Every finding on record at The Oaks at Timberline

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (Resident 34) reviewed for insulin (an injectable medication used to treat diabetes mellitus, a group of disorders characterized by an inability of the body to regulate its blood sugar levels). This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included. Resident 34 was admitted to the facility on [DATE] with multiple diagnoses to include Diabetes Mellitus. The Medicare - 5 Day Minimum Data Set, an assessment tool, dated 12/28/2025, showed resident 34 was cognitively intact, had a diagnosis of Diabetes Mellitus, and was on insulin injections. Record review of Resident 34's physician orders, dated 11/20/2025, documented, LN [licensed nurse] to perform Diabetic Nail Care. Record review of Resident 34's physician orders, dated 12/30/2025 showed an order for Insulin Glargine (an injectable medication for diabetes) daily at bedtime. Record review of Resident 34's Comprehensive Care Plan, date initiated 11/20/2025, did not show a Focus area or Goal for Diabetes and/or insulin use. Record review of Resident 34's Kardex (a nursing documentation system used to provide a quick summary of patient care needs), dated 03/03/2026, did not show Resident 34 was diabetic and/or LNs were to perform Diabetic Nail Care. In an interview on 03/03/2026 at 9:08 AM, Resident 34 said he had diabetes and was on insulin. In an interview on 03/03/2026 at 12:36 PM, Staff F, Certified Nursing Assistant, said they got information on care needs for residents, such as nail care or if they were diabetic, from the Kardex. In an interview on 03/03/2026 at 12:53 PM, Staff B, Director of Nursing/Registered Nurse, said information in the Kardex was triggered from the care plan. When asked about Resident 34's care plan, Staff B said she did not see a care plan for diabetes and there should have been. Reference WAC 388-97-1020(1)(2)(a)

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention, to include the use of gloves and a gown, during high contact care activities designed to reduce the transmission of organisms) when providing wound care for 1 of 2 sampled residents (Resident 1) reviewed for Pressure Ulcer (an injury or open wound to the skin and underlying soft tissue). This failure placed residents and staff at risk for the spread of infection transmission, and a decreased quality of life.Findings included. Resident 1 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 12/11/2025, documented Resident 1 was moderately cognitively impaired and was at risk for pressure ulcers. Record review of Resident 1's physician orders, dated 02/11/2026, showed an order, Stage 3 [a skin injury extending through all layers of the skin into the fat tissue] PU/I [pressure ulcer/injury], to mid back over bony prominence: Wound Cleansing: wound cleanser (NS [normal saline] if not available) Periwound [the skin and tissue immediately surrounding a wound] Treatment: skin prep Primary Treatment: collagen powder or sheet and calcium alginate Secondary Dressing: bordered foam Change: Daily PRN [as needed] every day shift. Record review of Resident 1's skin care plan, revised 02/25/2026, documented, Has actual impairment to skin integrity r/t [related to] -Stage 3 PU/I to mid back over bony prominence. Record review of Resident 1's Skin/Wound Note, dated 03/03/2026, documented, .Moderate amount of serosanguineous [a watery pale pink or light red fluid excreted from healing wounds] drainage.Daily Tx [treatment] in place. Review of Resident 1's Electronic Health Record did not show a physician's order or care plan for EBP. In an interview and observation on 03/04/2026 at 9:24 AM, Staff E, Wound Nurse/Licensed Practical Nurse (LPN), said Resident 1 had a Stage 3 PU to his mid back that had a scant amount of drainage. No EBP sign was observed to be posted outside Resident 1's door entrance. Staff E and Staff D, Resident Care Manager/LPN, were observed to enter Resident 1's room and performed wound care to the PU on Resident 1's back. Staff E and Staff D did not don (put on) a gown to perform wound care. When asked how it was determined if a resident was placed on EBP, Staff E looked at the entrance to Resident 1's room and said he did not have a sign up to indicate he was on EBP. Staff E said an EBP sign was posted at the door for residents when she needed to put a gown on to do wound care. Staff E then said to Staff D that Resident 1 did not have a sign for EBP. Staff D stated, Yes, I will need to get one, I need to talk to [Staff C, Infection Preventionist/LPN]. In an interview on 03/04/2026 at 1:43 PM, Staff C said if a resident had excessive wound care or had wound dressings saturated with drainage, they were placed on EBP with a sign outside their door. Staff C said she would get a physician's order for residents on EBP and add it to their care plan. Staff C said she thought if a wound was contained with drainage not soaking through a bandage, they did not need to be on EBP. Staff C said she just learned that pressure related wounds needed to be on EBP and said Resident 1 should have been on EBP. In an interview on 03/04/2026 at 3:11 PM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation residents with open pressure wounds were on EBP. Reference WAC 388-97-1320 (1)(a)(2)(b)

