016. Resident #1 received medications that were listed as allergies [REDACTED].#1 received Oxycontin and Gabapentin daily and Oxycodone PRN. Staff R, Pharmacist, was asked about resident's allergies [REDACTED]. Staff R stated that pharmacy records did not identify what reactions residents experienced towards those medications and were unable to verify they were true allergies [REDACTED]. A consultant's pharmacy report for March 2017 identified Resident #1 was part of the sample reviewed by the pharmacy. The statement in this report read residents' medication regimen contained no irregularities. ADMINISTRATION OF NARCOTIC MEDICATIONS RESIDENT #1 Resident #1 admitted to facility 12/12/15 with [DIAGNOSES REDACTED]. Resident #1 had a physician's orders [REDACTED]. Review of narcotic log and Medication Administration Records (MAR), found discrepancies between documented removal of Oxycodone and Oxycontin on the narcotic log and MAR from 02/24/17 to 03/27/17 for Resident #1. On the following dates facility's narcotic log showed multiple narcotic medications were logged as removed but were not documented as administered on the Medication Administration Record (MAR). On 02/24/17 at 05:18 AM, an Oxycodone 5 mg tablet was removed but not documented on the MAR as administered. On 03/08/17 at 1048 and at 1240 Oxycodone 5 mg tablet was removed but not documented on the MAR as administered. On 03/09/17 at 12:40 PM, an Oxycodone 5 mg tablet was removed according to the log but administered earlier at 12:15 p.m. On 03/27/17 at 12:34 PM, an Oxycodone 5 mg tablet was removed but was not documented on the MAR as administered. RESIDENT #2 Resident #2 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident had acute and chronic pain and was prescribed Hydromorphone 2 mg (narcotic pain reliever), 1-2 tablets every 6 hours as needed for pain. Reconciliation between the MAR and Narcotic log for April 2017 found multiple narcotic medications were logged removed from Resident #2's supply of medicaitons, but were not documented administered on the Medication Administration Record (MAR). On 04/03/17 at 10:15 PM, 2 tablets of Hydromorphone 2 mg was removed but not documented on the MAR as administered. On 04/09/17 at 4:00 PM, two tablets of Hydromorphone 2 mg, or total of 4mg, was removed but the MAR showed only 2 mg was administered. On 04/10/17 at 3:45 PM, two tablets of Hydromorphone 2mg were removed but not documented as administered on the MAR. On 04/12/17 at 6 PM. 4 mg of Hydromorphone were removed but not documented as administered on the MAR. On 4/25/17 at 2:35 PM, two tablets of Hydromorphone 2 mg, or total of 4 mg, were removed but on the MAR it was documented the resident received 2 mg. On 04/28/17 at 6:30 PM, a total of 4 mg of Hydromorphone was removed, but on the MAR it was not documented administered. On 04/30/17 at 3:40 AM, two Hydromorphone 2 mg tablets or total of 4 mg was documented removed on the narcotic log, an entry was written wasted/fell down and the count was corrected from 22 to 20 remaining pills. The next entry on the same narcotic log at 3:45 AM showed two, 2 mg Hydromorphone, or 4 mg, was removed but not documented on the MAR as administered. On the same day at 6:40 PM, 2 tablets of Hydromorphone 2 mg tablets, or total of 4 mg was removed, but the MAR documented 2 mg was administered. On this day there were a total of 6 mg of Hydromorphone unaccounted for. On 05/03/17 at 1:30 PM, 4mg of Hydromorphone was removed. The MAR showed the dose was administered later at 4:23 PM. On 05/04/17 at 5:00 PM, 4 mg of Hydromorphone was removed but not documented as administered on the MAR. On 05/05/17 at 3:00 PM 4 mg of Hydromorphone was removed, the MAR showed only 2 mg was administered at 3:14 PM. On 05/07/17 at 2:40 PM 4 mg of Hydromorphone was removed however the MAR shows resident received 2 mg at 2:33 PM for a pain level of 6 when the directions on the MAR specified to give Hydromorphone 4 mg for pain level 6-10. 05/08/17 at 9:15 PM, 4 mg of Hydromorphone was removed but not documented given on the MAR. The record showed the resident's pain level was documented as a 10 on 05/09/17. RESIDENT #3 Resident #3 was prescribed Oxycontin 10 mg (narcotic pain reliever) every 8 hours for pain. A bubble pack containing round pills had a prescription sticker identifying tablets inside were Oxycontin 10 mg, but on the back of the bubble pack showed each medication was labeled as Metoclopramide 10 mg. A second bubble pack of white round pills with a prescription label on the front showed it contained Oxycontin 10 mg. The back of the bubble pack identified it contained Hydroxyzine HCL(antihistamine and a sedative) 25 mg. RESIDENT #4 Resident #4 admitted to facility on 09/02/16 with diagnesis of [DIAGNOSES REDACTED], dysphagia, developmental disorder and had joint contractures. Resident #4 had orders for Oxycodone 5 mg tablets, 1-2 tablets every 6 hours, and Oxycodone 5 mg, ½ tablet (2.5 mg) every 4 hours as needed for pain according the to April 2017 MAR. The narcotic log contained a pharmacy label that showed for staff to administer Oxycodone 5 mg tableta and with instructions to give 2 tabs (10mg) by mouth every 6 hours, and to give 1/2 of tablet (2.5 mg) by mouth every 4 hours as needed for pain. These two separate orders were combined onto one single narcotic log form. The one narcotic sheet contained two different doses of pain medications. Entries on the narcotic log identified staff removed medications thirty eight individual times between 04/07/17 and 4/20/17 and thirty three times between 03/01/17 and 03/14/17. When staff signed for removal of medications, the log did not identify what dose was actually removed and dispensed. The records could not validate what actual dosage staff administered to Resident #4. On 05/09/17 at 5:52 PM, Staff K, Registered Nurse, (RN), was asked to clarify what doses were actually signed out and administered based on combined orders. Staff K, RN replied, that it was unclear and per reasonable deduction thinking and it is unknown what was removed and could lead to speculation. On 05/12/17 at 6:10 AM, Staff L, Licensed Practical Nurse, (LPN), was asked about administering narcotics when the pharmacy label combined different doses of Oxycodone on the log and on the bubble pack. For example, when nurses documented 1 under the dose on the narcotic log, Staff L was asked, which dose was signed out and given, 2.5 mg or 5 mg of Oxycodone? Staff L stated, I am confused now . I don't know. Review of narcotic log and medication administration records found discrepancies between documented removal of Oxycodone 5 mg and Oxycodone 2.5 mg on the narcotic log and Medication Administration Record (MAR). On 03/02/17 at 11:30 PM, two tablets of either 2.5 mg or 5 mg of Oxydone were logged as removed and not documented on the MAR as administered. On 03/06/17 at 230 (2:30 am or pm not identified), two doses of Oxycodone were removed as noted on the narcotic log, but were not documented administered on the MAR. This documentation was illegible. A narcotic log had a pharmacy label that combined Oxycodone 5 mg and 2.5 mg. On 03/04/17 at 5:00 AM, a remaining narcotic count was noted as 18. On 03/04/17 at 1:00 PM, one dose of Oxycodone was removed and the remaining count on the log was documented as 14. The remaining amount of Oxycodone on the log was incorrect when staff removed one dose but two doses were subtracted. On page 15 of the Narcotic Log dated 03/03/17, a pharmacy label read Oxycodone 5 mg tablet. On 03/08/17 at midnight, four doses were removed (20 mg of Oxycodone) but the MAR documented the resident received only 10 mg. On 03/07/17 at 5:00 AM, 4 doses were removed or 20 mg of Oxycodone. The MAR contained documentation staff administerd only 10 mg. On 04/02/17 at 9:56 A.M, nursing notes documented Resident #4 pulled out her gastric tube and was sent to the hospital on [DATE] for replacement. While the resident was without a gastric tube and was NPO (nothing by mouth), documentation on the MAR showed oral Oxycodone 5 mg was administered to the resident at 12:00 PM and at 6:00 PM. A narcotic log with entries from 04/16/17 to 04/20/17 had a label identifying medications as Oxycodone 5 mg tablets. Seven entries on the log documented four tablets were removed instead of two as prescribed by the physician. Narcotic log page #81 showed it had multiple illegible entries. From 04/07/17 to 04/08/17, the log had scibbling over the remaining number count, when staff wrote over the number 29 ; the number 28 was crossed off and next to number 26, the number 27 was written. There was no second nurse signatures next to altered documentation to verfiy accuracy of the counts. Narcotic log page # 83 showed reamining count numbers were altered on 04/15/17 and 4/17/17 without a second nurse signature. On 05/09/17 at 3:02 PM, Staff F, Registered Nurse, (RN), was asked about illegible documentation on narcotic logs for Resident #4, and stated when there was a miscount such as with documentation, two licensed nurses should co-sign verifying the count was accurate. Resident #4 had multiple illegible entries on narcotic logs. Staff B, Interim DNS, was made aware on 05/09/17 of identified disrepancies between the narcotig log and the MARs. On 05/12/17 at 2:00 PM, Staff U, Corporate Consulting Nurse, was informed about risk of error related to combining different Oxycodone doses on the narcotic log and the bubble pack. On the same day at approximatley2:07 PM, Staff U was informed about disrepancies and illegible documentaion on the narcotic log. At 2:40 PM, Staff U provided evidence the combined narcotic was clarified and separated. RESIDENT #8 Resident #8 admitted to the facility on [DATE]. Resident had [DIAGNOSES REDACTED]. Resident #8 had orders for Hydrocodone-Acetaminophen 7.5mg-325 mg with instructions to give one tablet every 6 hours as needed for moderate to severe pain and to give two tablets at bedtime routine according to the MAR. Narcotic log on page 73 had hand written instructions for Hydrocodone-Acetaminophen 7.5/325 mg. Administration frequency was not recorded on the log. An entry under directions read see MAR. The MAR for April 2017 listed two separtate orders, one for Hydrocodone-Acetaminophen 7.5/325 mg and to give two tablets at bedtime, and another for Hydrocodone-Acetaminophen 7.5/325 and to give one tablet every six hours as needed for moderate pain. Review of the narcotic log and MAR found disrepancies. On 04/11/17 at 5:03 AM, one Hydrocodone tablet for the day was removed but the MAR showed the resident received a total of three tablets. On 04/12/17, a total of two tablets were removed at 5:03 AM, 4:20 AM, but the MAR documented the resident received total of four tablets. On 04/13/17, a total of two tablets were removed at 3:40 AM and 9: 00 PM, but the MAR documentation indicated the resident received three tablets. Same findings of disrepancies were identified on MAY's 2017 MAR for Hydrocodone administration. On 05/03/17 the log showed two tablets were removed, but the MAR showed three tablets were documented administered. On 05/04/17, the log showeed three tablets were removed, and the MAR documented four tablets were administered to the resident. On 05/05/17, the narcotic log showed four tablets were removed and only three tablets were documented on the MAR given to the resident. RESIDENT #5 Review of Resident #5's medical record showed a physician's orders [REDACTED]. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported a consultant from the pharmacy had audited Resident #5's medication and determined a package labeled Oxycontin had actually contained Ondansetron (a prescription medication used to treat nausea). Review of the facility's investigation of the medication discrepancy showed eight of the Ondansetron pills had been removed from the package, indicating Resident #5 was given the wrong medication eight times. Further review of the facility's investigation showed photo copied pictures of the package of medication. The back of the package showed print over each pill which read Ondansetron, identifying the medication inside the package. Review of pharmacy delivery receipts dated 04/20/17 showed Resident #5 had a package of 14 Oxycontin pills. There was no signature on the receipt to indicate which nurse or who accepted the medication from the pharmacy courier. Review of narcotic log, page 1, line 16, showed staff documented administering one pill, and one pill remained. There were documented lines over existing documentation, showing the one pill administered had been changed to two, and the one remaining pill had been changed to zero. There were no initials to indicate which staff member altered the documentation or if two licensed verfified accuracy. Review of narcotic log page 67, showed documentation on 05/05/17 at 0:06 AM, just after midnight, showed staff removed two Oxycodone 5 milligram tablets. A box designated for a nurse's signature was documented refused. There were no initials as evidence nursing staff wasted (destroyed) the tablets. The Medication Administration Record showed no documented evidence the medication had been administered to the resident either. Further review of page 67 showed on 05/07/17 at 7:00 AM and at 12:45 PM, two tablets of Oxycodone were signed out. Under the column designated to document remaining tablets in the package, numbers documented for both administration times were written over and had been altered. RESIDENT #7 Review of Resident #7's medical record showed a progress note dated 04/03/17, patient may take only half tablet of Oxycodone 5 milligram, and the remaining half tab should be retained in the narcotic box (not wasted). During an interview 05/09/17 at 4:00 PM, Staff B, RN, DNS, stated it is not acceptable practice to retain a pill that had been removed from the package in the medication cart. During an interview on 05/15/17 at 3:35 PM, Staff N, Pharmacist, stated it is not acceptable practice to retain half of a pill in the medication cart. Review of narcotic log page 4, line 6, showed one Oxycodone pill was signed out at 9:21 PM. There was no documentated nurse signature to show who removed the pill. Further review of the narcotic log, page 4, showed Oxycodone was removed on 04/10/17, 04/11/17, 04/12/17, 04/17/17, 04/21/17, 04/23/17, and on 04/27/17. Review of the April 2017 Medication Administration Record, showed none of the listed dates had documentation to show the removed pills were administered to Resident #7. During an interview on 05/09/17 at 3:00 PM, Staff F reviewed the documentation on the narcotic log and compared it to the Medication Administration Record. Staff F stated there were seven doses of the narcotic pain medication not accounted for. Review of an undated facility investigation showed photo-copied images of a package of medication that contained Oxycodone 5 milligrams tablets. The photo showed 20 of the 30 pills that were in the package had been removed. Further review of the photo showed a sticker from the upper left corner had been removed from the package. The sticker should identify for staff the name and strength of the medication, the expiration date, a description of the appearance of the pill, and a bar code. RESIDENT #9 During an interview on 05/12/17 at 10:55 AM, Resident #9 stated that she admitted to the facility for therapy following surgery. Resident #9 stated that she had taken pain medications after admission and the pills made her feel loopy, like a whole different person. Review of the facility narcotic log book, page 37, line 4, showed Staff G, Licensed Practical Nurse (LPN), documented removal of one pill of Oxycodone at 9:30 AM on 04/17/17. Further review of page 37, showed under the column to document how many pills remained in the package, Staff G subtracted two pills from the remaining count when one had been removed. During an interview on 05/16/17 at 9:15 AM, Staff G, LPN, stated that she did not remember why she documented giving one pill, but removed two pills. Staff G then reviewed the Medication Administration Record (MAR), and stated that she did not document in the medical record that she had administered any of the Oxycodone pills on 04/17/17. Staff G stated she must have removed two pills, or the count of medications at the end of the shift would not have been accurate. During an interview on 05/15/17 at 3:35 PM, Staff N, Pharmacist, described the practice of signing out one pill and removing two as concerning behavior. RESIDENT #6 Review of Resident #6's medical record showed a physician's orders [REDACTED]. Review of the narcotic log book, page 42, line one and line two showed documentation of the number of Oxycodone (a narcotic pain reliever) pills that should be in the medication cart, had both been altered. The number of pills on both lines had been changed to a smaller quantity. There was no documented staff initials to indicate who had changed the numbers or signatures to verify what happened. Further review of the narcotic log showed additional alterations of the documentation; Page 76, line one, the time of administration had been changed, making the time illegible. No initials were documented to indicate which staff member made the changes. The narcotic log on page 59, lines one and eleven, both showed documentation of numbers written over existing numbers, with no staff initials next to them. On page 45, line one, the quantity of medication remaining showed documentation was written over existing documentation, with no initials to indicate which nurse made the changes. MANAGEMENT OF CONTROLLED SUBSTANCES Facility policy and procedure titled for managing controlled substances dated 06/01/16 indicated licensed nurses were to sign narcotic delieveries after verifying contents. E-kit containing narcotic medications delivered on 04/22/17, 04/25/17 04/26/17, and 04/28/17 did not have signatures. Narcotic medications delivery receipts were not signed for the following: 04/30/17 52 tablets of Oxycodone 5 mg. 05/01/17 6 tablets of Hydromorphone 2 mg and 30 tablets of Oxycontin 10 mg. 05/02/17 45 of Hydromorphone 2 mg tablets, 150 tablets of Oxycodone 5 mg tablets, 7 tablets of Oxycontin 20 mg and 30 tablets of Oxycontin 10 mg. 05/03/17 60 tablets of Oxycodone 5 mg and 10 of Morphine Sulfate (extended release) ER 15 mg . 05/04/17 60 of Oxycodone 5 mg tablets, 30 of Hydrocodone 5/325 mg, 45 of Oxycodone 5 mg. 05/06/17 30 of Morphine Sulfate ER 15 mg tablets, and 30 of Oxycodone 5/325 mg tablets. During interviews on 05/15/17 at 1:45 PM and on 05/10/17 at 2:10 PM, Staff E, Risk Manager, (RM), stated that there were process issues identified at the facility on how medications were received from the (pharmacy) courier. Staff E, RM, stated that changing the number count on the narcotic log was not acceptable. Staff E, RM, considered it a red flag if narcotics logged were not documented on the MAR when administered. On 05/12/17 at 6:05 AM during medication count, Staff L, Licensed Practical Nurse (LPN), and Staff I, Licensed Practical Nurse (LPN), wasted one pill of Vicodin by disposing it into a sharps container. Facility's policy and procedue procedure titled Management and Destruction of Controlled Substances dated 06/01/16, specified to destroy the medication. Placing the medication into a sharps container did not destroy the medication. On 05/15/17 at 3:11 PM, Staff N, Consulting Pharmacist, stated that she was concerned about missing signatures of staff on narcotic logs and E-kit logs not being signed. Staff N stated that it was unacceptable to waste narcotic medications without destroying them first.

Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for eight of nine Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7, and 8) reviewed for pain medication regimens. This failure placed all residents at potential risk for not getting pain relief, and at potential risk for serious adverse side effects of receiving medications that were not prescribed by a physician. Failure resulted in harm for Resident #5, Resident #6 and Resident #7 who did not receive the correct medication and did not obtain relief from pain. Failure to ensure residents received the correct prescribed medication resulted in determination of Immediate Jeopardy on 05/08/17. Immediate Jeopardy was removed on 05/17/17 with all licensed nursing staff being trained and implementation of new policies and procedures for checking medications prior to administration. Findings included . RESIDENT #3 Observations on 05/10/17 at 11:15 AM Resident #3 in bed. Resident #3 wore a splint on his hand. Resident #3 reported he was having pain in his hand. Review of Resident #3's medical record showed a physician's order dated 06/13/16 for [MEDICATION NAME] (a narcotic pain reliever) 10 milligrams to be given every eight hours for chronic pain. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported the facility's consulting pharmacist had audited the medications and determined Resident #3 had two packages of [MEDICATION NAME] which did not actually contain [MEDICATION NAME], but had a different prescription medication in them. Review of the facility's investigation showed Resident #3 had a package of 30 pills labeled [MEDICATION NAME]. The investigation showed the pills in the package were actually [MEDICATION NAME], a medication used to treat acid reflux. The investigation included photo-copied pictures of the [MEDICATION NAME] package. The photos showed the back side of the package had small labels over each pill which read [MEDICATION NAME], identifying the pill inside. Further review of the investigation showed 22 of the [MEDICATION NAME] tablets had been administered, indicating Resident #3 had received the wrong medication 22 times. Additionally, Resident #3 had a second package of thirty [MEDICATION NAME] in the medication cart. Review of the facility investigations showed the second package was determined to contain [MEDICATION NAME], an anti-[MEDICATION NAME], used to treat nausea, allergies, and itching. The second package had two pills of [MEDICATION NAME] removed, indicating Resident #3 had two doses of the medication in error. Review of Resident #3's medical record showed a progress note dated 04/28/17, Resident on alert for medication error. Scheduled [MEDICATION NAME] 10 milligrams every 8 hours has not been given x (times) 8 days. [MEDICATION NAME] 10mg po (by mouth) has been given instead. Photo-copies showed the back of the package which had a label over each pill which read [MEDICATION NAME], identifying the medication in the package. Review of Resident #3's medical record showed he did not have a physician orders for [MEDICATION NAME] or for [MEDICATION NAME]. RESIDENT #5 Observations on 05/12/17 at 1:50 PM, showed Resident #5 in bed. Resident #5 stated she has chronic pain and relies on opiate pain medications for relief. Review of Resident #5's medical record showed a physician's order dated 04/12/17 for [MEDICATION NAME] 10 milligrams to be given two times daily. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported a consultant from the pharmacy had audited Resident #5's medication and determined a package labeled [MEDICATION NAME] had actually contained [MEDICATION NAME] (a prescription medication used to treat nausea). Review of the facility's investigation of the medication discrepancy showed eight of the [MEDICATION NAME] pills had been removed from the package, indicating Resident #5 was given the wrong medication eight times. Further review of the facility's investigation showed photo copied pictures of the package of medication. The back of the package showed print over each pill which read [MEDICATION NAME], identifying the medication inside the package. Additionally, the investigation indicated Resident #5 did not receive her pain relieving medication on eight different occasions. RESIDENT #6 Observations on 05/12/17 at 10:55 AM, showed Resident #6 wearing a brace that wrapped around his upper body, from his waist to his shoulders. During an interview on 05/12/17 at 10:55 AM, Resident #6 stated he had been hit by a car and had severe pain. Review of Resident #6's medical record showed a physician's order dated 04/18/17 for [MEDICATION NAME] (a narcotic pain reliever) 5 milligrams, one to three tablets every three hours as needed for pain. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported a consultant from the pharmacy had audited Resident #6's medication and determined the package labeled [MEDICATION NAME], actually contained [MEDICATION NAME] (a prescription medication used to treat allergies and motion sickness). Review of the medication narcotic log, page 45, for the package that contained [MEDICATION NAME], showed on 04/27/17, staff removed one pill in the morning, two pills in the afternoon, and two pills in the evening. Additionally, the narcotic log showed two more pills were removed on the morning on 04/28/17. The log indicated staff had administered the medication on four separate occasions, giving seven pills in total, of the wrong the medication. The facility investigation related to the discrepancies indicated Resident #6 did not receive his pain medication on 04/27/17 and for part of the day on 04/28/17. Review of Resident #6's medical record showed no physician's order for the [MEDICATION NAME] that had been administered by nursing staff. Review of the facility investigation showed photo copied pictures of the medication packages. The back of the identified medication package showed print on the package over every pill which read [MEDICATION NAME], identifying the medication in the package. RESIDENT #7 Review of Resident #7's medical record showed a physician's order dated 04/03/17 for [MEDICATION NAME] 5 milligrams, one or two tablets to be given every four hours as needed for pain. Resident #7 was prescribed [MEDICATION NAME] 5 mg 1-2 tablets every 4 hours for pain as needed. A bubble pack of round pills with a prescription label of [MEDICATION NAME] 5 mg tablet was identified by a pharmacist on 4/28/17 as unknown medication. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported a consultant from the pharmacy had audited Resident #7's medication and determined a package labeled Oxycodne, actually contained a different medication. During an interview on 05/09/17 at 3:30 PM, Staff C, RN, MDS, stated she was with the pharmacist when the [MEDICATION NAME] package was removed. Staff C, RN, MDS, stated the pharmacist did not state what the pills in the package were, but did confirm, the pills were not [MEDICATION NAME] as labeled. Additionally, Staff C, RN, MDS, stated Resident #7 had chronic pain related to having fractures in both her right and left hips. Review of the facility investigation related to the discrepancies revealed a package containing 30 pills labeled [MEDICATION NAME] had been removed from the cart. Review of the package showed 20 pills had already been removed from the package by the time the discrepancy was identified. Review of the narcotic log, page 4, showed between 04/08/17 and 04/27/17, one pill from the package had been removed and administered every day, indicating Resident #7 received the wrong medication for twenty days. There was no evidence Resident #7 had received the pain medication prescribed by the physician. Failure to ensure residents received prescribed pain medications caused actual harm to residents by causing untreated pain. Additionally, administering medications not prescribed to residents placed the residents at risk for adverse effects of the medications. RESIDENT #1 Resident #1 admitted to facility 12/12/15 with [DIAGNOSES REDACTED]. Resident suffered from chronic back pain and experienced aching and throbbing sensations. According to the same pain assessment resident felt pain relieve from [MEDICATION NAME] (long acting narcotic medication) and [MEDICATION NAME] (short acting narcotic) for breakthrough pain on as needed basis. On 05/12/17 at 10:46 AM Resident #1 was observed in bed in a reclined position. Resident said she received either too much pain medications or not enough. Resident said she had severe pain in her back and legs since [DIAGNOSES REDACTED]. Record review showed in April 2017, Resident #1 had a physician's order for [MEDICATION NAME] 5 mg tablet (narcotic pain reliever) one tablet every four hours as needed for pain and [MEDICATION NAME] 10 mg one tablet every twelve hours. A bubble pack that in use in April 2017 labeled as [MEDICATION NAME] 5 mg tablet was actually [MEDICATION NAME] 12.5 mg (antinausea medication) as indicated on the back labels of each individual pill. A second bubble pack with round pills labeled as [MEDICATION NAME] mg was labeled as [MEDICATION NAME] 10 mg (antinausea medication) on the back of the pack. In April 2017 Resident #1 received 24 doses of [MEDICATION NAME] 10 mg labeled as [MEDICATION NAME] 10 mg as evidenced by documentation on the medication administration record, narcotic log (page 13) and provided copy of the bubble pack by Staff A on 05/09/17. Record review revealed Resident #1 was receiving medications listed as allergies. From 02/1/17 to 05/11/17 Resident #1 received [MEDICATION NAME] and [MEDICATION NAME] daily and [MEDICATION NAME] prn (as needed). On 05/12/17 at 1:07 PM during review of the resident's MAR review with Staff G, Staff G confirmed resident received [MEDICATION NAME] and [MEDICATION NAME]. Record review revealed resident was allergic to [MEDICATION NAME] (same substances in [MEDICATION NAME] and [MEDICATION NAME]) and [MEDICATION NAME] (brand name for [MEDICATION NAME]) .These medications were listed under allergies section on the MAR and the order. Records did not describe allergic reactions to the medications listed as allergies. Staff G stated resident was on these medications for a long time and she did not see resident developing hives. Staff R, pharmacist was asked about resident's allergies on 5/17/17 10:10 AM and said allergies should be clarified at the facillity. Staff R said pharmacy records did not identify what reactions resident experienced towards those medications. And was unable to verify they wer true allergies or intolerances. Staff R said the pharmcy records did not list [MEDICATION NAME] as an allergy in their system. RESIDENT #2 Resident #2 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident had acute and chronic pain due to history of multiple joint surgeries. Resident was prescribed [MEDICATION NAME] 2 mg (narcotic pain reliever), 1-2 tablets every 6 hours as needed for pain. On 05/12/17 at 12:35 PM Resident #2 was observed in bed. Resident was interviewed about pain management. During an interview resident said she took [MEDICATION NAME] (narcotic medication) for pain from wound on her back and experienced episodes of unrelieved pain and that it hurt like hell. Resident was unable to provide exact dates of when she had severe pain. During the same interview Resident #2 stated that she was not getting an antibiotic four times a day as prescribed by her wound physician. Resident #2 stated that she reported this to the nurse last night and was not sure if it was corrected. Facility's undated narcotic discrepancy investigated identified on 04/28/16 Resident #2's bubble pack labeled as [MEDICATION NAME] 2 mg tablets, had remaining 16 tablets of unknown medications when it was identified by the pharmacist on 04/28/17. Another bubble pack containing round pills had a prescription label of [MEDICATION NAME] 2 mg but the back of each pill was labeled as [MEDICATION NAME] 25 mg (blood pressure medication) tablet. Record review showed Resident #2 received 14 mislabeled medications instead of [MEDICATION NAME] 2 mg in April 2017 as identified on the narcotic log, medication administration record and copy of a bubble pack. A physician order dated 05/05/17 prescribed Keflex 500 mg to be administered four times a day for a week. The order did not specify indication for antibiotic use or the dignosis. Another order dated 05/09/17 at 11:30 AM prescribed Keflex 500 mg to be administered four times a day for a week. The order did not specify indication for the antibiotic use. Review of MAR with Staff J on 05/16/17 at 3:10 PM showed Resident #2 received Keflex 500 mg three times a day from 5/5/17 through 05/11/17 instead of four times a day. Staff J said he was not aware if a medication error report was done and said he would initiate one. RESIDENT #4 Record review and MDS dated [DATE] Resident #4 admitted to facility on 09/02/16 with diagnesis of [MEDICAL CONDITION], dysphagia, developmental disorder and had joint contractures. The MDS indicatd a BIMS of 3 meaning severe cognitive impairement. Resident received food, fluids and medications through a tube in the stomach. May 2017 MARs listed resident's diet as NPO (nothing by mouth). On 05/16/17 at 1:10 PM Resident #4 was in bed with eyes closed. Resident was unable to answer questions. Facility's undated investigation of narcotic disrepancies found Resident #4 had 29 tablets labeled as [MEDICATION NAME] 5 mg were not actual medications and 8 tablets labeled as [MEDICATION NAME] 10 mg were [MEDICATION NAME] (antinausea medications). Resident #4 had orders for [MEDICATION NAME] 5 mg tablet 1-2 tablets every 6 hours and [MEDICATION NAME] 5 mg, ½ tablet (2.5 mg) every 4 hours as needed for pain according to April 2017 MAR. The narcotic log contained a pharmacy label that showed for staff to administer [MEDICATION NAME] 5 mg tablet with instructions to give 2 tabs (10mg) by mouth every 6 hours, and to give 1/2 of tablet (2.5 mg) by mouth every 4 hours as needed for pain. These two separate orders were combined onto a single narcotic log form. The one narcotic sheet contained two different doses of pain medications. Entries on the narcotic log identified staff removed medications thirty eight individual times between 04/07/17 and 04/20/17 and thirty three times between 03/01/17 and 03/14/17. When staff signed for removal of medications the log did not identify what dose was actually removed and dispensed. The records could not validate what actual dosage were administered to Resident #4. On 05/12/17 at 6:10 AM Staff L was asked about administering narcotics when the pharmacy label combined different doses of [MEDICATION NAME] on the log and on the bubble pack. For example when nurses documented 1 under the dose on the narcotic log, which dose was signed out and given 2.5 mg or 5 mg of [MEDICATION NAME]. Staff L said I am confused now . I don't know. On 05/09/17 at 3:02 PM when Staff F was informed about combined two separate orders for Resident #4, she stated that orders should be separated and nurses needed education. The facilty was first informed by the investigator about risks of errors due to combining orders on 05/09/17, but did not take action to correct the orders until 05/12/17. RESIDENT #8 Resident #8 admitted to the facility on [DATE]. Resident had [DIAGNOSES REDACTED]. Resident #8 was prescribed [MEDICATION NAME] 20 mg 1 tablet at bedtime. A bubble pack containing round pills had a prescription label identifying medications as [MEDICATION NAME] 20 mg. Pharmacy verification on 04/28/17 revealed the bubble pack in use had white round pills labeled as [MEDICATION NAME] 20 mg but and it was an unknown substance when verified by pharmacy. Resident received three doses of unknown medications.

Based on observation, interview and record review facility administration failed to effectively use resources to attain or maintain the highest practicable well-being of each resident. Administration failed to ensure they were in compliance with the following regulatory requirements which affected or had the potential to affects all residents in the facility. These failures resulted in an Immediate Jeopardy as referenced in F309 related to pain management: F333 significant medication errors, and in F425 pharmacy services identified on 05/08/17 for 8 of 8 Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7 and 8). Residents # 5, Resident #6 and Resident #7 experienced harm due to uncontrolled pain when they did not receive narcotic pain medication prescribed for them. The facility removed the Immediate Jeopardy on 5/17/17 through extensive staff training, policy changes and facility wide audits. Findings included . Facility failures resulted in immediate jeopardy, substandard care and harm to residents from lack of effective administration to ensure standards of care were followed and staff practiced accountable management of scheduled medications. Refer to the following regulations for additional information regarding failed facility practice related to scheduled medications: [REDACTED] Substandard Care was found in the following: 42CFR 483.12(c)(1); F225 Report/Investigate Abuse, Neglect and Misappropriation. Failure to conduct a timely and thorough investigation for individual Residents (#s 1, 2, 3 4, 5, 6, 7, 8,) following a narcotic tampering incident; and unauthorized use and missing narcotics from E-kits placed all residents in the facility at risk for potential drug diversion activities. Failure to identify and investigate narcotic discrepancies resulted in actual harm to Resident # 5, Resident #6 and Resident #7 who experienced uncontrolled pain when their narcotic medications were misplaced with non-narcotic medications. Refer to 42CFR 483.45(f)(2) F333 Significant Medications Errors. Facility failed to ensure staff provided residents prescribed narcotic pain medications to eight Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7, & 8), when their pain narcotic medications were substituted with non-narcotic medications. This failure placed residents at potential risk for not getting pain relief and at potential risk for adverse side effects of receiving medications that were not prescribed by a physician. Harm occurred to Resident #5, Resident #6 and Resident #7 who had unrelieved pain. 42CFR 483.45(a)(b)(1); F425: Pharmaceutical Services. The facility failed to ensure control and accountability of scheduled medications prescribed for Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7, 8 and 9) and for those in facility Emergency Kits. Additional facility failures included: Refer to 42CFR 483.21(b)(3)(i); F281: Professional Standards of Care Failure to ensure nursing services met professional standards of practice for receipt, administration and accountability management of controlled substances for nine Sampled Residents (1, 2, 3 4, 5, 6, 7, 8 & 9). Staff failed to clarify orders for two Sampled Residents (#1 and 4) reviewed for physician orders. These failures placed these residents at potential risk for receiving medications that were not prescribed to them; for adverse effects associated with those medications, and at risk for misappropriation of medications; and resulted in unrelieved pain for Resident #5, Resident #6 and Resident #7 from unrelieved pain when they did not receive their prescribed pain medications. 42CFR 483.25(k); F309 Quality of Care. The facility failed to ensure Sampled Residents (#s 1, 2, 3, 4, 5, 6, 7 and 8) achieved their highest practicable level of well-being and comfort. Staff failed to ensure residents received medications as prescribed for pain relief. Harm occurred to Resident #5, Resident #6 and Resident #7 who had unrelieved pain. Refer to 483.35(a)(1)-(4); F353: Sufficient Qualified Nursing Staff. The facility failed to ensure Sampled Staff members (Staff I, G, L, J, T, H, P & O) were trained and competent to receive, administer and account for scheduled medications to meet the needs of the residents who required scheduled pain medications. This failure resulted in ineffective medication management and inadequate narcotic accountability placing the facility at risk for ongoing diversion. 42CFR 483.70(b)(c); F492 Compliance with laws and standards. Failure to ensure facility compliance with applicable State nursing home and pharmacy Washington Administrative Codes 246-865 related to pharmacy services and failed to resolve irregularities related to narcotic mislabeling, receipt, administration and documentation of scheduled medications.