Based on observation, interview, and record review, the facility failed to ensure medications were administered by professional standards of practice for 1 of 1 sampled resident (Resident 37) reviewed for medication administration. This failure placed residents at risk for medication errors, negative outcomes, and a diminished quality of life.Findings included.Review of the facility's policy titled, Self Administration of Medications, dated May 2016, showed, Purpose: To determine the ability of alert resident to participate in self-administration of medications. To Maintain the safety and accuracy of medication administration .Procedure:7. Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for medication storage. 9. Appropriate notation of these determinations will be placed in the residents [sic] care plan.Resident 37 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 02/07/2026, indicated Resident 37 was alert and oriented. During an observation and interview on 03/02/2026 at 11:01 AM, while in Resident 37's room, a small clear cup with several pills visible in it was sitting on top of the bedside table. Resident 37 said the nurse left them there and had gone to get some water. Resident 37 proceeded to swallow the medication without the nurse present.Record review of Resident 37's electronic health record did not show Resident 37 was approved to keep medication in the room and/or take medication without nursing supervision.During an interview on 03/05/2026 at 9:14 AM, Staff G, Licensed Practical Nurse, said nursing was supposed to stay and observe a resident take their medication. Staff G said Resident 37 mentioned to him the state surveyor had seen the medication in the room. During an interview on 03/05/2026 at 9:59 AM, Staff B, Director of Nursing/Registered Nurse, said staff were not to leave medication in a resident's room and was supposed to monitor the resident taking the medication. Staff B said a resident needed to be assessed, have an order, and care planned before a resident was able to self-administer medications. Reference WAC 388-97-1300 (1)(b)(i)(ii), (3)(a)

Based on observation and interview, the facility failed to ensure food items were labeled and had when opened dates in 1 of 1 kitchen walk-in refrigerators reviewed for food storage in a sanitary manner. This failure placed residents at risk for cross-contamination, food borne illness, and a diminished quality of life. Findings included . On [DATE] at 10:21 AM, the kitchen walk-in refrigerator was observed with the following expired, undated, and unlabeled opened items: 1. Jar of Maraschino Cherries- labeled with use by date of [DATE] 2. Jar of Peeled Garlic- labeled with use by date of [DATE] 3. Jar of Worcestershire Sauce- labeled with use by date of [DATE] 4. Jar of Raspberry Vinaigrette Dressing- not labeled or dated 5. Bag of shredded [NAME] Cheddar Cheese- not labeled or dated On [DATE] at 10:29 AM, Staff F, Dietary Supervisor, said the facility had a three day policy for opened items, and use-by-date for unopened items. Staff F was observed throwing away the identified items, and stated, These should not be there. On [DATE] at 11:10 AM, Staff A, Administrator, said she expected food items in the refrigerators and freezers to be dated and labeled per facility practice. Reference WAC [DATE] (3) & -2980

Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including nail care for 1 of 2 sampled residents (25) reviewed for ADLs. This failure placed residents at risk of not receiving the care and services needed for which they cannot perform themselves and a diminished quality of life. Findings included . Resident 25 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 12/04/2024, indicated Resident 25 was alert and oriented, and needed substantial/maximal assistance with shower/bathe and needed supervision or touching assistance with personal hygiene. The nail care, care plan for Resident 25, dated 06/23/2022, noted avoid scratching and keep hands and body from excessive moisture. Keep fingernails short. The Tub/Shower task documented Resident 25's had a shower on 01/14/2025 and on 01/18/2025. On 01/21/2025 at 11:05 AM, Resident 25 was observed with fingernails that appeared to be about 1/3 of an inch long. Resident 25 said he liked his fingernails short. On 01/23/2025 at 9:09 AM, Resident 25 said his last shower was on 01/18/2025. The resident's fingernails were observed to be about 1/3 of an inch long. At 2:33 PM, Staff K, Staffing Coordinator and Certified Nursing Assistant Supervisor, said resident showers included nail care. Staff K said Resident 25's Kardex (nurse assistants' reference for patient information) indicated to keep fingernails short. At 2:43 PM, Staff L, Resident Care Manager and Licensed Practical Nurse, said nail care was a part of resident showers. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure the recommendations of the Level II Preadmission Screen and Resident Review (PASARR) were implemented upon receiving recommendations for 2 of 8 sampled residents (55 & 38) reviewed for coordination of PASARR and assessments. This failure placed residents at risk of not receiving the necessary mental health services and a diminished quality of life. Findings included . 1) Resident 55 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Post-Traumatic Stress Disorder, and Suicide Attempt. The Admission/Medicare 5-day Minimum Data Set (MDS) assessment, dated 11/30/2024, indicated Resident 55 was alert and oriented. Review of Resident 55's Level I PASARR, dated 11/24/2024, showed, Level II evaluation referral required for SMI [serious mental illness]. Review of Resident 55's Level II PASARR, dated 11/25/2024, documented: Recommendations for Plan of Care . B. Recommendations for Nursing Facility 1. Environment Encourage him to focus on his goals for the future, purposeful activities, and DC plans. 2. Staff approaches/training [Resident 55] reported being irritated when others assist him. Encourage him to complete tasks on his own when he is able and avoid doing things for him that he can do on his own. Provide support and reassurance when assistance is needed. 3. Behavioral supports Monitor for symptoms of depression and anxiety as evidenced by social withdrawal, agitation, anger, negative statements, irritability, and overall mood presentation. Document changes when observed and update care plans as needed. 4. Activities Encourage daily activities for mental stimulation and improved emotional well-being. 5. Other [Resident 55] has a history of suicidal ideation when frustrated or overwhelmed. Listen and validate his concerns without being dismissive before providing support or reassurance. Avoid multitasking or rushing to reduce risk of frustration when completing tasks. Contact emergency services if he appears at increased risk of self-harm, as evidenced by increased statements of hopelessness. Review of Resident 55's Level II PASARR care plan, initiated 12/26/2024, 31 days after admission, did not show Interventions/Tasks related to numbers 2, 4, and 5 referenced above as Recommended for Plan of Care on the Level II PASARR. Review of Resident 55's Impaired Cognitive Function/Thought Processes care plan, dated 11/25/2024, showed Interventions/Tasks including PASARR Level II Recommendations as initiated on 01/21/2025, 57 days after admission. On 01/24/2025 at 11:11 AM, Staff C, Regional Patient Advocacy Resource, said a resident should be seen at the hospital for the Level II PASARR evaluation, if identified as required, prior to admission. Staff C said the recommendations for the facility would then be incorporated into the care plan from the Level II PASARR evaluation. When asked how soon the recommendations are incorporated into the care plan, Staff C said it depended on when they received the summary for the Level II PASARR. When asked about when the Level II PASARR was received for Resident 55, Staff C said she did not know, and stated, Let me check on that. When asked if Resident 55's care plan recommendations for the Level II PASARR were not added until 01/21/2025, Staff C nodded her head, indicating yes. At 11:26 AM, Staff C said the facility received Resident 55's Level II PASARR evaluation and recommendations on 12/20/2024 and were not completed in the care plan until 01/21/2025. Staff C stated, It should have been incorporated sooner than that. I agree with that, yes . It should be as soon as possible. On 01/27/2025 at 10:45 AM, Staff A, Administrator, said they received Level II PASARR recommendations for Resident 55 on 12/20/2024. Staff A nodded her head, indicating yes; and indicated they should have been implemented into the care plan prior to 01/21/2025. 50416 2) Resident 38 was admitted to the facility on [DATE] with diagnoses including Depression and Anxiety Disorder. The Quarterly MDS assessment, dated 08/05/2024, indicated Resident 38 was moderately cognitively impaired. Review of Resident 38's Level II PASARR evaluation, dated 06/11/2024, and reviewed by Psychiatrist on 07/25/2024 and 07/27/2024, documented: Recommendations for Plan of Care . B. Recommendations for Nursing Facility 1. Environment [Resident 38] reported a history of night terrors. Encourage her to avoid watching television prior to bedtime. Provide support and reassure her that she is safe if she wakes from a nightmare. Quickly ask her to think about her current environment, including sights, smells, and textures. 2. Staff approaches/training [Resident 38] reported increased anxiety or depression when other people are angry or aggressive. Attempt to assign her to a room that is not near the entrance or nursing station to reduce risk of loud noise. Speak calmly to her when communication with her. 3. Behavioral supports Monitor for symptoms of depression and anxiety as evidenced by social withdrawal, agitation, disinterest in activities, tearfulness, changes in sleep, and overall presentation. Document changes when observed and update care plans as needed. Provide female staff for personal care. Male caregiver should identify themselves prior to entering the room and should not attempt to provide personal care. 4. Activities Encourage daily activities for mental stimulation and improved emotional well-being. 5. Other Provide female staff for personal care. Male caregiver should identify themselves prior to entering the room and should not attempt to provide personal care. Review of Resident 38's care plan showed PASARR Level II Recommendations were initiated 01/20/2025, seven months after Level II PASARR evaluation was completed. On 01/23/2025 at 11:36 AM, when asked what the facility's process was for following up on Level II PASARR evaluations, Staff C said the facility did monthly follow ups. Staff C said the evaluation was completed in 07/2024 and was updated to the care plan on 01/20/2025. Staff C said Social Services was responsible for updating Level II PASARR recommendations into Resident 38's care plan. Reference WAC 388-97-1975 (10)

Based on interview and record review, the facility failed to provide care and services according to professional standards of practice when insulin was not held as per physician orders for 1 of 5 sampled residents (54) reviewed for care provided meeting professional standards. This placed the residents at risk for medical complications and a diminished quality of life. Findings included . Resident 54 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (a chronic condition that affects how the body uses sugar (glucose) for energy). Review of Resident's 54's record showed a physician order, dated 12/05/2024, for Insulin Lispro Injection Solution (Insulin Lispro) Inject 2 unit subcutaneously with meals related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (E11.9) HOLD for CBG (Capillary Blood Glucose-blood sugar) < (Less than) 100. Review of Resident 54's January 2025 blood glucose summary documented CBG level of 91.0 mg/dL (milligrams per deciliter) on 01/07/2025 at 8:10 AM and 90mg/dl on 01/14/2025 at 1:25 PM. Review of Resident 54's January 2025 Medication Administration Record (MAR) documented Insulin Lispro Injection Solution was administered to Resident 54 on 01/07/2025 morning and 01/14/2025 afternoon. On 01/23/2025 at 11:26 AM, Staff D, Resident Care Manager and Licensed Practical Nurse, said the expectation was if Resident 54's CBG was less than 100mg/dL, the medication would have been held per the physician's order. After reviewing Resident 54's January 2025 MAR, Staff D said the MAR showed Lispro Injection Solution had been administered on 01/07/2025 morning and 01/14/2025 afternoon. Reference WAC 388-97-1620 (2)(b)(i)(ii) .