Based on observations, interview and record review it was determined the facility failed to ensure they complied with applicable State nursing home and pharmaceutical regulations to ensure pharmacy services maintained a system of control on delivery and administration of Schedule II narcotic medications; addressed irregularities related to narcotic labeling and handling; tampering with narcotics in E-Kits, and narcotic control log discrepancies for 8 of 8 Sample Residents (#s 1, 2, 3, 4, 5, 6, 7 and 8) who were reviewed for narcotic medication management. These failures placed all residents at risk for misappropriation of narcotic medications and resulted in harm for Resident # 5, Resident #6, and Resident #7 who did not receive narcotic medications and experienced unrelieved pain. Findings included . Refer to F 309 for observations and pain management and harm for Resident #5, Resident #6 and Resident #7; F 333 for significant medication errors related to narcotics; and F 225 for failure to thoroughly investigate misappropriation of narcotic medications. Refer to F 425 for information on narcotic discrepancies and failure to maintain narcotic records and report irregularities of medication discrepancies. <BR/(NAME)Administrative Code (WAC) 388-97-1300(3) The nursing home must provide pharmaceutical services that: (a) Meet recognized and accepted standards of pharmaceutical services that: (b) Comply with chapter 246-865 WAC. WAC 246-865-030 Emergency kit (4) Records documenting the receipt and removal of drugs in the emergency kit shall be maintained by the nursing home and the supplying pharmacy. (5) The pharmaceutical services committee shall be responsible for ensuring proper storage, security and accountability of the emergency kit. WAC 246-865-060 Pharmaceutical Service. (2) A staff pharmacist or consultant pharmacist shall be responsible for coordinating pharmaceutical services which include: (b) On-site reviews to ensure that drug handling and utilization procedures are carried out in conformance with recognized standards of practice. (5) Control and accountability (a) The nursing home shall maintain and follow written procedures which provide for the accurate control and accountability of all drugs in the nursing home. (6) Special requirements for controlled substances (c) There shall be a record book for Schedule II and III controlled substances which shall be a bound book with consecutively numbered pages in which complete records of receipt and withdrawal of Schedule II and III controlled substances are maintained. Withdrawal of controlled substances are maintained. (d) At least each 24 hours, the amount of all Schedule II controlled substances stored in facility shall be counted by at least two persons legally authorized to administer drugs. Records of count shall be entered in the Schedule II and III controlled substances book(s). The Service agreement between the Pharmacy and Facility signed on 05/11/11 showed the following: -Pharmacy shall assist Customer in addressing a report of clinical significance or existing adverse consequences or other irregularities. -Each party shall comply with all Applicable Law in effect - -Pharmacy consulting services report should document any identified irregularities. E-KITS According to a typed statement by Staff GG, Pharmacist dated 05/01/17, pharmacy received tampered e-kits after they were in the facility's possession in April 2017. The pharmacy did not find narcotic slips in the E-kits to account for missing medications. Unaccounted narcotics included: 16 [MEDICATION NAME] tablets, one bottle of liquid [MEDICATION NAME], 10 [MEDICATION NAME] tablets, and 10 [MEDICATION NAME] tablets. Narcotic E-kit deliveries on 05/02/17, 05/03/17 and 05/09/17 found were not signed for by two staff. Between 04/30/17 and 05/09/17, twenty one controlled substances delivered were missing signatures on the receipts. During interviews on 05/8/17 at 7:00 PM and on 05/12/17 at 3:40 PM, Staff F, Registered Nurse, Resident Care Manager (RN, RCM), stated that she was unable to reconcile E-kits in question. Staff F, RN, RCM, stated that she repeatedly requested pharmacy's delivery receipts for each E-kit in question but had not received them. On 05/1/17, the pharmacy faxed notification of an unauthorized removal of narcotics or missing narcotics from E-kits to the facility. Six of seven notifications reviewed with Staff F did not list the sealed numbers specific to each kit and the pharmacy E-kit delivery receipts did not contain zip lock identifiers and/or box numbers for each E-kit in question. During record review and interview with Staff F, RN, RCM, on 05/12/17 at 11:04 PM, she confirmed the central nursing station boxes that contained E-kits, did not have a record of the delivery number associated with those boxes that were delivered by the pharmacy on 04/25/17, 04/28/17, and 04/29/17. On 05/12/17 at 9:55 AM, Staff A, Administrator, stated that he contacted Staff GG Pharmacist more than once and requested all delivery receipts for e-kits in question. Staff A said Staff GG were unable to provide receipts because they were archived. The pharmacy did not provide receipts until requested by the investigator on 05/12/17 at 3:00 PM. During an interview on 05/12/17 at 9:55 AM, Staff A stated that when pharmacy couriers delivered medications there were inconsistent methods for obtaining signatures. Staff A stated that at times, a paper receipt was used and other times a electronic device used. Review of pharmacy delivery receipts showed that upon delivery of medications including narcotics, the courier had either a paper delivery receipt for the facility nurse to sign or an electronic device to obtain nurse signature. The electronic shipment summary had a place for the nurses' name and a square space designated for nurses signature or initials acknowledging acceptance of the E-kit. Review of electronic pharmacy delivery receipts for E-kits in question from 04/03/17 to 04/28/17, revealed 11 of 14 did not contain nurses signatures on the screen and 8 of the 11 nurses noted only the first named on the electronic device. Three of those receipts contained a statement no record delivery and did not list nurse's names or signatures. Delivery receipts did not contain identification numbers such as an E-kit box number or zip tie lock number, in order to periodically reconcile deliveries to ensure narcotic accountability between the pharmacy and the facility to ensure no medications were diverted. Facility policy dated 06/01/16 for managing controlled substances, specified a licensed nurse and the delivery driver should verify content of delivery from the pharmacy and the nurse should signs the receipts. MANAGEMENT OF CONTROLLED SUBSTANCES During an interview on 05/15/17 at 3:35 PM, Staff N, Pharmacist, stated that she visited the facility quarterly, but does not compare and check the narcotic log to medication records that documented what was administered to the resident. During an interview on 05/17/17 at 11:56 AM, Staff V, Pharmacy Nurse Consultant, stated that she visited the facility quarterly. Staff V, Pharmacy Nurse Consultant, stated that she did not check the narcotic logs for accuracy, unless requested to do so by the facility. Staff V, Pharmacy Nurse Consultant, additionally stated, there had not been a narcotic log audit done in the facility since July 2016. Review of monthly pharmacy consultant reports included a section titled evaluation of Controlled Substances (F425, F431). The report indicated the following were reviewed during visits: controlled substances inventory was reconciled to facility procedure, and controlled substance documentation was accurate and complete. Monthly Pharmacy Summaries reviewed for January 2017, February 2017 and May 2017 all stated No irregularities observed related to Controlled Substances although multiple irregularities were identified by the surveyors for narcotic control records reviewed from February 2017 through May 2017. On 5/10/17 at 9:40 AM, review of E-kit control logs at two of two nurse's stations revealed multiple counts contained only one signature and not two as required, for the following dates: 01/24/17, 01/26/17, 01/29/17, 01/31/17, 02/13/17, 03/21/17, 04/23/17, 04/24/17, 04/27/17 and 05/04/17. Narcotic Count Logs from February 2017 to May 2017 found entries were missing two nurses signatures for shift to shift narcotic accountability count on the following dates: 02/25/17, 03/03/17, 03/09/17, 03/10/17, 03/16/17 on all three shifts, 03/25/17 on all three shifts, 3/28/17,4/01/17, 04/03/17 on two shifts, and on 04/18/17, 04/20/17 on two shifts.

Based on observation, interview and record review, the facility failed to ensure licensed staff were reviewed for competency to administer medications at the time of hire or annually to ensure they had the training and skills set to meet the needs of residents for medication administration involving eight of eight Sampled Staff members (Staff I, G, L, J, T, H, P and O) reviewed for medication administration training. These failures resulted in significant medication errors and ineffective management of residents' pain, and failure to demonstrate professional standards of practice of narcotic medication records. Failure to ensure licensed staff demonsrated competency to administer medications, resulted in harm for Resident #5, Resident #6 and Resident #7 who experienced inadequate control of pain. Findings included . Refer to F281 for failure to maintain professional standards of practice and F 333 for significant medication errors. Interviews conducted on 05/12/17 between 6:10 AM and 7:00 AM, Staff L, Licensed Nurse (LN), Staff G, Staff L, Licensed Nurse (LN), and Staff I, Staff L, Licensed Nurse (LN), were asked if they received training on narcotics and/or scheduled medications during general orientation and/or yearly. All staff stated that they did not receive narcotic training during orientation and on a regular basis while employed at the facility. During an interview on 05/16/17 at 1:00 PM, Staff D, Registered Nurse, Staff Development (RN, SD), stated that the facility policy directed all licensed nurses employed at the facility to complete competencies on a yearly basis. Staff D, RN, SD, provided a list of competencies which nurses were evaluated on. The list included medication administration skills. Record review of the facility Annual Licensed Nurse Competencies - Northwest 2015 policy, showed staff were observed demonstrating medication administration two times each year. Each staff was scored on the task during both observations. Record review of staff training records on 05/16/17 at 1:00 PM, showed the following; STAFF I, Licensed Practical Nurse, (LPN) Record review of Staff I, LPN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required training. STAFF G, Licensed Practical Nurse, (LPN) Record review of Staff G, LPN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required training. Staff D, SD, confirmed that Staff G, LPN, had worked at the facility since March 2015, therefore, should have completed annual competencies. STAFF L, Licensed Practical Nurse, (LPN) Record review of Staff L, LPN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required training. Staff D, SD, confirmed that Staff L, LPN, had worked at the facility since January 2014, therefore, should have completed annual competencies. STAFF J, LPN Record review of Staff J, LPN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required training. Staff D, SD, confirmed that Staff J, LPN, had worked at the facility since March 2015, therefore, should have completed annual competencies. STAFF T, Licensed Practical Nurse, (LPN) Record review of Staff T, LPN's, training file showed no documentation to support annual nurse competencies had been done since 2014. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required annual trainings since 2014. STAFF H, Registered Nurse (RN) Record review of Staff H, RN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, stated the competencies should have been completed at the time of hire. Staff D, RN, SD, stated Staff H, RN, was hired in July 2016. STAFF P, Licensed Practical Nurse, (LPN) Record review of Staff P, LPN's, training file showed no documentation to support annual nurse competencies had been done since 2015. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, confirmed there was no record of the required annual training since 2015. STAFF O, Licensed Practical Nurse, (LPN) Record review of Staff O, LPN's, training file showed no documentation to support annual nurse competencies had been done. During an interview on 5/16/17 at 1:00 PM, Staff D, RN, SD, stated the competencies should have been completed at the time of hire. Staff D, RN, SD, stated Staff O, LPN, was hired in September 2016. Failure to ensure licensed nursing staff had the required annual trainings placed residents at potential risk for receiving substandard care.

Based on observation, interview, and record review, the licensed staff failed failed to meet professional standards of practice for medication administration and management and accuracy of receipt and dispensing of controlled substances for nine of nine Sampled Residents (#s 1, 2, 3 4, 5, 6, 7, 8 and 9) reviewed for medications. Licensed staff failed to validate medications dispensed matched those actually prescribed; failed to ensure accurate accounting of received and dispensed narcotic medications; or clarify physician orders [REDACTED].#s 1 and 4.) These failures placed all residents at risk for receipt of medications not prescribed for them; for adverse effects associated with those medications, and at risk for misappropriation of medications. Failures resulted in harm for Resident #5, Resident #6 and Resident #7 who did not receive the correct medications to relieve their pain. Findings included . Refer to F333, for failures related to medication errors; refer to F425, pharmacy services and refer to F309, for failure to dispense pain medication as prescribed for pain management for Resident (#s 1, 2, 3 4, 5, 6, 7, 8 and 9) . According to Clinical Nursing Skills, Smith, Duell & Martin, eighth edition, page 572, the nurse is responsible for validating, preparing, and administering medications safely and in accordance with agency policies and procedures. Further review of Smith, Duell & Martin, page 578, It is the nurse's responsibility to account for all controlled substances dispensed. Additionally, Smith, Duell & Martin, page 41, Correct errors by drawing a single line through the error, write the words mistaken entry (ME) above it, and then initial the error. The error must be readable. Review of facility/pharmacy policy, Delivery and Receipt of Routine Deliveries, showed upon delivery, the facility nurse should inspect the packages for damage or errors and notify the pharmacy as soon as possible. The policy showed nurses document any discrepancies, e.g. labeling error. Review of Kindred Registered Nurse Job Description, and the Licensed Practical Nurse Job Description, showed the nurse participates by administering medications as ordered, and maintaining narcotic records accurately. RESIDENT #5 Review of pharmacy delivery receipts dated 04/20/17 showed Resident #5 had a package of 14 [MEDICATION NAME] pills. There was no signature on the receipt to indicate which nurse accepted the medication from the pharmacy courier, or if a nurse had verified the medication on arrival to the facility. On 04/28/17 the package of [MEDICATION NAME] (a narcotic pain reliever) with 14 pills in it, was identified to contain [MEDICATION NAME], a medication used to treat nausea. Review of the narcotic log page 14, showed on 04/03/17, documentation indicating one [MEDICATION NAME] (a narcotic pain reliever) pill was administered. The time of the dose had multiple circular markings over the time, making the time of administration illegible. Review of narcotic log page 1, line 16, showed on 04/03/17 at 5:15 AM, [MEDICATION NAME] was administered. The box to indicate how many pills were given had been written over, and the number changed. Additionally, the box indicating the number of pills remaining had been written over with the number changed. Review of narcotic log page 67, showed documentation on 05/05/17 at 0:06 AM, just after midnight, staff removed two [MEDICATION NAME] 5 milligram tablets. In the box designated for nurse's signature was documented refused. There was no initials to evidence nursing staff wasted the tablets, or to indicate which staff member had removed the medications. The Medication Administration Record showed no documented evidence the medication had been administered. Further review of page 67 showed on 05/07/17 at 7:00 AM and at 12:45 PM, two tablets of [MEDICATION NAME] were signed out. Under the column designated to document remain tablets in the package, numbers documented for both administration times were written over and had been altered. During an interview on 05/15/17 at 3:35 PM, Staff N, Pharmacist, stated it is not acceptable practice to cross off entries in the narcotic log book or make changes without initialing the changes. RESIDENT #6 During an interview on 05/12/17 at 10:55 AM, Resident #6 stated he had been hit by a car and had severe pain. Review of Resident #6's medical record showed a physician's orders [REDACTED]. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported a consultant from the pharmacy had audited Resident #6's medication and determined the package labeled [MEDICATION NAME], actually contained [MEDICATION NAME] (a prescription medication used to treat allergies and motion sickness). Review of the medication narcotic log, page 45, for the package that contained [MEDICATION NAME], showed on 04/27/17, staff removed one pill in the morning, two pills in the afternoon, and two pills in the evening. Additionally, the narcotic log showed two more pills were removed on the morning of 04/28/17. The log indicated staff had administered the medication on four separate occasions, giving seven pills in total, of the wrong the medication. RESIDENT #7 Review of narcotic log page 4, line 6, showed one [MEDICATION NAME] pill signed out at 9:21 PM. There was not documentation of a nurse signature to evidence who removed the medication. Further review of the narcotic log, page 4, showed [MEDICATION NAME] removed on 04/10/17, 04/11/17, 04/12/17, 04/17/17, 04/21/17, 04/23/17, and on 04/27/17. Review on the April 2017 Medication Administration Record showed, none of the listed dates had documentation to show the pills were administered to the resident. During an interview on 05/09/17 at 3:00 PM, Staff F, Resident Care Manager (RCM) reviewed the documentation on the narcotic log and compared to the Medication Administration Record. Staff F stated there were seven doses of the narcotic pain reliever not accounted for. RESIDENT #3 During an interview on 05/10/17 at 11:15 AM, Resident #3 stated he has pain in his right hand. Resident #3 stated he gets little relief from his pain medication. Review of Resident #3's medical record showed a progress note dated 04/28/17, Resident on alert for medication error. Scheduled [MEDICATION NAME] 10 milligrams every 8 hours has not been given x (times) 8 days. [MEDICATION NAME] 10 mg po (by mouth) has been given instead. [MEDICATION NAME] medication is given to relieve gastrointestinal symptoms. During an interview on 05/08/17 at 12:50 PM, Staff F, RN, RCM, reported the facility's consulting pharmacist had audited the medications and determined Resident #3 had two packages of [MEDICATION NAME] which did not actually contain [MEDICATION NAME], but had a different prescription medication in them. Staff F stated the medications that were administered to Resident #3 from the [MEDICATION NAME] packages, were not medications that relieve pain. RESIDENT #9 During an interview on 05/12/17 at 10:55 AM, Resident #9 stated she admitted to the facility for therapy following surgery. Resident #9 stated she had taken pain medications after admit and the pills made her feel loopy, like a whole different person. Review of the facility narcotic log book, page 37, line 4, showed Staff G, Licensed Practical Nurse (LPN), documented she was going to administer one pill of [MEDICATION NAME] at 9:30 AM on 04/17/17. Further review of page 37, showed under the column to document how many pills remained in the package, Staff G subtracted two pills from the remaining count. During an interview on 05/16/17 at 9:15 AM, Staff G, LPN stated she did not remember why she documented giving one pill, but removed two pills. Staff G then reviewed the Medication Administration Record, and stated she did not document in the medical record that she had administered any of [MEDICATION NAME] on 04/17/17. Staff G stated she must have removed two pills, or the count of medications at the end of the shift would not have been accurate. RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dementia. Resident suffered from chronic back pain and had relief from [MEDICATION NAME] (long acting narcotic medication) and [MEDICATION NAME] (short acting narcotic) for breakthrough pain on as needed basis according to facility's pain assessment on 04/28/17. On 05/12/17 at 10:46 AM Resident #1 lay in bed in a reclined position. Resident stated that she received either too much pain medications or not enough. Resident stated that she had severe pain in her back since diagnosed with [REDACTED]. Physician orders [REDACTED]. Two bubble packs labeled as narcotics were used in April 2017. One was labeled as [MEDICATION NAME] 5 mg but actually was [MEDICATION NAME] 12.5 mg (anti-nausea medication). A second bubble packed labeled as [MEDICATION NAME] 10 mg was actually [MEDICATION NAME] 10 mg (anti-nausea medication). Resident #1 received 24 doses of [MEDICATION NAME] 10 mg labeled as [MEDICATION NAME] 10 mg instead of a narcotic pain medicine. Review of nursing notes following narcotic discrepancy identified on 04/28/17, did not include evidence of a thorough pain assessment and assessment for potential signs of narcotic withdrawals. Nursing documentation describe verbal and non-verbal signs and symptoms of pain, what made pain better or worse and did not mention resident's baseline pain level and a tolerable or acceptable pain levels. On 05/17/17 at 6:00 PM Staff Q, Facility Medical Director, stated that he expected residents who were affected by mislabeled narcotics to have been monitored for signs of withdrawal symptoms and effectiveness of pain. Staff Q explained withdrawal symptoms typically were demonstrated as restlessness, increased agitation, nausea, vomiting, diarrhea, changes of vital signs such as a fast heart rate. Narcotic dispensing was documented on narcotic logs when removed and on the Medication Administration Record (MAR) when administered to the resident. Documentation from 02/24/17 to 03/27/17 showed four [MEDICATION NAME] 5 mg tablets were removed but not administered on the MAR. On 05/12/17 at 1:07 PM, MAR review with Staff G, Licensed Practical Nurse (LP) showed Resident #1 received [MEDICATION NAME] and [MEDICATION NAME]. Record review revealed the resident was allergic to both medications as they were listed under allergies section on the MAR and the physician order. The MAR showed the resident received medications she was allergic to between 02/01/17 to 05/11/17. Record review did not describe allergic reactions to the medications. Staff G, LPN, stated that the resident was on these medications for a long time and she did not see resident developing hives. Staff R, Pharmacist was asked about resident's allergies on 5/17/17 at 10:10 AM. Staff R stated that the allergies should be clarified. Staff R, Pharmacist, was unable to find information about type of reactions resident had to medications listed as allergies. Staff R stated that the pharmacy records did not have Neuron listed as allergy. Staff R said that allergies should be reconciled or clarified at the facility. RESIDENT #2 Resident #2 admitted on [DATE] with [DIAGNOSES REDACTED]. Resident had acute and chronic pain due to history of multiple joint surgeries according to History and Physical dated 10/28/16. On 05/12/17 at 12:35 PM Resident #2 was in bed. Resident #2 stated that she took [MEDICATION NAME] (narcotic medication) for wound pain. Resident recalled she experienced severe pain at times and it hurt like hell. She was unable to provide specific time or dates of uncontrolled pain episodes. Facility's undated narcotic discrepancy investigated indicated on 4/28/16 Resident #2's medication bubble pack labeled as [MEDICATION NAME] 2 mg tablets were not narcotic medications. Another bubble pack containing round pills was labeled as [MEDICATION NAME] 2 mg but the back of the pack each medication was identified as [MEDICATION NAME] 25 mg (blood pressure medication). Resident #2 received 14 mislabeled medications instead of narcotic pain medications. Record review of dispensed narcotics between 04/3/17 to 5/8/17 revealed 19 doses of [MEDICATION NAME] 2 mg tablets were documented as removed on the narcotic log but were not documented administered on the MAR. On 05/07/17 at 2:40 PM, 4 mg of [MEDICATION NAME] was removed but the MAR showed 2 mg were given at 2:33 PM for a pain level of 6 when the directions on the MAR specified to give [MEDICATION NAME] 4 mg for pain level 6-10. RESIDENT #4 Resident #4 admitted to facility on 09/02/16 with [DIAGNOSES REDACTED]. Resident received food, fluids and medications through a tube in the stomach. May 2017 Mars listed resident's diet as PO (nothing by mouth). On 05/16/17 at 1:10 PM Resident #4 was in bed with eyes closed. Resident was unable to answer questions. Facility's undated investigation showed Resident #4 had 29 tablets labeled as [MEDICATION NAME] 5 mg were unknown substance. Medication pack with 8 tablets labeled as [MEDICATION NAME] 10 mg was actually [MEDICATION NAME] (anti-nausea medication). Resident #4 had orders for [MEDICATION NAME] 5 mg tablet 1-2 tablets every 6 hours and [MEDICATION NAME] 5 mg, ½ tablet (2.5 mg) every 4 hours as needed for pain according to April 2017 Mars and physician orders. The narcotic log contained a pharmacy label that showed for staff to administer [MEDICATION NAME] 5 mg tablet with instructions to give 2 tabs (10 mg) by mouth every 6 hours, and to give 1/2 of tablet (2.5 mg) by mouth every 4 hours as needed for pain. These two different orders were combined onto a single narcotic log form. The one narcotic sheet contained two different doses of pain medications. Entries on the narcotic log identified staff removed medications thirty eight individual times between 04/07/17 and 4/20/17 and thirty three times between 03/01/17 and 03/14/17. When staff signed for removal of medications, the log did not identify what dose was actually removed and dispensed. The records could not validate what actual dosage Resident #4 received. On 05/9/17 at 3:02 PM Staff F, Resident Care Manager, (RCM) was informed about combined different orders on the same pharmacy label in the log. Staff F, RCM, stated that the orders should be separated and nurses needed education on clarifying such orders. On 05/12/17 at 6:10 AM Staff L, Licensed practical nurse (LPN), was asked about administering narcotics when combined different doses of [MEDICATION NAME] were on one log and the combined orders were also on the bubble pack label. Staff L was asked when a dose of 1 was documented on the log as removed, does that refer to the 2.5 mg or the 5 mg of [MEDICATION NAME]? Staff L, LPN, stated I am confused now . I don't know. Record review for narcotic logs and the MARs found discrepancies when [MEDICATION NAME] 2.5 mg and [MEDICATION NAME] 5 mg were dispensed. On 03/02/17 at 11:30 PM and on 03/06/17 at 2:30 (staff did not identify if AM or PM), staff noted on the NL two tablets of either 2.5 mg or 5 mg [MEDICATION NAME] were removed, but the MAR did not have documentation showing staff administered the medication. The pharmacy label on the narcotic log with the same combined order of [MEDICATION NAME] 5 mg and [MEDICATION NAME] 2.5 mg identified a miscount. Entry on narcotic log on 03/04/17 at 0500 showed the remaining count was 18. On 03/04/17 at 1:00 PM 1 dose was removed and remaining count of 14 was documented. A miscount resulted when one dose was removed but two doses were subtracted. Page 15 of Narcotic Log dated 3/3 with a pharmacy label for [MEDICATION NAME] 5 mg tablet' showed on 03/08/17 at midnight, 4 doses were removed or (20 mg of [MEDICATION NAME]). The MAR documented resident received 10 mg. On 04/02/17 at 09:56 A.M. nursing notes documented resident pulled out feeding tube out of her stomach and was sent to the hospital on [DATE] to have it replaced. While resident was without a gastric tube and was PO according to nurse's notes. The MAR showed [MEDICATION NAME] 5 mg was administered at 12:00 PM and at 6:00 PM. A narcotic log labeled for [MEDICATION NAME] 5 mg. From 04/16/17 to 04/20/17 4 tablets or 20 mg of [MEDICATION NAME] was removed seven times which was not consistent with physicians order. From 04/7/17 to 04/8/17 narcotic log page #81 had multiple illegible entries. Remaining count numbers were written over, crossed off without a second nurse signature and explanation for changed entries. Narcotic log page # 83 showed narcotic count was altered on 4/15/17 and 4/17/17 without reconciliation and a second nurse signature. On 05/09/17 at 3:02 PM Staff F, Resident Care Manager, (RCM) was asked about illegible documentation on narcotic logs for Resident #4. Staff F, RCM, stated that when there was a miscount on documentation, two licensed nurses should co-sign verifying the count is accurate. Resident #4's multiple illegible entries on narcotic logs, and discrepancies identified on combined orders were reported to the Director of Nursing on 05/09/17. The facility did not separate the two orders on one narcotic pharmacy label and the bubble pack until surveyor reported concern to the corporate Staff U, Corporate Consulting Nurse, on 05/12/17. RESIDENT #5 Resident #5 was prescribed [MEDICATION NAME] 10 mg, one tablet twice a day. A bubble pack with round pills had a prescription label of [MEDICATION NAME] mg but the back of each bubble listed [MEDICATION NAME] HCL 4 mg (anti-nausea medication). Resident #6 was prescribed [MEDICATION NAME] 5 mg 1-3 tablets every 3 hours as needed for pain. A bubble pack of white round pills had a prescription label of [MEDICATION NAME] 5 mg but the on back of the pack each individual bubble was labeled as Promethean 12.5 mg. Resident #7 was prescribed [MEDICATION NAME] 5 mg 1-2 tablets every 4 hours for pain as needed. A bubble pack of round pills with a prescription label of [MEDICATION NAME] 5 mg tablet was identified by a pharmacist on 04/28/17 as unknown medication. RESIDENT #8 Resident #8 admitted to the facility on [DATE]. Resident had [DIAGNOSES REDACTED]. Resident had acute and chronic pain described as stabbing, tingling, and throbbing sensations according to facility pain assessment dated [DATE]. Observations on 5/12/17 at 5:48 AM, and 10:37 AM resident was in bed with eyes closed. At 11:31 AM, the resident stated that sometimes pain medications were helpful. Resident complained about having pain in the knee. Resident #8 had orders for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325 mg with instructions to give one tablet every 6 hours as needed for moderate to severe pain and to give two tablets at bedtime routine according to the MAR. Narcotic log on page 73 had hand written instructions for [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg. Administration frequency was not recorded on the log. An entry under directions read see MAR. MAR for April 2017 listed two separate orders for [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg to give 2 tablets at bedtime and [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 1 tablet every six hours as needed for moderate pain. Review of narcotic log and MAR reconciliation found discrepancies: Narcotic log entry on 4/11/17 at 5:03 AM showed one [MEDICATION NAME] tablet was removed but the MAR identified resident received total of three tablets. Narcotic log entries on 4/12/17 and 4/13/17 showed four [MEDICATION NAME] tablets were removed but the MAR showed resident received seven tablets. Similar discrepancies were identified on MAY 2017 MAR and Log for [MEDICATION NAME] administration. On 5/3/17 , 5/4/17 and 5/5/17 narcotic log showed total of 9 tablets [MEDICATION NAME] tablets were removed but the MAR had 10 tablets documented as administered. FAILURE TO IMPLEMENT CORRECTIVE MEASURES On 05/8/17 at 7:00 PM Staff F, Resident Care Manager, RCM, stated that two nurses were expected to verify each delivery of scheduled II medications and two nurses should sign the delivery slips acknowledging content was verified. Staff F, RCM, also stated that nurses were to check the front and the back of each medication card. Facility's Immediate Jeopardy removal plan dated 05/08/17 at 7:30 PM included the following actions: -Both Licensed Nurses will visually inspect and count each scheduled medication and both nurses will sign indicating the count was complete and correct. - Upon administration licensed staff will verify the front and back of the bubble pack to ensure they contained accurate medication. - Delivery of controlled substances will be verified by two nurses both signing off on the delivery receipt and facility receipt. -All licensed nurses were educated on the above processes Facility staff did not demonstrate they followed the Immediate Jeopardy removal plan as evidenced by observations, interviews and record reviews between 05/8/17 and 05/16/17. During observations of medication pass on 05/08/17 at 7:07 PM Staff K, Registered Nurse, (RN), removed medications from three different bubble packs without visualizing the back of the bubble pack to ensure the label on the bubble pack matched the name of the medication on the back of the bubble pack On 05/8/17 at 7:31 PM Staff M, Registered Nurse (RN) stated that she did not know two nurses had to verify narcotic deliveries and for both sign the receipts. During observation on 05/12/17 at 5:45 AM, Staff H, Registered Nurse (RN), removed medication from a package and placed it in the administration cup, without comparing the dose to the MAR. During the same observations, a Narcotic Log book showed Staff H, RN, pre-signed narcotic count before conducting the actual count with the oncoming nurse. The narcotic log had staff initials next to entry 5/12/17 6:30 AM. Staff verified her initials and was asked why she signed the log without doing the count. Staff H did not answer the question. Staff H said the oncoming nurse was not at the facility yet. During narcotic count observations at the Central Nurses station on 05/12/17 at 6:00 AM, Staff L, Licensed Practical Nurse, (LPN), and Staff I, Licensed Practical Nurse, (LPN), failed to both visually inspect the backs of each controlled medication. Observations of narcotic count on 05/12/17 at 2:20 PM at the West Nurses Station, showed Staff M, RN, was handling narcotic cards and looked at the front labels and read page numbers. Staff M did not visualize the backs of the bubble packs. Staff M confirmed she did not visualize the back of the cards and said she has been here every day and knew they were the same. During rounds on 05/09/17 at 9:02 AM, narcotic delivery receipts found at the West and Central Nurses Station dating from 05/02/17 to 05/09/17, were not signed or were missing two nurse signatures.