Based on interview and record review, the facility failed to ensure residents were treated with respect and dignity to enhance their quality of life when a resident called out for help and a licensed nurse told the resident they could not help for 1 of 2 sampled residents (38) reviewed for resident rights. This failure placed residents at risk of not meeting their highest practical psychosocial well being, unmet care needs, and a diminished quality of life. Findings included . Resident 38 was admitted to the facility on [DATE] with diagnoses including depression and anxiety. The Quarterly Minimum Data Set assessment, dated 08/05/2024, indicated Resident 38 was moderately cognitively impaired. The care plan interventions/task, dated 09/06/2024, documented, [Resident 38] has increased anxiety when other people are angry or aggressive. Staff to speak calmly to her when communicating with her. Resident 38's care plan, dated 09/06/2024 and revised 01/08/2025, documented, Focus:[Resident 38] is at risk for depression/low mood r/t [related to] diagnosis of Depression. Review of Resident 38's progress notes, dated 01/18/2025 at 1:55 PM, documented Resident on alert r/t [related to] psychological distress. Resident displayed mild distress first thing this morning when I went in to see her to check blood sugar. She asked what I was doing here, and I told her I worked here. She seemed a little upset and requested to check her own blood sugar and I let her. I also explained to her that I wanted to get her pain meds on board before her shower. I went back in to talk with her about being upset and asking why I was here. She spoke with me a little bit. Then I went about the morning routine as usual and she was pleasant and cooperative with me the rest of my shift without any issue. A progress note, dated 01/19/2025 at 2:54 PM, documented LN [License Nurse] followed up with resident. She states that she is feeling much better today. Resident states that she received the care that she needed and denies any harm. However, she prefers to not have specific nurse [Staff G, Licensed Practical Nurse-LPN] tend to her. LN asked resident if she feels safe. Resident states that she feels safe and enjoys the nurse on shift today, and is not in any distress at this time. Care plan reviewed and updated. On 01/21/2025 at 11:40 AM, Resident 38 said she had an incident with a nurse (Staff G, LPN), approximately a week ago. Resident 38 said she almost fell out of her bed and yelled out for help. Resident 38 said Staff G responded to Resident 38's call for help saying she was giving out medication. Resident 38 said Staff H, Certified Nursing Assistant (CNA), came into her room to help her and then another CNA (Staff J, CNA) came into the room to assist. On 01/24/2025 at 11:07 AM, Resident 38 stated, I lost my balance trying to sit up on the side of the bed. I just know that I said help help, I am falling. I have fallen many times before, but I have never called out that frantic before. I didn't know what else to do. I know I was going to land on the floor. Resident 38 stated, It made me feel like crap. I am already planning on stopping dialysis and slowly die. Having that happen made me feel like its okay for me to leave. I didn't feel like that before. Resident 38 said Staff G was in another section in the building the next day. When asked how Resident 38 knew Staff G was in another section of the building, Resident 38 stated, I asked one of the CNAs and they told me she was on another cart. In my mind I was nervous that she was going to be here that day. Resident 38 stated, After that incident, [Staff G] worked with me. I didn't like that she was here. It was uncomfortable. [Staff G] came in the room and asked is there was a problem that she should know about. I asked why are you here. I asked if you had a patient in distress would you help, and [Staff G] said she would. I didn't like the way I was feeling and I just stopped. Resident 38 stated, I told [Staff I, Infection Preventionist and Staff Development Coordinator] about what I had said to [Staff G]. I told [Staff I] if I was not able to get out of bed, if the building was burning, I don't think she [Staff G] would help. I told [Staff I] I don't feel comfortable with her [Staff G's] care. [Staff G] could have put the medication in a basket and come in to help [when Resident 38 was falling and called out for help]. At 3:04 PM, Staff I said on 01/16/2025, Staff H reported a concern saying she was not sure how to address it. Staff H told Staff I she heard Resident 38 yelling for help and Staff G yelled at Resident 38 that she could not help. Staff I stated, [Staff H and I] said that was abuse and needed to report it to [Staff A, Administrator]. Staff I said it was the expectation that Staff G should have locked the medication she had in the cart and went to assist Resident 38. On 01/27/2025 at 10:20 AM, Staff A said she was immediately made aware of the incident that occurred on 01/16/2025 in relation to Resident 38's interaction with Staff G. Staff A stated, The investigation completed was unsubstantiated. Staff A said Staff G had narcotics on the cart and called Staff H to assist Resident 38. At 10:49 AM, Staff H stated, On the 16th [01/16/2025] around 1:00 PM we were doing lunch. I pushed the cart down the hallway. I grabbed one tray and heard the nurse screaming a little bit. She had yelled a little bit. [The nurse] said I am busy. I have meds right now. My [Staff H's] plan was to deliver the tray I had. Then I heard another yell, and they [the person yelling] had yelled help me please two or three times. I walked into the room [room [ROOM NUMBER]] and Resident 38 was tangled in her oxygen tubing and a little bit frantic. The resident said I don't feel safe here with this nurse [Staff G]. I [Staff H] immediately went to report to a manger. When asked if Staff G had asked Staff H to go into Resident 38's room and assist her, Staff H stated, The nurse [Staff G] did not ask me to come and help the resident [Resident 38]. At 12:11 PM, Staff J stated, I heard the nurse [Staff G] say to Resident 38, I can't come. I have narcotics out. [Staff G] asked me to assist Resident 38. I went into room [ROOM NUMBER] and saw [Staff H] trying to assist Resident 38 get untangled. Staff J said she did not recall seeing Staff H going into Resident 38's room and she found Staff H in the room already assisting Resident 38. Additional documentation provided by the facility on 01/29/2025 included SSD (Social Services Director) follow up note, dated 01/28/2025, documented Resident 38's recount of her interaction with Staff G. Per the follow-up note, Resident 38 stated, After yelling