Based on interview and record review the facility failed to log on the State reporting log; conduct thorough investigations of incidents involving identification of incorrectly labeled medication bubble packs and unauthorized removal of residents' schedule II medications (narcotics), and unauthorized use or missing narcotics from Emergency Kits (E-kits) for 8 out of 8 Sampled Residents #'s (1, 2, 3 4, 5, 6, 7 and 8) who were reviewed for narcotic medications prescribed. Failure to thoroughly investigate, prevented the facility from identifying all contributing factors for breaks in the narcotic control system and delayed implementation of corrective measures that were effective to ensure residents were protected. These failures had the potential to result in adverse reactions to medications their providers had not prescribed for them when medications were incorrectly labeled or to not receive therapeutic value of medications prescribed for Resident (#s 1, 2, 3. 4 and 8). Failures resulted in harm for Resident # 5, Resident #6 and Resident #7 who did not receive prescribed medications for pain control from incorrectly labeled medications and did not obtain relief from their pain. Findings included . Facility's Drug Diversion Policy dated 01/26/14, showed that the facility management should investigate and make every reasonable effort to reconcile discrepancies. Investigation includes, but not limited to: interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluate if the loss is associated with or attributed to specific individual(s) time period or unique situation .and analyze findings from any discrepancy events. Individual Narcotic Logs (NL) of Schedule II narcotic medications (highly addictive substances with high potential for abuse and are controlled or regulated) were reviewed for narcotic accountability. Each resident had a separate sheet in the narcotic log to identify amounts of each separate scheduled II medication. This sheet tracked how much medication was removed by licensed staff and how much remained. The amount of pain medication removed should also be documented onto Medication Administration Records (MARs) for all licensed staff to know how much and when the resident received the medication. Maintaining accurate counts on scheduled II medication NL and MARS ensures residents receive medication as ordered by their physician, maintains a system of accountability for each nurse that dispenses these medications and discourages diversion of drugs. FAILURE TO INVESTIGATE DISREPANCIES AND ILLEGIBLE DOCUMENTATION OF SCHEDULE II CONTROLLED SUBSTANCES. The following discrepancies in narcotic logs and medication records occurred and were not logged onto the State reporting log or thoroughly investigated by the facility: RESIDENT #7 Resident #7 admitted to the facility 08/22/16 with [DIAGNOSES REDACTED]. Resident #7 was prescribed [MEDICATION NAME] 5 mg 1-2 tablets every 4 hours for pain as needed. A bubble pack of round pills with a prescription label of [MEDICATION NAME] 5 mg tablet was identified by a pharmacist on 04/28/17 as unknown medication Review of narcotic log page 4, line 6, showed one [MEDICATION NAME] pill signed out at 9:21 PM. There was no documentation of a nurse signature to evidence who had removed the pill. Further review of the narcotic log, page 4, showed [MEDICATION NAME] removed on 04/10/17, 04/11/17, 04/12/17, 04/17/17, 04/21/17, 04/23/17, and on 04/27/17. Review on the April 2017 Medication Administration Record showed, none of the listed dates had documentation to show the pills were administered to the resident. During an interview on 05/09/17 at 3:00 PM, Staff F reviewed the documentation on the narcotic log and compared to the Medication Administration Record. Staff F stated there were seven doses of the narcotic pain reliever not accounted for. Facility's pain assessment dated [DATE], showed Resident #7 had pain related to diabetic [MEDICAL CONDITION] and history of right and left [MEDICAL CONDITION]. During an interview on 05/09/17 at 3:30 PM, Staff F, RN, RCM, stated Resident #7 had chronic pain related to having fractures in both her right and left hips. During an interview on 05/12/17 at 1:00 PM, Resident #7 stated she had told the nurses her pain pills were not working. Resident #7 stated prior to the medication discrepancy she only took half of her pain pill and her pain level remained three to four on the one to ten pain scale. Then she noticed her pain levels worsening. Resident #7 stated she started taking two whole pain pills, and her pain level never went below eight, and had increased to 13 on a one to ten scale. Review of the narcotic log, page 4, showed between 04/08/17 and 04/27/17, one pill from the package had been removed and administered every day, indicating Resident #7 received the wrong medication for twenty days. Review of the April 2017 Medication Administration Record showed staff asked Resident #7 three times daily to rate her pain using a one to ten scale. Pain ratings were documented as zero on all three shifts for the first six days of April. On 04/07/17 Resident #7 rated her pain as seven during the evening and at night. Resident #7 continued to report pain 15 of the next 21 days, until the wrong medication was identified. RESIDENT #5 Resident #5 was prescribed [MEDICATION NAME] 10 mg, one tablet twice a day. A bubble pack with round pills had a prescription label of [MEDICATION NAME] 10 mg but the back of each bubble listed [MEDICATION NAME] HCL 4 mg (anti-nausea medication). Review of narcotic log, page 1, line 16, showed staff documented administering one pill, and leaving one pill remaining. There was documented lines over the existing documentation showing the one pill administered had been changed to two, and the one remaining pill had been changed to zero. There were no initials to indicate which staff member had altered the documentation. Review of narcotic log page 67, showed documentation on 05/05/17 at 0:06 AM, just after midnight, staff removed two [MEDICATION NAME] 5 milligram tablets. In the box designated for nurse's signature was documented refused. There was no initials to evidence nursing staff wasted the tablets. The Medication Administration Record showed no documented evidence the medication had been administered. Further review of page 67 showed on 05/07/17 at 7:00 AM and at 12:45 PM, two tablets of [MEDICATION NAME] were signed out. Under the column designated to document remaining tablets in the package, numbers documented for both administration times were written over and had been altered. Resident #5's pain assessment dated [DATE] showed pain of eight out of ten in severity and described the pain as aching and throbbing, which had affected her sleep, ability to participate in activities and mood/emotions. During an interview on 05/12/17 at 1:50 PM, Resident #5 stated she has continuous pain that throbbed, and shoot down her right leg due to right hip and right upper leg fractures. Resident #5 stated recently her pain level had increased from a seven out of ten rating to a ten out of ten all the time. During an interview on 05/12/17 at 2:00 PM, Staff G stated Resident #5 did have recent complaints of increased pain levels. Staff G stated, at the time she did not know why Resident #5 was experiencing more pain. During an interview on 05/17/17 at 4:00 PM, Resident #5 stated she was told by staff that she had not had her prescribed pain medication for ten days. Resident #5 stated she had used opiate pain medications to relieve her pain. Resident #5 stated she felt like she was going through withdrawls from the medication. Resident #5 stated, she was nauseated, ached all over, clammy, shaking, was irritable and hurt like hell. Resident #5 stated she knew the staff were concerned, but they didn't live it, they have no idea what I felt. During an interview on 05/17/17 at 4:00 PM, Staff K stated that during the timeframe when the medication discrepancies were identified, Resident #5 had shown symptoms which may have been sign of withdrawal from the opiate medication. Staff K stated Resident #5 had experienced nausea, shaking and was irritable. During an interview on 05/17/17 at 5:46 PM, Staff Q, Medical Director, stated signs and symptoms of withdrawls can occur after stopping opiate medications. Staff Q, Medical Director, stated the symptoms can start within one to two days. RESIDENT #6 Resident #6 admitted to the facility from a trauma center on 04/18/17. During interviews on 05/12/17 at 10:55 AM and on 05/17/17 at 4:15 PM, Resident #6 stated he had been hit by a car and spent 3 weeks in the hospital prior to admitting to the facility. Resident #6 stated he had multiple fractures and had pain in his shoulders, neck, spine, ribs, and down his arms, extending to his fingers. Resident #6 stated the first couple of days after he admitted to the facility his pain medications were effective at relieving his pain, then it changed. Resident #6 stated his pills looked the same, but tasted different. Resident #6 stated the pills did not give him any pain relief. Resident #6 stated he would lay in bed watching the clock, waiting for it to be time to get another pain pill, hoping the nurse would give him a pill before he had to work with the therapist. Resident #6 stated he was dying, and just tried to get used to being in pain. Resident #6 was prescribed [MEDICATION NAME] 5 mg 1-3 tablets every 3 hours as needed for pain. A bubble pack of white round pills had a prescription label of [MEDICATION NAME] 5mg but the on back of the pack each individual bubble was labeled [MEDICATION NAME] 12.5 mg (medication used to treat nausea and assist pain medication work better). Review of Resident #6's medical record showed a physician's orders [REDACTED]. Review of the narcotic log book, page 42, line one and line two showed documentation of the number of [MEDICATION NAME] (a narcotic pain reliever) pills that should be in the medication cart, had both been altered. The number of pills on both lines had been changed to a smaller quantity. There was no documented staff initials to indicate who had changed the numbers or why. Further review of the narcotic log showed additional alterations of the documentation; Page 76, line one, the time of administration had been changed, making the time illegible, no initials were documented to indicate which staff member had made the changes. Page 59, lines one and eleven, both showed documentation of numbers written over existing numbers, with no staff initials. Page 45, line one, quantity of medication remaining showed documentation written over the existing documentation, with no initials to indicate which nurse made the changes. During an interview on 05/08/17 at 5:00 PM, Staff F, RN, RCM, stated Resident #6 had been hit by a car and has had increased pain. Staff F, RN, RCM, stated Resident #6 was not getting pain relief when he was given his prescribed [MEDICATION NAME] (a narcotic pain reliever). Staff F, RN, RCM, stated, she could not figure out why Resident #6 got more pain relief from taking an over the counter pain reliever, such as Tylenol, than he did from taking the narcotic pain reliever. Review of the narcotic log showed when Resident #6 first arrived at the facility his pain medications were supplied from the emergency kit. The second day in the facility Resident #6 received packaged pain medication from the pharmacy. Resident #6 experienced increase pain as a result of not receiving his prescribed pain medications. RESIDENT #4 Resident #4's narcotic logs contained pages with labels that identified the quantity of [MEDICATION NAME] 5 mg ordered by the physician and instructions for administration. Narcotic log pages showed the total amount of narcotic initially received from the pharmacy and the number of tablets removed by staff each time they were dispensed. Subtotals of remaining tablets were documented following removal of medication. Resident #4's Medication Administration Record for the months of March 2017 and April 2017 instructed staff to administer two tablets of [MEDICATION NAME] 5 mg every 6 hours or ½ tablet of [MEDICATION NAME] 5 mg every 4 hours as needed for pain. 1. On 03/04/17 at 5:00 AM, the NL showed the resident had 18 tablets of [MEDICATION NAME] remaining. Nursing staff documented they removed one tablet from the NL on 03/04/17 at 1:00 PM and one tablet at 7:00 PM, for a total of two tablets removed. The NL showed staff documented there were only 14 tablets remaining, instead of 16 tablets, which should have remained (18 - 2 = 16). The narcotic log showed two additional [MEDICATION NAME] tablets were unaccounted for. Medication doses documented on Resident #4's MAR for 03/04/17 did not match the amount of tablets removed from the narcotic log. Staff documented they administered two tablets to the resident at 1:00 PM and 7:00 PM on the MAR and signed out one tablet each time in the narcotic log. 2. Page 8 on Resident #4's [MEDICATION NAME] NL showed four tablets of [MEDICATION NAME] 5 mg were removed on three different occasions (total of 12 tablets) on 03/01/17. The resident's MAR documented staff administered only eight tablets to the resident that day. The amount removed and the amount administered to the resident showed four tablets were unaccounted for. 3. Page 15 and page 16 of Resident #4's [MEDICATION NAME] NL showed staff removed four tablets of [MEDICATION NAME] thirteen different times between 03/06/17 through 03/10/17 (total of 52 tablets.) MARs for this same time period showed staff administered a total of 32 tablets and not 52 tablets which were signed out on the narcotic log. 4. Page 27 for Resident #4's NL showed on 03/16/17 four [MEDICATION NAME] tablets were removed by staff at 5:00 AM. The resident's MAR documented staff administered two tablets at 6:00 AM. On 03/16/17 at 12:00 PM, staff documented on the NL two tablets were removed and did not document on the MAR they were administered. 5. On page 28 of the NL, staff removed four tablets of Resident #4's [MEDICATION NAME] each time during seven different times between 03/12/17 and 03/23/17. A total of 28 tablets were removed. The resident's Medication Record showed staff administered only 14 tablets to Resident #4 of the 28 pills during these dates. 6. Page 44 in the NL, for Resident #4, contained a page for [MEDICATION NAME] 5 mg. Staff documented on the narcotic log on seven separate occasions between 03/29/17 and 03/31/17 staff documented they removed four tablets of [MEDICATION NAME] each time (for a total of 20 mg each time). The resident's MAR for dates tablets were removed, showed only two [MEDICATION NAME] tablets (10 mg) were given to the resident. 7. On page 82 of the narcotic log from 04/16/17 - 04/17/17, showed on seven separate occasions staff documented they removed four tablets of [MEDICATION NAME] each time for a total of 28 tablets. The resident's MAR for dates tablets were removed, showed only a total of fourteen tablets were administered to the resident. Staff documented they removed twice as many tablets as they dispensed. RESIDENT #8 Resident #8 was prescribed [MEDICATION NAME] 20 mg 1 tablet at bedtime. A bubble pack containing round pills had a prescription label identifying medications as [MEDICATION NAME] 20 mg. Pharmacy verification on 4/28/17 revealed the bubble pack of white round pills was not [MEDICATION NAME] and it was an unknown medication. Resident #8 had orders for [MEDICATION NAME]-[MEDICATION NAME] 7.5 mg-325 mg with instructions to give one tablet every 6 hours as needed for moderate to severe pain and to give two tablets scheduled at bedtime according the physician orders. The MAR for April 2017 listed two separate orders, one for [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 mg 2 tablets at bedtime and another for [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 1 tablet every six hours as needed for moderate pain. Resident's narcotic log from 04/11/17 to 04/13/17 showed 5 [MEDICATION NAME] tablets were signed out, but the MAR had 10 tablets documented as administered. On narcotic log from 05/03/17 to 05/05/17 it was documented 9 tablets were signed out but the MAR had 10 tablets documented as administered. RESIDENT #1 On 4/28/17 a bubble pack containing Resident #1's medications was labeled as [MEDICATION NAME] 5 mg tablet was actually [MEDICATION NAME] 12.5 mg (anti-nausea medication). A second bubble pack with round pills labeled as [MEDICATION NAME] mg was labeled as [MEDICATION NAME] 10 mg (ant-nausea medication) on the back of the pack. In April 2017 Resident #1 received 24 doses of [MEDICATION NAME] 10 mg labeled as [MEDICATION NAME] 10 mg. Narcotic log on 02/24/17 at 05:18 AM, on 03/08/17 at 10:48 AM and 12:40 PM, and on 03/27/17 at 12:34 PM showed documentation for administering [MEDICATION NAME] 5 mg tablets but the MAR on these days did not contain documentation indicating it was not administered. RESIDENT #2 Narcotic log for Resident#2 from 04/03/17 to 05/08/17 showed 22 of [MEDICATION NAME] 2 mg tablets were documented, but the MAR showed only 6 tablets were documented as administered. 4/28/16 Resident #2's bubble pack labeled as [MEDICATION NAME] 2 mg tablets, had remaining 16 tablets of unknown medications. Another bubble pack containing round pills had a prescription label of [MEDICATION NAME] 2 mg but the back of each pill was labeled as [MEDICATION NAME] 25 mg (blood pressure medication) tablet. Resident #2 received 14 mislabeled medications instead of [MEDICATION NAME] 2 mg in April 2017. RESIDENT #3 Resident #3 was prescribed [MEDICATION NAME] 10 mg (narcotic pain reliever) every 8 hours for pain. A bubble pack containing round pills had a prescription sticker identifying tablets as [MEDICATION NAME] 10 mg but on the back of the bubble pack each medication was labeled as [MEDICATION NAME] 10 mg. A second bubble pack of white round pills with prescription label of [MEDICATION NAME] 10 mg identified the medication on the back of the bubble pack as [MEDICATION NAME] HCL([MEDICATION NAME] and a sedative) 25 mg LACK OF THOROUGH AND TIMELY INVESTIGATION During an interview at 05/08/17 at 12:35 PM with Staff C, and at 12:50 PM with Staff F, both reported on 04/28/17, the facility identified Residents (#s 1, 2, 3, 4, 5, 6, 7 and 8) medications or a total of twelve bubble packs labeled as narcotics were actually not narcotics. On 04/28/17, medications were verified by pharmacy staff and confirmed the actual content of each mislabeled medication bubble pack was not a narcotic. Discrepancies were found in 3 out of 3 medication carts in the facility. The facility copied front and back of the mislabeled bubble packs and returned them back to pharmacy per pharmacy request. The pharmacy replaced all mislabeled bubble packs. The state reporting log did not contain incidents of narcotic tampering logged as misappropriation for 8 of 8 residents involved. Investigators asked the facility for evidence of investigations related to narcotic discrepancies and tampering with e kits on 05/08/17 and 05/09/17. On 05/09/17 at 1:54 PM Staff A, Administrator provided, a document titled Lakewood Medication Discrepancy Investigative Summary. The document was undated and signed by Staff E, Company Risk Manager. The document contained a timeline of events that began on 04/28/17. Investigations provided did not include witness statements, staff interviews, pharmacy staff interviews and delivery personnel interviews. It did not contain evidence that facility records were audited such including resident narcotic logs and resident medication records. The provided documents did not include investigations or explanations of multiple illegible documentation on narcotic control logs, e-kit control logs analysis, and evidence that employee's signatures and/or initials were analyzed for patterns or trends. Additionally, the investigations did not include evidence that a thorough review was completed of other components of narcotic management such as narcotic wasting, comparing physician orders [REDACTED]. The investigation did not include evidence facility staff were observed completing narcotic dispensing immediately following discovery of potential diversion. The facility did not provide evidence the facility conducted individual investigations for each resident affected by mislabeled medications. There was no evidence residents affected were interviewed. The facility was unable to provide evidence that all licensed nurses were immediately trained following all incidents in order to protect the residents from further potential drug diversion and/or medication related concerns. EMERGENCY KITS (E-KITS) The facility received a separate locked container (E-Kit) that contained scheduled II (narcotic) medications for emergency use when resident medications were not available. Each E-Kit was secured with a zip tie and had an identified tag number associated with each kit before the pharmacy transported it to the facility. A typed statement written by Staff R, Pharmacist dated 05/01/17, showed in April 2017, when the pharmacy received e-kits after they were in the facility's possession, the e-kits appeared tampered with. The pharmacy did not find narcotic slips in either kits to account for missing medications. Unaccounted Schedule II narcotics included: 16 [MEDICATION NAME] tablets, one bottle of liquid [MEDICATION NAME], 10 [MEDICATION NAME] tablets, and 10 [MEDICATION NAME] tablets. On 05/09/17 at 3:45 PM, the facility provided a document dated 05/05/17 as evidence of investigation for missing schedule II narcotics from the e-kit, identified by the pharmacy on 05/01/17. The document contained seven faxed notifications from the pharmacy titled Potential Undocumented E-Kit/Pyxis withdrawal(s) and two pages of typed E-Kit numbers with correlating dates from 04/23/17 and 05/03/17. There were no witness statements included. Six of seven faxed notifications did not provide the E-Kit seal numbers. The E-Kit investigation did not include witness statements. On 05/17/17 at 1:30 PM Staff F, Resident Care Manager, stated that she was still waiting to receive pharmacy delivery receipts on three of E-Kits in question. During phone interviews on 05/10/17 at 11:45 AM and on 05/15/17 at 2:50 PM, Staff E, Company Risk Manager, (CRM) indicated she was responsible for a portion of the investigation. She stated that she was at the facility between 05/03/17 and 05/05/17 and met with selected nurses on April's schedule individually. Staff E, Risk Manager (RM), was asked if at that time the narcotic logs and MARs were reconciled. Staff E, RM, explained that due to limited time it was not done. Staff E, RM, also stated that she did not observe narcotic count or observe medication pass. Staff E stated that she had concerns about narcotic documentation and staff not signing narcotic delivery receipts. Staff E also mentioned discrepancies in narcotic documentation was a red flag for diversion. On 05/10/17 at 12:38 PM Staff B, Interim Director of Nursing, stated that the narcotic investigation is not complete. Staff B indicated Staff E was responsible for conducting the investigation and completing the summary. Staff B stated that he did not participate in the investigation, his role was to be a scribe for Staff E during interviews with nurses last week. On 05/12/17 at 3:00 PM Staff A, Administrator, was asked about delay in providing the final summary and lacking data. Staff A stated that when he received results of investigations it was not what he expected. During interviews on 05/15/17 at 3:55 PM with Staff U, Corporate Support and Staff W, Corporate Support, stated that they clarified Staff B, Interim Director of Nursing, provided oversight of clinical services. When asked who was responsible for data analysis and investigation summary, both reported the Divisional Nurse would be completing the summary and it should be ready tomorrow. Staff V, Omnicare Nurse, clarified that initial investigative summary provided by facility of 05/9/17 was not the actual summary. Both corporate support staff were informed that surveyors requested evidence that all nurses received immediate training following 04/28/17 discovery of narcotic tampering.

Based on observation, interview and record review, it was determined that the facility failed to ensure staff conducted a transfer using a mechanical lift as outlined in the resident's plan of care for 1 of 3 Sampled Residents (#1) reviewed for falls. Failure to use the mechanical lift resulted in Resident #1 falling and sustaining a fracture, thus causing harm to Resident #1. Findings include: Review of Resident #1's medical record revealed she was blind in her left eye. Additionally, Resident #1's record indicated she had a [DIAGNOSES REDACTED]. Observations on 2/1/17 at 2:10 p.m., revealed Resident #1 in her bed. Resident #1 confirmed staff usually assist her transfer using a mechanical lift, however, on the day she fell , the lift was not in her room. Review of Resident #1's medical record revealed a care plan dated 11/24/2014, which indicated she had lower extremity weakness and required 2 person total assist with transfers. During an interview on 2/13/17 at 12:20 p.m., Staff C reported Resident #1 had been in the facility for more than 2 years, and during that time, she had always required 2 staff using a mechanical lift to complete transfers. Staff C further reported Resident #1 is not able to stand to transfer. During an interview on 2/1/17 at 2:15 p.m., Staff H reported all staff should check the Kardex (a computerized care plan) to see how a resident transfers, independently, with assist from 1 staff, 2 staff or with the use of a mechanical lift. Staff H stated staff should never transfer a resident unless they know what type of transfer is listed in the kardex. Review of a facility incident investigation indicated that on 1/20/17 at 11:30 a.m., Resident #1 put on her call light and when Staff G entered the room, she requested assistance in moving from her bed to her wheelchair. Further review of the investigation indicated Staff G did not use a mechanical lift and did not seek assistance from a second staff member, even though the Kardex care plan indicated 2 staff and a mechanical lift should have been used. The investigation indicated as Staff G assisted Resident #1 to stand and transfer, Resident #1 slid straight to the floor. Review of hospital records revealed an x-ray report dated 1/22/17 which indicated Resident #1 had a fracture in her right upper leg as a result of the fall. Resident #1 had been identified as being at risk for falls. A care plan was developed with interventions for fall prevention, including the use of 2 staff and a mechanical lift when transferring the resident. On 1/20/17, at 11:30 a.m., Staff G failed to implement the fall prevention interventions as directed in the plan of care. Failure to transfer Resident #1 without staff and a mechanical lift caused Resident #1 to fall and sustain a fracture which later required hospitalization .

Based on observation, interview, and record review, the facility failed to monitor neurological changes following a fall for 3 of 6 Sampled Residents (#s 1, 3 & 6) reviewed for accidents. Additionally, the facility failed to monitor and treat a skin condition for 2 of 3 Sampled Residents (#s 2 & 4) reviewed for skin conditions. These failures placed residents at potential risk for unnoticed decline in condition, thus a delay in identification and treatment. The failure to monitor and treat a skin condition for Resident #4 contributed to worsening of the wound, thus causing harm to the resident. Findings include: SKIN MONITORING RESIDENT #4 Observations on 5/4/16 at 12:25 p.m. revealed Resident #4 had large gauze bandages wrapped around her arm. Review of the facility policy entitled Pressure Ulcer/Non-Pressure Ulcer Assessment dated 12/19/15 revealed directives to staff when assessing a wound they should document the anatomical location, size, ulcer bed, drainage, odor, [MEDICAL CONDITION] of the ulcer and/or foreign objects in the ulcer on the designated form in the patient's medical record. In an interview on 5/4/16 at 10:30 a.m., Staff G reported skin conditions are documented on the treatment administration record (TAR) for both monitoring and treatment orders. Review of a facility investigation revealed Staff C noted Resident #4 had a 2 cm wide by 2 cm long open area on her right arm on 4/14/16. The investigation indicated Staff C did not document the open area on the TAR. Additionally, the investigation indicated Staff C had not documented the sized and characteristics of the wound until 4/20/16. The investigation indicated Staff C noted Resident #4's open area again on 4/17/16 and indicated the area had increased in size. There was no documentation related to the observations of the wound on 4/17/16 until 4/20/16. During an interview on 5/4/16 at 1:00 p.m., Staff A confirmed there was not documentation on the TAR to alert other staff to monitor the area. Staff A confirmed the wound increased in size and the tissue in and around the wound deteriorated while staff was unaware. Progress notes indicated the wound and its characteristics were not entered onto the TAR until 11:30 p.m. on 4/19/16, five days after it was discovered by staff, and two days after Staff C noted the wound had increased in size. Progress notes on 4/19/16 indicated the wound appeared red and tender with necrotic (dead) tissue. Lab tests confirmed the wound had become infected. By not documenting the wound, staff on other shifts or working other days were left unaware it had developed. Without staff knowing to monitor the wound, it deteriorated to the point of infection with necrotic tissue, thus causing harm to Resident #4. RESIDENT #2 Observations on 5/2/16 at 11:40 a.m. revealed Resident #2 with slight discolorations of the skin on her hands. Review of a facility investigation dated 4/6/16 revealed staff were notified by Resident #2's family that she had bruises to both of her hands. Review of Resident #2's medical record revealed only one progress note written about the bruises, however, the note was not written until 5/2/16 at 11:30 a.m., after the survey team had requested the facility investigation related to the bruises. Further review of the record revealed a skin assessment that was not documented until 5/2/16 at 11:13 a.m., after the survey team had requested the facility investigation. The skin assessment indicated the resident's left hand had an 8 cm long by 7 cm wide, and her right hand had a 7 cm long by 6 cm wide bruise. Review of the April 2016 TAR revealed no orders to monitor the hand bruising. The TAR did have entry directing staff to monitor Resident #2 for side effects of taking blood thinning medication, such as bruising and bleeding. The monitor for side effects had documentation that indicated the resident was assessed three times daily. The documentation for 4/6/16, the day the bruises were noted, and the following week, all indicated Resident #2 had no bruising. NEUROLOGICAL MONITORING Review of the facility policy dated 7/16/14 entitled Fall Response and Management revealed for an unwitnessed fall staff should monitor neurological assessments per physician's orders or monitor every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for 2 hours, or until condition stabilizes. During an interview on 5/2/16 at 3:05 p.m., Staff H reported when a resident has an unwitnessed fall the staff implement neurological monitoring since it is unknown if the resident has a head injury. RESIDENT #1 Review of Resident #1's record revealed a progress noted dated 4/21/16 at 2:10 a.m. that indicated the resident was found laying on the floor in his room. The note indicated the resident was not able to report how he fell and was confused. The note also indicated neurological monitoring was initiated. Review of the Neurological Record dated 4/20/16 revealed documentation to support the resident's neurological status was assessed at 11:05 p.m. and again at 11:20 p.m. The neurological record indicated the resident should have been assessed again at 11:35 p.m., 11:50 p.m., 12:20 a.m., 12:50 a.m., 1:20 a.m., 1:50 a.m., 2:50 a.m., 3:50 a.m., 4:50 a.m., and 5:50 a.m. The 5:50 a.m. assessment had been left blank, and all the times previous to 5:50 a.m. had a hand written note through the assessment sleeping. There were no assessments documented between 4/20/16 at 11:20 p.m. and 4/21/16 at 9:50 a.m., ten and a half hours later. During an interview on 5/4/16 at 12:15 p.m. Staff A reported the neurological assessments are done to assess alertness, and rule out head injury. Staff A confirmed Resident #1 should have been woken up to ensure his neurological functions were intact. RESIDENT #3 Review of facility investigations dated 4/23/16 indicated Resident #3 was found sitting on the floor in his room at 11:00 a.m. and was found on the floor again at 12:00 noon the same day. Review of the Post-Fall Investigation dated 4/23/16 at 11:00 a.m. revealed the resident had last been seen by staff at approximately 10:45 a.m. Review of a second Post-Fall Investigation dated 4/23/16 at 12:30 p.m. revealed Resident #3 had another unwitnessed fall. The 12:30 p.m. investigation indicated Resident #3 had last been seen at 10:45 a.m. There was not documentation to support neurological checks were done after the fall. The documentation that state Resident #3 had not been seen since his earlier fall indicated neurological assessments were not done. During an interview on 5/5/16 at 3:40 p.m. Staff B confirmed that since both falls were unwitnessed, both would require neurological assessments. Staff B confirmed she was not able to locate the neurological assessments in Resident #3's medical record. During an interview on 5/5/16 at 3:35 p.m. Staff H reported she was not able to locate neurological checks for either fall on 4/23/16 in the medical records department. RESIDENT #6 Review of the facility incident log revealed Resident #6 fell on [DATE] at 1:40 a.m. Review of the facility Post-Fall Investigation indicated the fall was unwitnessed. Review of Resident #6's medical record revealed no neurological assessment done after the fall. There was one undated neurological flow sheet in Resident #6's chart; however the times of the assessments did not match the times of the fall. The undated assessment was not complete and only included 4 complete assessments between 2:40 p.m. and 8:00 p.m., when there should have been 11 assessments completed in the identified timeframe. During an interview on 5/4/16 at 3 p.m., Staff A confirmed the assessment had not been completed in accordance with facility standards. Failure to monitor for decline following a change of condition placed residents at risk for unnoticed decline and delayed treatment. .

Based on observation, interview, and record review, the facility failed to timely notify a physician and notify the family when a resident had a change in condition on two separate occasions, for 1 of 6 Sampled residents (#4) reviewed for reporting a change in condition. This failure caused Resident #4's wound to increase in size and deteriorate in condition, and actual harm to the resident. Findings include: Review of the facility policy titled Condition Change of a Patient dated 5/28/15 revealed directives to staff to notify both the physician and the resident's family member/responsible party when there had been a change in status or decline in health of a resident. Review of a facility policy dated 12/19/15 entitled Pressure Ulcer/Non-Pressure Ulcer Assessment revealed directives to staff to notify the physician and the resident's family member/responsible party when a skin condition was noted. Observations on 5/4/16 at 12:25 p.m. revealed Resident #1 in her room with a large gauze wrap around her right arm. Review of Resident #4's record revealed a progress note dated 4/19/16 at 11:33 p.m., which indicated the resident was found to have a pressure area on right arm by elbow, 2 cm X 2 cm appears to be necrotic tissue in the middle. The note indicated the area was very pink and hot. Review of the facility investigation dated 4/19/16 of how the injury occurred revealed when the wound was noted Resident #4's medical record was reviewed by staff and it was identified that there were no previous notes or assessments related to the wound. The facility investigation identified that Staff C had first noted the wound five days earlier on 4/14/16. The investigation identified that Staff C did not notify Resident #4's physician or family of the wound on 4/14/16. Further review of the facility investigation revealed that Staff C again assessed the wound and provided treatment to the wound on 4/17/16 when she noted the gauzed dressing was no longer covering it. The investigation included a statement from Staff C that indicated the wound was larger in size on 4/17/16 then it was when she first noted it on 4/14/16. The investigation indicated Staff C did not notify the physician or the resident's family on 4/17/16. During an interview on 5/4/16 at 12:20 p.m. Staff D reported when nurses note a new wound they should report to the physician. Staff D confirmed if a nurse provides treatment to a wound they should have an order, and if they do not have an order, the physician should be notified of the treatment given so orders can be made. During an interview on 5/4/16 at 1:00 p.m., Staff A confirmed the nurse had noted the new wound on two separate occasions and did not notify anybody of the change in skin condition. Staff A confirmed the wound had increased in the time frame when Staff C first noted it on 4/14/16 and when she saw it the second time on 4/17/16. Review of a skin assessment dated [DATE] at 11:38 p.m., revealed when Staff E first noted the wound, the wound had increased in size to 2 centimeters in length and 3 centimeters in width. Additionally, the wound declined in condition, going from pink on 4/14/16, to pink, hot and tender on 4/17/16 to being necrotic (dead tissue) on 4/19/16. Review of Resident #4's medical record revealed lab results dated 4/21/16 showeing the wound had become infected during the same time frame. Failure to notify the physician when the wound was first identified caused a delay in treatment and monitoring of the wound. The wound grew in size and the condition of the wound declined as a result. The delay in treatment and monitoring caused harm to Resident #4.

Based on observation, interview, and record review, the facility failed to supervise a resident during a bed move for 1 of 3 Sampled Residents (#1) reviewed for accidents. This failure resulted in Resident #1 having two broken bones, thus causing harm. Findings include: RESIDENT #1 Observations on 5/2/16 at 3:30 p.m., revealed Resident #1 returning to the facility from a local hospital with a large gauze bandage wrapped around his right foot and ankle. During an interview on 5/4/16 at 2:00 p.m. Resident #1 stated that his foot had been injured when staff was moving a bed and his foot became caught between two parts of the bed. Resident #1 reported he had pain to his right foot. Review of a facility incident investigation dated 4/20/16 revealed Resident #1 was found on the floor in his room on the evening of 4/20/16. The investigation indicated staff were going to assist the resident back into his bed, but was going to move the bed of his roommate to allow for more space. The investigation included a statement from Staff F that indicated when she lowered the roommate's bed down she heard Resident #1 state aw, my foot, she then raised the bed back up. Additionally, the investigation included a statement by Resident #1's roommate that stated one of the aids lowered the bed and his (Resident #1) foot was under the bed. Review of an x-ray report dated 4/21/16 revealed Resident #1 had a fracture in both his third and fourth toes. Review of progress notes and medication administration records revealed following the incident on 4/20/16, Resident #1 voiced complaints of pain on 4/21/16, 4/22/16, 4/23/16, 4/24/16 and 4/25/16. There were no notes documented for 4/26/16. Progress notes dated 4/27/16 at 6:25 p.m. indicated Resident #1's foot had dried blood and dorsal foot is with black-purplish discoloration. Progress notes dated 4/28/16 at 9:46 a.m. indicated Resident #1 again had increased swelling to his right foot and the decision was made to send him to the hospital. Review of hospital records indicated Resident #1 present to the emergency room (ER) with his right foot red, swollen, with bleeding. Resident #1 was admitted to the hospital for treatment of [REDACTED]. During an interview on 5/4/16 at 3:00 p.m., Staff A confirmed there was three staff members present in Resident #1's room when his roommate's bed was being lowered. Staff A confirmed staff should have assessed the environment for safety prior to moving the bed. Staff A confirmed none of the three staff noticed Resident #1's foot was under the bed at the time the bed was being lowered. Staff actions of lowering the bed onto the resident's foot caused the two fractures in Resident #1's foot. There were two other staff were present at the time of the incident, however, both failed to noticed Resident #1's foot, and failed to prevent the incident. Resident #1 sustained two fractured bones and was hospitalized from [DATE] to 5/2/16, constituting harm for the resident.

Based on interview and record review, the facility failed to notify the physician in a timely manner following discovery of a deteriorating decubitis (pressure) ulcer, for 1 of 3 sampled residents (R#1-closed record) reviewed for physician notification. This failure caused the resident actual harm. Findings Include: Refer to citation written for F314 for further information. Resident #1's record indicated when Resident #1 experienced pain and mental status changes, the facility did not notify the physician. The resident was sent to the hospital for wound debridement and change in condition. In an interview on 4/7/16 at 3:40 p.m., Staff B said staff was expected to report a change in a wound to the physician. Staff B explained that on 4/4/16, the physician was called and a referral was made to the wound team, eleven days after the resident was admitted to the facility with identified pressure ulcers. According to Staff B, the new orders were changed to reflect [MEDICATION NAME] as part of the wound treatment, and interventions such as an air mattress and roho cushion were instituted. During an interview on 4/7/16 at 3:45 p.m., Staff A stated that on 4/3/16, he/she previously took care of Resident #1, and called the Director of Nursing Services to report a deterioration of the pressure ulcer. According to the 4/3/16 progress note, Staff A removed a dressing full of drainage, and the wound bed presented with black and purple areas, was bigger in size, and there was redness and induration (hardness) around the wound. The physician was not notified of the change in condition at this time. In an interview on 4/7/16 at 4:45 p.m., Staff C stated he/she discovered the wound in the medical record on 4/2/16 while doing an audit. Staff C explained staff notified her/him when there was a pressure ulcer, and the wound consultants were called for an appointment. Staff C stated, I should have looked at the wound (then). Staff C was not aware until 4/4/16, that the wound was deteriorating, and would expect the staff to alert her if a wound was deteriorating.

Based on interview, and record review, the facility failed to ensure a resident received necessary care and treatment on admission to the facility with pressure ulcers, to promote healing and prevent infection, for 1 of 3 sampled residents (R#1-closed record), identified at risk for skin breakdown, or at risk of deterioration of current wounds. The facility failed to adequately assess, monitor, evaluate, and provide timely treatment according to accepted standards of practice. The resident was not evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the resident in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent infection and promote prompt healing of existing pressure ulcers, resulted in harm to Resident #1, and placed all residents at risk of harm from similar deficient practice. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was assessed as at risk for skin breakdown. During a record review of Resident #1's Patient Nursing Evaluation, dated 3/25/16, (PNE-an initial nursing assessment completed on admission), it was noted that on admission, Resident #1's right and left buttocks had a stage two pressure ulcer (skin layers missing), and a stage two to the coccyx. There were no measurements of the wounds on the PNE. An additional skin assessment was completed on 3/25/16, called a Weekly Pressure Ulcer BWAT, and a score of 22 was given. The assessment revealed a right and left buttock stage two pressure ulcer without mention of the coccyx area, and measurement of the wounds were not present. There was no necrotic tissue noted on the buttocks at this time. The 3/25/16 physician order [REDACTED]. The 3/25/16 PO directed staff to clean each wound with normal saline, pat dry, and apply Alginate (medicated topical treatment-medicated pad) to the wound bed. Then staff were to cover the wound with a foam dressing until it was resolved. According to the treatment administration record (TAR) for 3/2016, the staff were providing the wound care every day in the evening. On a document called Skin inspection Anatomy Diagram, dated 3/26/16, the each pressure ulcer length and width were assessed and documented as follows: Right buttock: length 6 cm (centimeter) width 5 cm. Left buttock: length: 7cm width: 5cm and Sacrum: length: 4 cm width: 4cm. There was no documentation to describe the resident's wounds, or to show assessment, monitoring, or evaluation of the wounds was being done between 3/27/16 and 4/3/16. The facility did not refer the resident to the wound clinic on admission. The first weekly BWAT (wound assessment tool) was due on 3/30/16 and it was not conducted. Review of Resident #1's nursing progress notes revealed on 4/3/16, the resident requested a dressing change. According to the 4/3/16 progress note, while changing the saturated dressing, Staff A noted the wound bed presents with black and purple areas of discoloration, bigger in size, redness/induration (process of becoming hard) around the wound . The physician was not notified at this time, per progress notes. Review of the 4/4/16 progress note revealed, the facility assessed the wound with a BWAT by a licensed nurse. According to the 4/4/16 care plan, Resident #1 required one staff to assist with toileting, transfer, and bed mobility. Under interventions, the care plan revealed the pressure ulcers (PU) were to be assessed, recorded and to monitor wound healing, although the frequency was not addressed. Licensed Nurses (LN) were to measure length width and depth where possible, and assess and document the status of the wound perimeter, wound bed and healing process, and report improvements and declines to the medical doctor. On 4/6/16, the wound care team noted, the wounds had a strong odor, and had necrotic (dead) tissue. The sacral wound measured (Length/width cm) 3.6X2, and was 76-100% eschar (black tissue) the L buttock was 9X8.4 and was 26-50% eschar, and R buttock was 7.2X5 cm. and 26-50% eschar. The wound team evaluated the resident on 4/6/16, and found between 3/25/16, Resident #1's admitted , and 4/6/16, the resident's BWAT (a score indicating the severity and size of a pressure ulcer) score climbed from 22 to 52. Review of the 4/6/16 nurse progress note revealed, the resident was evaluated by the nurse practitioner, and recommended sending the resident to the wound clinic. However, the facility notified the physician, and the physician ordered the resident to go to the emergency room , immedicately. In an interview on 4/7/16 at 3:40 p.m., Staff B explained the admitting nurse was responsible for making an appointment to the wound team, and that the wound team was in the facility every Wednesday. According to Staff B, There was a miscommunication. Resident #1 was not referred to the wound team at the time of admission, and should have been seen on 3/30/16, per Staff B. In an interview on 4/7/16 at 4:30, Staff B stated the on-call physician was called on 4/4/16 and then a referral was made to the wound team. At this time the dressing order was changed, and interventions such as an air mattress and roho cushion were instituted. The resident was sent out for wound debridment and change in condition, on 4/6/16. The wound orders directed staff to continue with dressing changes every day, and a gauze soaked in medication was added. During an interview with a collateral contact (CC #1) on 4/18/16 at 9:30 a.m., CC #1 stated, What really worried me is that (Resident #1) was in pain. According to CC #1, the odor from Resident #1's wound was atrocious. In an interview on 4/19/16 at 12:45, Staff B stated the BWAT score change indicated the wound was getting worse. Staff B said the BWAT was not completed on 3/30/16. Although staff provided wound care as ordered by the physician, staff did not assess, monitor,or evaluate Resident #1's wounds, in a time consistent with the resident's needs.