for help several times, [Staff G] screamed at me that she couldn't help me right now because she was holding medications . Per SSD follow-up note, Resident 38 indicated she did not trust Staff G with her care and seeing Staff G on the day SSD followed up, triggered Resident 38's PTSD (Post-traumatic Stress Disorder) and anxiety. Additional documentation provided by the facility on 01/29/2025 included a Primary physician progress note, undated, with a print date of 01/29/2025, documented a conversation between the provider and Resident 38. The progress notes highlighted Resident 38's past medical and psychosocial history and documented, Unfortunately, [Resident 38] feels that she was inappropriately treated by the nurse who noted she was busy at the time, and subsequently feels that she cannot trust this nurse to have her care as a top priority in her day to day operations . The progress note documented Resident 38's personal history of abuse and panic attacks and the event that occurred on 01/16/2025 triggered her response. On 01/30/2025 at 10:56 AM, Staff G said she was standing at her medication cart and had liquid medication and narcotics belonging to the resident in room [ROOM NUMBER] in her hand. Staff G stated, Resident 38 was calling my name as she usually does, and I had a CNA go check on her. When asked which CNA she asked to check on Resident 38, Staff G stated, I asked [Staff H] to go check on Resident 38. When asked if Resident 38 was calling out saying help, Staff G stated, Resident 38 did not call out for help. Reference WAC 388-97-0180 (1-4)

Based on interviews and record review, the facility failed to ensure bowel management interventions were initiated for 2 of 6 sampled residents (15 & 45) and failed to ensure dental care was completed for 1 of 2 sampled residents (20) reviewed for quality of care. These failures placed residents at risk for discomfort, health complications and a diminished quality of life. Findings included . <Bowel Management> The facility's policy entitled, House Bowel Protocol/Constipation, updated 04/02/2024, documented to implement the following interventions: -- Miralax [laxative]- Give 17 grams PRN for no BM [bowel movement] x3 days --Dulcolax Suppository 10mg- Insert one suppository daily PRN (if Miralax ineffective) --Fleet Enema 7-19 GM/118 ML QD PRN (if Miralax and suppository ineffective) --May administer Miralax up to three times daily PRN until BM. May schedule Miralax up to three times daily. 1) Resident 15 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 11/13/2024, documented the resident was moderately cognitively impaired. The January 2025 Bowel Movement task sheet documented Resident 15 had a BM (bowel movement) on 01/12/2025 at 1:59 PM, and did not have another BM until 01/17/2025 at 11:09 AM, over 117 hours (over 4 1/2 days) since her last BM. Resident 15's January 2025 Medication Administration Record (MAR), and January 2025 Progress Notes, did not show the bowel protocol was initiated. 2) Resident 45 was admitted to the facility on [DATE]. The Admission 5-Day MDS assessment, dated 11/30/2024, documented the resident was moderately cognitively impaired. The December 2024 Bowel Movement task sheet documented Resident 45 had a BM on 12/27/2024 at 11:59 PM, and did not have another BM until 12/31/2024 at 5:48 PM, over 89 hours (over 3 1/2 days) since her last BM. The December 2024 and January 2025 Bowel Movement task sheet documented Resident 45 had a BM on 12/31/2024 at 5:48 PM, and did not have another BM until 01/04/2025 at 6:21 PM, over 96 hours (over 4 days) since her last BM. The January 2025 Bowel Movement task sheet documented Resident 45 had a BM on 01/15/2025 at 11:53 AM, and did not have another BM until 01/19/2025 at 2:06 PM, over 98 hours (over 4 days) since her last BM. Resident 45's December 2024 and January 2025 Medication Administration Record (MAR), and December 2024 and January 2025 Progress Notes, did not show the bowel protocol was initiated. On 01/23/2025 at 10:57 AM, Staff E, Licensed Practical Nurse (LPN), said if a resident did not have a BM in over three days, they would be started on Miralax on the very next shift. If that was not effective, the resident would be given a suppository, and enema. Staff E stated, We are charting what was given in MAR, even refusals. On 01/24/2025 at 9:50 AM, Staff D, LPN and Resident Care Manager (RCM), said the BM protocol should have been initiated per facility bowel policy for both residents. Staff D was unable to provide additional documentation showing how the bowel protocol was initiated. Staff D said BM interventions should have been given on 1/15/2025 in the PM for Resident 45. At 11:10 AM, Staff A, Administrator, said the BM protocol should have been started at day 3 per policy. Staff A was unable to provide further documentation. 51254 <Dental> Resident 20 was admitted to the facility on [DATE] for long term care placement. The Quarterly MDS assessment, dated 12/31/2024, indicated Resident 20 was moderately cognitively impaired. Review of the Electronic Health Record (EHR) for Resident 20 showed a referral was sent for an emergency appointment for teeth extraction on 11/30/2023. Resident 20 was seen by a local dental office on 12/07/2023, with teeth extractions arranged with another dental office on 01/10/2024, and subsequent denture fitting and placement at the first local dental office on 02/07/2024. No further documentation was found in the EHR indicating that Resident 20 attended the appointments on 01/10/2024 or 02/07/2024. On 01/21/2025 at 10:20 AM, Resident 20 said he would like to get his teeth pulled and some dentures made as his teeth were all rotten. Resident 20 said he was unsure what was taking so long but would still like to pursue denture placement. On 01/23/2025 at 2:33 PM, Staff C, Social Services and Patient Advocacy Resource, said she was unsure about specific resident dental concerns, but would review the EHR for documentation. Staff C was unable to provide documentation related to dental care for Resident 20. At 4:09 PM, Staff D, Licensed Practical Nurse and Resident Care Manager, said she was not sure why the appointment for Resident 20 was not rescheduled after 01/10/2024. Staff D was unable to provide documentation as to why Resident 20 was not seen for the teeth extraction and denture fitting as planned. On 01/24/2025 at 10:20 AM, Staff B, Registered Nurse and Interim Director of Nursing Services, indicated she looked for communication from Resident 20's guardian to determine why the dental appointments had not been attended or rescheduled. Staff B was unable to provide documentation to support why the dental procedure had not been rescheduled. At 1:36 PM, Staff A, Administrator, said there was generally documentation in the EHR to support why the resident did not go to an appointment, or why it had not been rescheduled in the last year. Staff A said 12 months was longer than it should take to have a new appointment arranged. Reference WAC 388-97-1060 (1), (3)(c)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's health status and/or care needs for 1 of 4 sampled residents (3) reviewed for assessment accuracy. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings included . Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. The Admission MDS, dated [DATE], showed Resident 3 was alert and oriented, had diabetes mellitus, and did not receive insulin (a medication used to help regulate blood sugar levels and treat diabetes) injections in the last 7 days. Review of Resident 3's November 2024 Electronic Medication Administration Record (EMAR), documented Resident 3 received Insulin Lispro (a type of rapid-acting insulin) on 11/11/2024, 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, and 11/17/2024. The November 2024 EMAR also showed Resident 3 received Insulin Glargine (a type of long-acting insulin) on 11/12/2024, 11/13/2024, 11/14/2024, 11/15/2024, 11/16/2024, and 11/17/2024. On 01/23/2025 at 10:43 AM, Staff B; Interim Director of Nursing Services, MDS Coordinator, and Registered Nurse; said they looked at the Electronic Health Record (EHR), including the EMAR, to gather information to complete the MDS. After looking at Resident 3's EHR, Staff B said Resident 3 received insulin that was not coded correctly on the MDS. Staff B stated, Yes, we will need to modify it [MDS]. Staff B said it was her expectation the MDS was completed accurately to reflect the resident and the care received. Reference WAC 388-97-1000 (1)(b), (2)(n)

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) assessment accurately reflected the resident's mental health diagnoses and Level II PASARR evaluations were referred and completed timely for 1 of 8 sampled residents (15) reviewed for PASARRs. This failure placed residents at risk for inappropriate placement, not receiving timely and necessary mental health services to meet their mental health needs, and a diminished quality of life. Findings included . Resident 15 was admitted to the facility on [DATE] with diagnoses including Adjustment Disorder (psychiatric diagnosis characterized by unhealthy reaction to a stressful event), and Bipolar Disorder (psychiatric diagnosis characterized by extreme mood and emotional states). The Admission Minimum Data Set assessment, dated 11/13/2024, documented the resident was moderately cognitively impaired. A Level I PASARR, dated 11/07/2024, documented Resident 15 had a diagnosis of Adjustment Disorder, with no indicators of Serious Mental Illness (SMI) requiring a Level II PASARR. Per the Level I PASARR, a Level II must be completed if scheduled discharge does not occur. The Electronic Health Record (EHR) documented Resident 15 had a diagnosis of Bipolar Disorder and physician's order for Ripiprazole (an antipsychotic medication). The EHR did not include a Level II PASARR, or a referral for Level II PASARR for Resident 15. On 01/24/2025 at 9:36 AM, Staff C, Social Worker and Patient Advocacy, said residents' Level I PASARR should be sent for a Level II within 30 days if there is was not a discharge. Staff C said the facility received an inaccurate Level I PASARR prior to Resident 15's admission from the hospital and was unable to provide documentation of a Level II referral. Staff C stated, It should be marked and sent in for a Level II. At 11:10 AM, Staff A, Administrator, said she would expect accurate completion and referral of PASARR for residents. Reference: WAC 388-97-1915 (1)(2) (a-c)

Based on interview and record review, the facility failed to ensure nursing assistants were screened through the nurse aide registry [OBRA] prior to providing care to the residents for 1 of 2 staff [Staff C] reviewed for staff qualifications. This failure placed residents at risk for abuse and unmet care needs. Findings included . Staff C was hired on 02/26/2024. Review of Staff C's employee record did not include documentation from the nurse aide registry. On 08/12/2024 at 3:15 PM, Staff B, Human Resource and Payroll Representative, said he had been in his role for six months. Staff B said originally he was under the impression the OBRA registry was only for NARs (nursing assistants registered), and not NACs (nursing assistants certified). Staff B said he was in the process of reviewing all NACs through the nursing assistant registry. Reference WAC 388-97-1660 (3)(c)

Based on interview, observation and record review, the facility failed to maintain a clean homelike environment by failing to ensure resident room windows were clean for 9 of 43 resident rooms (4, 5, 6, 19, 25, 28, 38, 41 & 44) reviewed for environment. This failure placed residents at risk for a diminished quality of life. Findings included . The Resident Council Minutes, dated 01/25/2024, documented, the windows need washing. On 02/04/2024 at 11:42 AM, Resident 2 said the window in her room was dirty. The window was observed to have brown discoloration and debris on the lower left side of the window. The rest of the window was cloudy. On 02/06/2024 between 1:26 PM and 1:50 PM, the windows in Rooms 4, 5, 6, 19, 25, 28, 38, 41 and 44 were observed to be cloudy with water stains. At 1:50 PM, Staff C, Plant Director, said resident room windows were not clean and were not on a cleaning schedule. At 1:59 PM, Staff A, Administrator, said windows should be clean. While observing the window in room [ROOM NUMBER], Staff A said it looked like the dirt or debris was in-between the outer side of the window and the screen. At 2:40 PM, Staff A said the window in room [ROOM NUMBER] was under a runoff and unfortunately will get dirty quicker. Reference WAC 388-97-0880