Based on record review and interview, the facility failed to ensure 1 of 4 residents (Former Resident #1) reviewed for coordination of appointments in the community was free from neglect. Staff E had knowledge that Resident #1's appointment was cancelled and neglected to report the information to oncoming staff. This failure resulted in psychological harm for Resident #1 who suffered emotional distress when she was left in the lobby of the community building for an undetermined amount of time. The failure also potentially placed the resident at risk for an undetected change of medical condition while alone in the lobby. Findings include: Record review revealed Resident #1 admitted to the facility during 3/2014 with medical [DIAGNOSES REDACTED]. Review of the resident's most recent comprehensive assessment dated [DATE] revealed the resident required 1 person assistance for mobility in the wheel chair. Review of a physician order [REDACTED]. Telephone interview with hospice staff (G) on 5/14/14 at 11:50 a.m. revealed she called the facility early in the morning on 4/29/14 and spoke with Staff E (RN). She stated she was concerned about the resident making the trip to her appointment because of a recent decline in the resident's terminal illness. Staff E reported the resident had a "bad night" and stated she would not be able to make the appointment. Hospice staff G informed Staff E she would cancel the resident's appointment which she did. Staff E did not inform Staff D (day shift RN) that the appointment was cancelled. During interview on 5/15/14 at 10:15 a.m., Staff D (day shift RN) revealed she received report and Resident #1's appointment packet from Staff E on 4/29/14. Staff E did not report concerns about the resident and did not inform her that hospice was going to cancel the appointment. Staff D stated she assessed the resident and did not note acute change of condition or distress. She informed the resident about the appointment and the resident agreed to go. Staff D administered pain medication prior to transferring the resident to her wheel chair with portable oxygen applied. Review of Resident #1's appointment packet cover sheet revealed information that the resident's family would meet the resident at the clinic. This was confirmed during interview with Staff C (social service) on 5/15/14 at 11:20 a.m. Satff C had made the arrangements with the family. Telephone interview with the resident's legal representative on 5/15/14 at 2:05 p.m. revealed on 4/29/14 she was on her way to meet Resident #1 at the clinic when she was notified by the clinic that the resident's appointment was cancelled. On the way home, she received a call notifying her the resident was at the clinic. She stated when she arrived at the clinic, the resident was upset, confused and in a lot of pain. She stated she did not know how long the resident was in the lobby and was concerned because she did not have the strength to push herself around in the wheel chair to get assistance if she needed it. During telephone interview on 5/20/14 at 2:20 p.m. with Staff H (community office nurse) revealed on 4/29/14, another patient came to their office and reported seeing Resident #1 alone in the lobby. He reported she was upset and crying and appeared to be in pain. Staff H confirmed when she went to the lobby, she observed the resident was crying, upset and in pain. Staff H stated the resident was upset, asking why she was just "dropped off". Review of the facility's investigation of alleged neglect dated 4/30/14 revealed Staff E confirmed he spoke with Staff G (hospice) on 4/29/14 and reported his concerns to her that the resident was weak and in pain during the night. Staff E stated he "did not do anything about it and did not pass on his concerns; the hospice nurse should call back so I did not pass it on". The facility's investigation concluded Staff E was neglectful in not communicating the above information.

Based on interview and record review it was determined that the facility failed to ensure 1 of 3 residents (#141) reviewed for nutrition was comprehensively assessed and received identified interventions regarding severe weight loss. Failure to monitor and put intervention in place to maintain this resident's highest practicable physical, mental and or psychosocial well-being caused harm for this resident. Findings included: Resident #141 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the record revealed that the resident weighed 117 pounds on 6/24/12. On 7/15/12, 21 days after admit, the resident weighed 99 pounds, and sustained an 18 pound or 15.4% weight loss. Review of the nutrition data collection assessment revealed that the resident was on many vitamins and had fair food and fluid intake, added a snack at bedtime and the resident will ask for other snacks as needed, resident losing weight gradually related to fluid loss, wearing ted hose, usual body weight 104-110 pounds, 121 at admit, 117 on 6/24/12. The nutrition data collection assessment also revealed that the resident received protein powder in the hospital because s/he had not been eating much. Further review of the record revealed that the facility did not put in place any further interventions once the resident sustained [REDACTED]. On 10/5/12 at 1:02 p.m. Resident Care Manager (RCM) A reported that weights are done weekly and confirmed that weekly weights for this resident had not been done. RCM A also reported that interventions had not been put in place when severe weight loss of 15.4% had been identified. RCM A stated referrals to the Registered Dietitian, Physician or Interdisciplinary Team had not been made. The facility's failure to monitor the resident's nutrition status caused harm for this resident. The resident sustained [REDACTED]. .

Based on observation, interview and record review, the facility failed to ensure psychosocial evaluations and interventions were provided to preserve the integrity of each residents identity and individual life preferences. This caused harm to 2 of 6 current sampled residents (#79 &72) who reviewed for psychosocial impact. This failure placed all residents at risk for negative psychosocial impact. Findings include: <Resident #79> Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), a resident assessment tool, dated 3/8/12 and 5/24/12 documented the resident's preferred language was Korean and she needed or requested an interpreter to communicate with a doctor or health care staff. Each MDS documented the resident had minimal difficulty hearing, sometimes understood others and sometimes was able to make herself understood. The MDS dated [DATE] documented she did not need an interpreter, and did not have a preferential language listed. The MDS documented the resident had minimal difficulty with hearing, and usually was understood, and capable to comprehend most of a conversation. An annual Social Services Note, dated 8/31/12, documented "Per the nursing staff, pt. (patient) is alert and oriented x 3 although due to her language barrier she has difficulty at times making her needs known and will become frustrated. Pt. (patient) continues to be 100% reliant on staff for all aspects of ADL's (activities of daily living). In the last quarter,resident has been refusing meals quite often nursing staff often brings in cup of noodles for her." In the format of the note, an area that directs staff to document the residents level of psychosocial well-being, the SS person documented the resident was well known to the facility, enjoyed interaction with staff, and the resident's family did not visit often. There was no documentation regarding the resident's level of psychosocial well-being. The resident's care plan, dated,7/13/12, documented the resident had impaired cognitive function/impaired thought processes related to Alzheimer's/dementia. The care plan goal documented the resident was to "be able to communicate basic needs on a daily basis." It directed staff to "use communication techniques that facilitate interaction: use preferred name, identify yourself with each contact PRN (as needed), face when speaking and make eye contact, request feedback to ensure understanding, use brief simple consistent words/cues/statements." The care plan documented impaired communication problems for the resident related to language barriers. The goal was documented that the resident "will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately and using communication board." It directed staff that resident is "able to communicate basic English words such as pee-pee, coffee etc. Staff to utilize a translator when necessary. Use effective communication strategies such as touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm distinct manner, interpreter." The communication board was reviewed. It had 3 photocopied pages. On the first page,12 pictures with English words were observed. Underneath the English word was written in approximate 1/4 inch Korean characters, only 11 pictures had the Korean characters. Four of the English words were not applicable to the resident, glasses, dentures, tv, and radio, as she did not have those items. The second page contained 13 English words and pictures with the same 1/4 inch Korean characters, the last page was with 15 English words and 1/4 inch Korean characters underneath. The care plan documented the resident was at risk for nutritional decline related to the [DIAGNOSES REDACTED]. It directed staff to "determine resident's food/beverage preferences and eating patterns." On 10/2/12 at 12:36 p.m., the resident was observed in the dining room staring at the chicken fajita served for lunch, she began offering her plate of food to her table mates. Staff then gave Resident #79 a plate of beef stroganoff. Resident #79 was observed offering the beef stroganoff to her tables mates again, then to Licensed Nurse B (LN) and then to two surveyors. Resident #79's tabelmate, Resident #34 stated "she does this everyday, all the time we tell her it is her food, but she keeps trying to give it to us." At 2:07 p.m., the resident's family member was interviewed. The family member was asked about the previous life preferences and routines of the resident prior to her admission to the facility. "She doesn't like any of the food, it's not Korean, it's bland, she (Resident #79) likes salty soups with cabbage or seaweed." The family member showed the surveyor the soup that was brought in for Resident #79. "She has no teeth, she can't eat that other stuff, see the seaweed in here? That's miyuk, that's what she likes, or soft cabbage in soups." The family member stated there were not many Korean based activities for Resident #79. She stated Resident #79 loves Korean drama, similar to what would be an American soap opera, and that since that was not available, she would be willing to pay the facility money to provide that for her family member. She stated the resident was deaf in one ear, and able to hear a little in the other ear, but still could watch the television. On 10/3/12 at 10:52 a.m., the surveyor approached Resident #79 who appeared to be speaking to Resident #64 in Korean. She turned to the surveyor and spoke in her primary language. Resident #64 translated, stating Resident #79 said she was deaf in her one ear, and the surveyor should be on her other side to speak to her. At 11:00 a.m., Resident #79 was observed near the nurses' station yelling loudly, and was very agitated. Five staff members were observed offering guesses about what she wanted, without success. Resident #79 remained agitated, saying the word "pecca." One staff said, "What does that mean?" Another staff stated, "It means push her wheelchair." A staff person tried to push Resident #79 in her wheel chair, but Resident #79 continued to yell. A staff member stated someone should get a language board for the resident, which, when brought for use was not successful and the resident pushed it away. Then a staff member gestured with their hands drinking a beverage. Resident #79 nodded, was given a beverage and was less agitated for a short time. At 11:23 a.m., Nursing Assistant (NA) A was asked how staff communicate with the resident, as the resident had been observed from 8:00 a.m. until the present time with 4 observed agitated yelling episodes, where the resident appeared upset. NA A stated she tries to use Korean translation application she downloaded to her phone to communicate with Resident #79 but it was difficult. NA A stated, "She (the resident) communicates real well, she says "pee pee" for the bathroom, says coffee for coffee and motions with her hands against head to lie down, she says "pecca" when she wants to be pushed in her wheelchair." Resident #64 was sitting near and began laughing. Resident #64 stated Korean was her primary language but she spoke Japanese and English. She stated "pecca" was not a Korean word. Resident #79 began speaking to Resident #64. Resident #64 stated that Resident #79 said she wanted gim. Resident #79 was given seaweed from her family member, but want seaweed with rice, which was called gim. At 12:16 p.m., the Activities Assistant (AA) stated Resident #79 went to activities but the activites were English based. The AA stated,"We used to have Korean drama movies but only Resident #72 watched them, and the facility used to take residents out for a Korean luncheon on Wednesdays." The AA was not aware Resident #79 wanted to watch the Korean dramas. At 1:17 p.m., the AA stated Resident #79 had been added to the outing on Wednesday. The AA was asked regarding how it would feel to live in a facility that does not speak your preferred language. The AA stated, "I know, it would be scary, with no way to really talk." On 10/4/12, at 1:30 p.m., the Social Service Director (SSD) stated the facility had in the past used the language bank to communicate at times with the resident, but the resident does not always respond appropriately to the questions, and the facility has a communication board that was tried, but the resident will at times push it away. When asked about psycho-social assessments being completed for residents who are not English speaking as a primary language with limited ways to communicate their needs to the staff, and the impact it has on residents' psyche, sense of self and their dignity, the SSD stated, "There was none." The SSD continued,"Now in our Point Click Care computer system there are some, but Resident #79 has not been assessed yet." The surveyor relayed the concern over the facility's lack of assessment systems in identifying residents at risk for negative psychosocial impact regarding previous life routines, cultural beliefs including language and food. The SSD stated, "I agree, I see what you are saying." At 1:38 p.m., Resident #79 had been observed in 7 different situations where she displayed agitation and yelling. The DNS stated she knew Resident #79 was upset, and the daughter of Resident #72 translated for Resident #79. The visitor translated that Resident #79 was upset because she could not find her family member (who had visited the day previous), and she wanted to go home with her family member. On 10/8/12, at 2:40 p.m., the DNS stated the facility did not know what to do with Resident #79. The DNS said, "The facility just learned Resident #79 was deaf." <Resident #72> Resident #72 was originally admitted to the facility on [DATE], and then readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), a resident assessment tool, dated 2/9/12 documented the resident's preferred language was Korean and she needed or requested an interpreter to communicate with a doctor or health care staff. On 10/3/12 at 12:42 p.m., the resident was observed in her room, eating with chopsticks from a container the family member brought in for her, watching a small portable video of Korean singers in a contest. The resident's family member stated she brings the resident food every day, because "she doesn't eat that stuff, she will drink the shakes or eat the ice cream, but you know, it s not Korean food. I bring her gimbap or buloggi. No offense, but she would never eat something like that (pointing to the facility food), maybe if they had something more like Korean food she might eat it." The family member stated the video and player was not supplied by the facility. The family member stated she goes to the public library and rents the videos for her family member to watch because she enjoys them. The family member indicated Resident #72 is not interested in American television shows because she speaks Korean, and understands only a little English. .

Based on observation, interview and record review the facility failed to ensure adequate range of motion services were provided to prevent an increase in contractures for 1 of 4 residents (# 61) who were reviewed for contractures. This failure to provide adequate restorative nursing interventions caused harm to Resident #61 who had a worsening of his known contractures that caused him pain. This failure placed all residents at risk for decreased joint mobility and quality of life. Findings include: Resident #61 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident 's Minimum Data Set (MDS), an assessment tool, dated 8/28/12, documented the resident was cognitively intact and was able to make needs known. It documented he had functional limitation on one side of his body for upper and lower extremities. On 11/25/09, the Occupational Therapy Evaluation documented the resident had left shoulder 80 degrees of flexion, elbow -90 degrees flexion, wrist -10 degrees within extension and his fingers -90 degrees flexion with 10 degrees fluctuation (resident's hand and fingers contracted into a fist shape) upon admission to the facility. On 5/24/11, the Occupation Therapy Evaluation done after the resident's readmission to the facility documented the resident had "left upper extremity contracted, left upper extremity tone high, no active movement. Flexed, fisted, elbow at 90 degrees flexion. Shoulder adducted, wrist flex, fingers fisted " The goal was for the resident to have a decrease in his contractures by 25 % and for him to have a dynamic splint applied up to 5 hours daily to achieve that goal. On 5/25/11, the Physical Therapy Evaluation documented the resident had range of motion deficits as " left ankle dorsiflexion (toes point upward) at -28 degrees, plantar flexion 38 degrees, inversion 26 degrees, left knee extension -35 degrees from neutral (a straight leg position) and flexion 55 degrees at hip." The clinical summary by the physical therapist documented "Pt(patient) has LLE (left lower extremity) knee and ankle contracture that are increasing." The goal was documented for the resident to wear a dynamic splint applied up to 4 hours that the restorative nursing staff would apply and monitor weekly. The Physical Therapy Care plan, dated, 5/25/11, documented the goal was to improve Range of Motion (ROM) to "Left knee to 0 degrees extension and Left ankle to 0 degrees dorsiflexion." It directed staff to provide "dyna-splinting to Left knee, Left ankle, restorative nursing program, PT (physical therapy weekly check." A Physical Therapy Discharge Summary dated 7/6/11 documented the resident was tolerating the dynamic splint to his left ankle and left knee, but unable to advance the tension of the brace. The PT's discharge recommendations were for the restorative nursing program aide for the left lower extremity brace, and that restorative aide staff were trained. A Occupational Therapy Discharge Summary dated 7/19/11 documented the resident was tolerating the splints with no pain or skin breakdown and the discharge recommendations was for a restorative nursing program aide to provide a splint program with application of the splint and care. There was no evidence in the chart that the resident had received restorative nursing services with applications of the splints as recommended by the Occupational Therapist (OT) or PT. On 8/29/12, 13 months after the recommendations of dynamic splinting to the resident's contractures on his left side, a physician's telephone order documented for "OT to eval (evaluate) for proper splint to Left hand 2 (secondary to) contractures." On 9/7/12, a physician telephone order documented "OT to eval and tx (treat) for restorative program 2(secondary) contracted hand." On 9/11/12, a physician's telephone order documented "OT to eval and tx for restorative." On 9/14/12, an Occupational Therapy Evaluation documented the "Left upper extremity increased tone, elbow flexion at 90 degrees-80 degrees, wrist -35-30 degrees extension." It did not address the resident's fingers, or left knee. On 9/21/12, The Occupational Therapy Discharge Summary documented the resident was to have a restorative nursing program that provided Passive Range of Motion (PROM) to the resident's left upper extremity. It directed the restorative staff to " initiate left arm PROM stretches as instructed to prevent contractures." It did not address the resident's contracted hand as directed by the physician. There was no recommendation for the resident's contracted wrist which worsened as per the OT's assessment. On 10/2/2012, at 4:00 p.m., Resident # 61 was observed in his wheel chair with a contracted wrist (bent toward the ground), contracted fingers that were bent in toward the palm of his hand. Resident # 61 stated he had pain in his hand, and thought his rough fingernail touching his palm was causing his pain. At approximately 10:00 a.m., a nurse had trimmed that fingernail, yet the resident still complained of pain in his hand. At approximately 11:00 a.m., Resident Care Manager (RCM) B, came to assess the resident's left hand. As she gently pulled back the resident's contracted fingers the resident grimaced and cried out "Ouch!" On 10/4/12, approximately at 2:00 p.m., RCM B stated she was not sure what had happened since she wrote the 8/29/12, for the OT evaluation of the resident for a proper splint to his left hand. RCM B directed the surveyor to speak to the Restorative Aide (RA) A. RA A stated that PROM for Resident #61's left hand had just recently been initiated. There was no documentation of other restorative nursing interventions from 4/2011 until 10/2012. There was no assessment as to why the resident's wrist contracture had worsened. On 10/5/12, the Certified Occupational Therapy Assistant (COTA) A stated he had not worked with Resident #61 for several months, but several months ago he had successfully increased the resident's ROM in his elbow. He now "heard that the elbow was now more contracted." When the surveyor asked about Resident #61's contracted hand and digits, COTA A stated that the strategy was to not work on the resident's wrist and hand until his shoulder and elbow ROM had improved. On 10/8/12 at 10:51 a.m., Resident #61 stated he loved the dyna-splint, and wished he could have it back. The resident believed his knee contracture was worse than previous, and more painful, and his wrist and finger contractures remained at the same level of pain as previous. At 11:03 a.m., the therapy director (TD), stated therapies staff make recommendation for all the restorative nursing programs, and the restorative staff initiate the recommendations exactly. Therapies will verbally check on each resident's progress, but it's up to RNA to report any progress or decline. At 11:14 a.m., the Restorative Nurse Manager (RNM) stated that therapies did write all the restorative nursing programs and "they just institute it." The RNM stated there is no baseline nursing assessment done prior to the start of the restorative program. There were weekly notes on what the residents are doing during the program, but the restorative nursing programs do not have resident specific, clearly defined individualized goals. She stated progression or lack of progression toward goals was not documented. The RNM stated Resident #61's contracted left knee was not being addressed or receiving interventions. The facility failed to provide interventions and periodic reassessment of the resident's known contractures or new interventions to prevent worsening of his contractures. .