Based on observation and interview, the facility failed to ensure staff performed hand hygiene during meal assistance for 1 of 4 sampled residents (15) reviewed for dining assistance and food service. This failure placed residents at risk for cross-contamination, food borne illness and a diminished quality of life. Findings included . On 02/04/2024 at 12:16 PM, Staff D, Occupational Therapist Assistant, was observed assisting Resident 15 with an adaptive utensil. Staff D had her left hand on the edge of the table. Staff D was wearing gloves. At 12:17 PM, Staff D was observed touching Resident 15's right arm with her left hand. At 12:20 PM, Resident 15 began to cough. Staff D was observed using both hands to grab Resident 15's clothing protector to cover Resident 15's mouth. Staff D then put her left hand on Resident 15's back. At 12:22 PM, Staff D was observed touching the clothing protector with her left and then assisted Resident 15 by grabbing his right hand with her left hand. At 12:23 PM, Staff D was observed stopping Resident 15's right hand with Staff D's left hand, from putting more food in the resident's mouth. Staff D asked Resident 15 to finish eating and to swallow first. At 12:25 PM, Staff D was observed putting her left hand on Resident 15's right wheelchair arm. Staff D lifted her left hand from the wheelchair and grabbed Resident 15's right arm and stopped Resident 15 from putting more food in his mouth. At 12:26 PM, Staff D was observed using Resident 15's spoon to move the food around the plate. Resident 15 began to cough. Staff D put her hands under the clothing protector to cover Resident 15's mouth. The plate was pulled down under the clothing protector with some of the food touching the underside of the clothing protector. At 12:28 PM, Staff D was observed removing the paper from around the straw and placed it in a cup. Staff D lifted the cup with her left hand and used two right fingers, touching just below the bend in the straw, to guide the straw to Resident 15's mouth. At 12:29 PM, Staff D was observed adjusting Resident 15's clothing protector with both her hands. At 12:30 PM, Staff D was observed stopping Resident 15 from putting more food in the resident's mouth with Staff D's left hand. Staff D did not wash or sanitized her hands and did not change her gloves during this dining session. At 12:31 PM, Staff E, Nursing Assistant, was observed walking over to Staff D and relieved Staff D. At 12:47 PM, Staff E said they were supposed to wash or sanitize their hands anytime they touched something dirty. On 02/06/2024 at 9:39 AM, Staff B, Director of Nursing Services and Registered Nurse, said staff should wash their hand anytime they touched anything dirty. On 02/07/2024 at 8:41 AM, Staff D said she was not aware she was touching anything dirty like Resident 15's wheelchair or clothing protector. Staff D said she was aware she was supposed to wash her hands and change gloves if she touched anything dirty. Reference WAC 388-97-1100 (3) & [PHONE NUMBER]0 (1) & (9)

Based on observation, interview, and record review, the facility failed to implement an infection control program documenting the monitoring of controls for 1 of 1 water management program and failed to provide wound dressing changes without the risk of contaminating the site for 2 of 5 sampled residents (24 & 29) reviewed for infection prevention and control related to the water management program and wound care. This failure placed residents at risk for potential bacterial water and wound contamination. Findings included . <Water Management Program> On 03/23/2023 at 10:26 AM, Staff D, Director of Environmental Services, said he could not provide documentation of the results of the controls he monitored and tested for possible contamination of Legionella (waterborne bacteria) growth. On 03/24/2023 at 10:40 AM, Staff D said he did not have documentation and he was going to use a program for documenting in the future. At 10:40 AM, Staff A, Administrator, said she was not able to provide documentation of the results related to the facility's monitoring and testing of the controls for the water management program. 46244 <Wound Care> 1) Resident 24 was admitted on [DATE] with diagnoses including diabetes, kidney failure and multiple types of skin wounds to the legs. The admission Minimum Data Set (MDS), an assessment tool, dated 01/20/2023, showed Resident 24 was cognitively intact, able to make needs known and required extensive assistance from staff with activities of daily living including bed mobility and transfers to a chair. On 03/24/2023 at 9:45 AM, Staff K, Licensed Practical Nurse and Wound Care Nurse, was observed providing wound care for Resident 24. While completing the dressing change on the right heel, Staff K did not change her gloves or clean her hands after cleaning the wound site and prior to completing the clean part of the dressing change. Staff K's break point in the process from dirty to clean did not include cleaning the wound area in the 'dirty' portion of a dressing change. Staff K used contaminated gloves to handle a multi-use packaging of medicated dressing, including the scissors, and took from a pile of clean gauze. While completing the dressing change on the left heel, Staff K did not change her gloves when moving from dirty to clean tasks. Staff K used the contaminated gauze pile, scissors, and multi-use package of medicated dressing to complete the dressing change. While completing the dressing change to a wound on the right lower leg, Staff K did not change her gloves or clean her hands when moving from dirty to clean tasks. Staff K used contaminated gauze to clean the wound and contaminated scissors to cut medicated dressings prior to application. At 11:09 AM, Resident 24 had been provided stool incontinence care by a floor staff and was turned on her side to allow for the dressing change. Staff K touched around Resident 24's buttock to view the wound. Staff K cleaned the wound on Resident 24's buttock with gauze and saline, applied a medicated treatment and foam dressing. Staff K did not change her gloves or clean her hands after cleaning the wound, prior to applying the treatment and dressing. 2) Resident 29 was admitted on [DATE] with diagnoses including diabetes and kidney disease. The quarterly MDS, dated [DATE], showed Resident 29 was cognitively intact and was at risk for skin impairments. On 03/22/2023 at 10:09 AM, Staff K was observed providing wound care on Resident 29's feet and legs. Staff K did not change her gloves and sanitize her hands after touching Resident 29's feet, and before getting a dressing from a multi use package to complete the dressing change. On 03/24/2023 at 11:30 AM, Staff B, Director of Nursing Services and Registered Nurse, said staff should change gloves and sanitize hands when going from dirty to clean, and after cleaning the wound. Staff B said she had audited Staff K several times related to this process. At 11:38 AM, Staff K said during a dressing change, she would change gloves and cleaned her hands after taking the dressing off and prior to cleaning the wound. Staff K indicated she was not aware to change gloves and clean hands after cleaning a wound. Reference WAC 388-97-1320 (1)(a)