Based on interview and record review the facility failed to establish and implement a system for identifying new residents to the facility and correctly verifying residents prior to administering medication. This failure resulted in harm to 1 of 19 Sampled Residents (#1), due to the resident being hospitalized for [REDACTED]. The facility failed to follow the recommended guidelines for administration of a hormone replacement medication for 1 of 3 Sampled Residents (#7). This failure resulted in potential for sub-therapeutic dose of medication and exacerbation of symptoms associated with low hormone. Findings include: RESIDENT #1 Resident #1 was [AGE] years old diagnosed with [REDACTED]. Interview with Staff E on 03/12/12 at 5:00 p.m. revealed on 03/01/12 at 7:00 a.m. Staff E entered room [ROOM NUMBER] to give medications to Resident #24. The room door was only labeled with Resident #24's name. There was no picture in the MAR (medication administration record) to refer to, the residents were not wearing arm bands and there was only one person in the room. Staff E asked the resident if she was (Resident #24) and the resident said yes. The resident's blood pressure and blood glucose was assessed then the resident was administered the prescribed medication for Resident #24. Staff E then entered the room next door. As she passed room [ROOM NUMBER] she noticed there were two residents in the room. She approached the other resident and asked who she was. The resident stated she was (Resident #24). Staff E realized she gave the medication to the wrong resident; Resident #1 received the medication instead of Resident #24. Record review of hospital records revealed Resident #1 was admitted to the hospital on [DATE] for [MEDICAL CONDITION](low blood pressure) and [DIAGNOSES REDACTED] (low blood sugar) secondary to inadvertent administration of multiple antihypertensive medications. Resident #1's blood pressure was 78/45 mm/hg and her blood glucose was 81 mg/dl when she arrived at the hospital. Interview with Staff B on 03/14/12 at 3:30 p.m. revealed the facility implemented numerous interventions to ensure staff had more than one method of identifying residents to prevent medication error. Staff B said the measures were implemented on 03/01/12 when the facility found the medication error occurred due to inability to accurately identify Resident #24. Facility policy for medication administration dated 08/31/11 directed staff to use two identifiers such as name band, patient pronouncing name or picture. Interview with Resident #1 on 03/14/12 at 3:15 a.m. revealed no recollection of the incident. Record review revealed on 03/01/12 at approximately 7:00 a.m. Resident #1 received medications intended for Resident #24. Staff E was unable to verify the right resident due to no pictures in the MAR (medication administration record), no name bands on the resident and no names posted at the resident's room. The nurse asked Resident #1 if she was (Resident #24) and the resident stated yes. Staff E gave eleven (11) medications that included an antidiabetic, blood pressure lowering agents, thryroid hormone, antacid, [MEDICAL CONDITION], and antiincontinence agent. When Resident #24 returned to the room at approximately 7:40 a.m. Staff E realized the medication error. The facility, physician and family were notified and the resident was monitored for adverse effects to the medication. Resident #1 became "clammy and lethargic" with blood pressure reading of 70/42, the resident was non-responsive and ultimately sent to the resident was sent to the hospital where she remained until the following day. RESIDENT #7 Interview with Staff F on 03/12/12 at 12:45 p.m. revealed Resident #7 usually received her medications thirty minutes after she awakened. Staff F indicated all the resident's a.m. medications were given at that time. Record review revealed all resident's medications including the [MEDICAL CONDITION] hormone were scheduled to be given at "a.m., noon or p.m." Interview with pharmacist from Pharmerica (pharmacy contracted with the facility) on 03/14/12 at 11:40 a.m. revealed the [MEDICAL CONDITION] hormone should be given by itself and on an empty stomach particularly the morning dose of medication. Interview with Resident #7 on 03/14/12 at 3:15 p.m. revealed prior to coming to the facility she always received the [MEDICAL CONDITION] hormone by itself either in the morning or the evening. Review of medication revealed potential side effects associated with sub-therapeutic levels of [MEDICAL CONDITION] hormone include slow speech; lack of energy; weight gain; hair loss; dry, thick skin; and increased sensitivity to cold. Resident #7 was prescribed a [MEDICAL CONDITION] hormone. The [MEDICAL CONDITION] hormone was recommended to be given on an empty stomach to prevent interference with absorption. The medication was necessary to maintain a therapeutic level of the hormone. .

Based on observation interview and record review the facility failed to provide care and services to prevent the development of pressure ulcers for 1 of 7 Sampled Residents (#2). This failure resulted in harm due to resident admitted to the facility with intact skin and developed numerous, avoidable, pressure ulcers. Findings include: Stage I: Intact skin with non-blanchable (lack of redness when pressed) skin of a localized area usually over a bony prominence. Stage II: Partial thickness loss of dermis (vascular inner layer of the skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (no-viable tissue). May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous (beneath the skin) fat may be visible but bone, tendon or muscles are not exposed. Slough (non-viable tissue) may be present but does not obscure the depth of tissue loss. May include undermining (tissue destruction to underlying intact skin along wound margins) and tunneling (narrow open or tract usually associated with infection that may extend in any direction leaving dead space). Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue usually black) may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown non-viable tissue) and/or eschar (tan, brown or black leathery no-viable tissue) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Pressure Ulcers may be caused by many factors including unrelieved pressure, friction, humidity, shearing forces, temperature, continence, pressure to any part of the body especially portions over the bony areas such as sacrum, elbows ankles, heels etc. Pressure ulcers are preventable and treatable if found early, but can be fatal. Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Patient Nursing Assessment completed by facility on 12/20/11 indicated the resident was alert and oriented, required staff assistance with mechanical lift and was continent of bowel and bladder. Interview with Interested Party on 03/09/12 at 9:40 a.m. revealed Resident #2 admitted to the hospital with [REDACTED]. Interview with Family Member on 03/12/12 at 12:15 p.m. revealed the skin of Resident #2 was intact upon admission to the facility. The Family Member reported the resident admitted to the facility on [DATE] for rehabilitation after hip surgery. The Family Member said after the resident developed a pressure ulcer on his heel the facility provided "airboots" for the resident to relieve pressure; meanwhile Resident #2 spent more time in bed and developed three more pressure ulcers. The family member said Resident #2 complained to her about the delay in call light response, sometimes taking hours. The family member reported waiting for up to two hours for the call light to be answered while in the room with Resident #2. During interview on 03/12/12 at 3:40 p.m. Staff G revealed the resident developed the pressure ulcers while in the facility. Staff G was unable to say what caused the pressure ulcers but stated when she took over the care for the resident the pressure ulcers were already in place. Staff G said she debrided (removed the dead/non-viable tissue) the two open areas on the coccyx of Resident #2. The eschar remained on the right heel. Record review revealed Resident #2's skin assessment on 12/20/11 indicated the resident had scattered bruising to the upper extremities and buttocks with blanchable redness. The follow-up skin assessments on 12/21/11 and 12/22/11 indicated no additional skin impairments. Record review revealed on 12/29/11 the physical therapist reported the resident had a pressure area to right heel. Upon assessment the nurse found the resident with unstagable, purple area on right heel measuring 1 x 1.5 cm. The progress note dated 01/09/12 indicated the resident's right heel had a fluid-filled blister. Review of Weekly Pressure Ulcer BWAT (Bates-Jenson wound assessment tool) Report revealed on 01/16/12 the pressure ulcer on the right heel measured 2 x 1 cm and determined to be a Stage II. No non-viable tissue was visible but the wound had serosanguinous (thin, watery, pale, pink/red) drainage. On 02/15/12 the wound measured 5 x 4 cm covered with eschar. Record review revealed Resident #2 was found with two pressure ulcers on 01/16/12; one pressure ulcer on each side of the coccygeal area. Review of Weekly Pressure Ulcer BWAT Report revealed on 01/16/12 the pressure ulcer on the left coccygeal of Resident #2 measured 3 x 1.5 cm and was determined to be Stage II. On 02/15/12 the wound increased to Stage III and measured 4 x 2 cm with undermining of less than 2 cm. Review of Weekly Pressure Ulcer BWAT Report revealed on 01/16/12 the pressure ulcer on the right coccygeal of Resident #2 measured 0.8 cm x 1 cm and was determined to be a Stage II without dead/non-viable tissue. On 02/15/12 the wound remained a Stage II and increased in size to 1 x 1 cm with slough. On 01/30/12 Resident #2 was found with blisters on right calf area. The open blister measured 3.2 x 1.5 cm and the intact blister measured 5 x 1 cm. Record review revealed on 02/10/12 a pressure relieving mattress and referral to the wound clinic was ordered. Resident #2 entered facility after surgery with intact skin (with exception of surgical wound). Less than two months later the resident presented with numerous open areas form his buttocks to his heels. Pressure relieving devices were not implemented until after pressure ulcers developed. .

Based on interview and record review the facility failed to implement measures to prevent constipation for 1 of 15 Sampled Residents (#1). This failure resulted in harm due to hospitalization for fecal impaction and placed the resident at risk for complications such as bowel obstruction. Findings include: Interview with Family Member on 02/21/12 at 10:45 a.m. revealed Resident #1 was hosptalized on [DATE] with a fecal impaction. The resident was discharged back to the facility on [DATE]. On 02/05/12 Resident #1 returned to the hospital with another fecal impaction. Record review of hospital records of Resident #1 dated 12/28/11 revealed "fecal impaction with severe constipation due to narcotic medication use." Record review of hospital records dated 02/05/12 indicated Resident #1 presented with fecal impaction requiring digital disimpaction while in the ER (emergency room ). CT (computed tomography) of the abdomen conducted in the ER revealed "marked stool in colon". The resident was started on bowel medications and monitored for small bowel obstruction. Hospital records dated 02/05/12 revealed the resident "vomited yellow green emesis" while in the ER. An NG ([MEDICAL CONDITION]) tube was placed on low intermittent suction. The hospital records indicated the facility reported the resident was vomiting but there was no documentation in the facility records regarding emesis or nausea. Interview with Staff C on 02/22/12 at 2:40 p.m. revealed the system currently in place for monitoring BMs (bowel movement) required the nursing assistant to document BM size on the flow sheets. The night shift nurse reviewed the flow sheets and prepared a list for the day shift nurse to initiate the bowel protocol. Residents with three documented days with no BM or less than a medium BM (small BMs do not count) received milk of magnesia. If the milk of magnesia was not effective the resident received a suppository on day four. If the suppository was not effective the resident received an enema on day five. If the enema was not effective then the physician was notified. Record review of Flow Sheet Record for Resident #1 revealed the resident did not have a medium or larger BM from 01/14/12 to 02/05/12. Record review of the resident's MAR indicated [REDACTED]. The milk of magnesia was not effective in stimulating a bowel movement. No other intervention was implemented. During interview with Staff C on 02/22/12 at 2:40 p.m. revealed inability to recall details of Resident #1 but admitted the resident should have received interventions for lack of bowel movement, and confirmed the records indicated the resident did not have a medium or larger BM for 22 days and there was no evidence of interventions to stimulate a bowel movement. Record review of MDS (minimum data set/ an assessment) for Resident #1 dated 02/05/12 indicated the resident was bowel incontinent and required extensive assistance with ADLs to include toileting. The MDS also indicated the resident had memory problems and was rarely understood and was unable to make self understood. .

Based on interview and record review the facility failed to assess and treat compromised skin integrity to heels of 1 of 6 Sampled Residents (#1) during daily foot treatment. This failure resulted in harm for Resident #1 who admitted to the hospital with [REDACTED]. A pressure ulcer is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue and usually occurs over boney prominences. The severity of pressure ulcers is described by stages as follows: Stage I: A persistent area of skin redness (without an opening in the integrity of the skin) that does not disappear when pressure is relieved and may appear with persistent red, blue or purple hues. Stage II: A partial thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater. Stage III: A full thickness loss involving damage to, or necrosis (dead, non-viable tissue) of, subcutaneous tissue that may extend down to but not through underlying fascia (tissue binding muscles and organs). The pressure sore presents as a deep crater with or without undermining (separation of the skin from the wound) of adjacent tissue. Stage IV: A full thickness loss of skin with extensive destruction, tissue necrosis and underlying tissue or damage to muscle, bone or supporting structure (i.e. tendon). Findings include: Interview with Family Member on 10/10/11 at 10:40 a.m. revealed Resident #1 resided in the facility from [DATE] until 09/06/11. The resident transferred from the facility to an AFH (Adult Family Home). The day after the resident was admitted to the AFH the staff from the AFH notified the family member of an area on the resident's foot that appeared infected and requested the family member take the resident to the ER (emergency room ). Upon arriving at the ER the physician said the resident's foot was infected and ordered antibiotics. The family member indicated the resident was only at the AFH overnight and upon leaving the facility no one from the facility indicated the resident had a wound on his foot. Hospital records revealed Resident #1 presented to the ER (emergency room ) on 09/07/11 with pressure ulcers on the left and right heels and sacral area. The left heel pressure ulcer was determined to be infected. The resident received an order for [REDACTED]. Facility TAR (Treatment Administration Record) for Resident #1 revealed an order to apply lotion to the resident's feet daily. Review of the TAR for September 2011 revealed an order dated 05/23/11 instructed staff to apply lotion to the resident's feet daily. The TAR indicated the treatment was done 1-4 September and 6 September (the day of discharge). The TAR did not contain any documentation indicating the skin on the resident's heels was compromised. The Resident was scheduled for weekly skin checks on the TAR. The TAR instructed staff to use a positive or negative sign to document results of the skin check and document any abnormal findings in addition to notifying the physician. The last skin check was on 09/02/11, four days before the resident was discharged from the facility. The TAR contained initials indicating the skin check was completed but lacked an indication of the results of the skin check. No documentation was found indicating negative skin check although the TAR indicated the resident presented with a pressure ulcer on the coccyx. Interview with Staff A on 10/10/11 at 4:45 p.m. revealed skin sheets are updated by the care managers. However; the nurse responsible for the resident's medications and treatments completed the skin assessments and documented abnormal findings in the resident's chart. Record review revealed Resident #1 entered the facility on 10/28/10 the resident presented with Stage IV pressure sores on both of his heels and on his coccyx. TAR (treatment record) indicated the resident's pressure sore on his heels resolved in 05/11. No further monitoring was implemented on the heels after the wounds were determined to be resolved to include monitoring although the skin on the heels was fragile after resolution of pressure ulcers. Resident #1's care plan directed staff to monitor for signs and symptoms of infection, assess for pain, encourage frequent repositioning, turn and reposition as needed, heels offloaded when in bed, foam dressing to coccyx and turn side to side. The same care plan indicated the left heel wound was resolved, however the only area documented as having a "history of healed pressure ulcer" was the coccyx, there was no mention of the left or right heel. Interview with Staff B on 10/10/11 at 5:05 p.m. revealed Resident #1 was assigned to Staff C therefore Staff B was unable to provide any information about Resident #1. However; Staff C reported the resident was assigned to Staff B and was unable to provide information about Resident #1. Interview with the resident's physician on 10/10/11 at 5:15 p.m. revealed he did not remember if the staff reported if the resident's skin integrity was compromised when the resident was in the facility.