46244 Based on observation, interview, and record review, the facility failed to maintain a comfortable homelike environment that was free of unpleasant odors from 1 of 1 smoking areas and failed to have a system in place to identified resident clothing to prevent loss for 2 of 3 sampled residents (3 & 24) reviewed for safe, comfortable homelike environment. This failure placed residents at risk for a diminished quality of life. Findings included . <Smoking Area> On 03/22/2023 at 1:16 PM, the resident's outside smoking area (courtyard) was observed. Inside the facility, by the door, there was a smell of cigarette smoke. On 03/23/2023 at 11:03 AM, during the resident council group meeting, the group indicated they had concerns of smelling smoke in the facility while residents were smoking next to the door and window in the courtyard. On 03/27/2023 at 11:22 AM, residents were observed opening the door and entering the facility from the courtyard after their smoke break. There was a smell of cigarette smoke in the facility hallway, by the doorway to the designated smoking area. At 11:25 AM, Staff E, Activities Director, said she could smell cigarette smoke in the hallway. At 11:36 AM, Staff A, Administrator, stated she did not believe the smell of smoke in the hallway was an adequate homelike environment for the residents. <Loss of clothing> 1) Resident 3 was admitted on [DATE] with diagnosis including vision loss. The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/22/2022, showed Resident 3 was cognitively intact. On 03/20/2023 at 3:22 PM, Resident 3 said her clothes were sent down to the laundry and sometimes did not come back. Resident 3 said the staff sometimes marked her clothes, but not always. Resident 3 said last week she had pants and some tee-shirts go missing. 2) Resident 24 was admitted on [DATE]. The admission MDS, dated [DATE], showed Resident 24 was cognitively intact and could make her needs known. On 03/21/2023 at 8:49 AM, Resident 24 said she filed a missing items report two months ago for multiple items including several pants. Resident 24 said the staff had not found her pants which were easily identifiable due to the bottom legs being cut off. Review of January 2023 grievance log showed four of nine grievances were for missing items. Review of February 2023 grievance log showed two of eight grievances were for missing items. Review of March 2023 grievance log showed four of nine grievances were for missing items. On 03/23/2023 at 1:35 PM, Staff F, Social Services Director, said the facility had a lot of missing clothing grievances. Staff F said it was in part because staff did not write the resident's name or initials on the clothing. On 03/24/2023 at 11:46 AM, Staff Q, Laundry Services, said to sort the clean clothes, she matched the resident identifier to room number. Staff Q said when she had laundry items without an identifier, she would ask the care staff, but they rarely knew whose item it was. A four sided clothing rack was observed with approximately 50 items of missing clothes. Staff Q said if they did not find the owner after a month, the item was placed in the donation box. Staff Q said the care staff took items out of the donation box for a new resident, then forgot to place a new identifier on the clothing. Then the item would come back through the laundry and get placed into the missing clothes system again. Staff Q said using the room number as an identifier caused problems when the facility changed rooms frequently. On 03/27/2023 at 10:27 AM, Staff R, Licensed Practical Nurse and Admissions, said the Certified Nursing Assistants (CNA) created an inventory list when the resident was admitted . Staff R said any staff could place an identifier on clothing, whoever encountered the clothing item. Staff R said about 100 percent of the time the CNAs were responsible for marking the clothing. At 10:35 AM, Staff Q said the CNAs were responsible to put names on clothing. At 10:38 AM, Staff S, CNA, said if she was completing the admission, she would mark the clothing. Staff S said she saw other staff mark the clothing like environmental services or the CNA that had the room. Staff S said she did not know if it was the CNA's responsibility to mark clothing, and she would mark clothing if a nurse asked her to. At 11:17 AM, Staff A, Administrator, said laundry services was an ongoing issue with multiple performance improvement plans. Staff A said the facility had tried multiple interventions. Staff A said the facility identified an issue of staff using the room numbers to identify clothing when the residents were moved frequently. Staff A said there was a breakdown in the system was with CNAs not labeling clothes. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to obtain, provide and/or have procedures in place to assist with completing Advance Directives (ADs) for 3 of 7 sampled residents (10, 15 & 58) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . 1) Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 01/17/2023, documented the resident was cognitively intact. A review of Resident 10's electronic health record did not show documentation of an AD. On 03/22/2023 at 2:40 PM, after reviewing Resident 10's electronic health record, Staff F, Social Services Director, said the facility did not have an AD on file for the resident. 2) Resident 15 was admitted to the facility on [DATE]. The annual MDS, dated [DATE], documented the resident was cognitively intact. An advance directive receipt, dated 03/03/2022, documented, I am interested in formulating an advance directive, and will provide a copy upon completion. A review of Resident 15's electronic health record did not show documentation of an AD. On 03/22/2023 at 2:40 PM, after reviewing Resident 15's electronic health record, Staff F said the resident should have received an information packet to help the resident formulate an AD. Staff F said she did not give him the packet personally. Staff F said she would put Resident 15 on her AD follow-up list. 3) Resident 58 was admitted on [DATE]. The admission MDS, dated [DATE], showed Resident 58 was cognitively impaired. Review of Resident 58's electronic health record did not show documentation of an AD. Resident 58's Care Plan, dated 02/02/2023, showed the following conflicting statement, I have an advance directive Specify: (DPOA, Guardianship, living will) I choose not to formulate an advance directive at this time, but am aware I may do so at a later date. I am interested in formulating an advance directive, and will provide a copy upon completion. On 03/22/2023 at 3:19 PM, Staff F said Resident 58 did not have an AD. At 2:40 PM, Staff F said social services would obtain an AD upon admission if the resident had one. Staff F said if the resident did not have an AD, social services was supposed to ask if the resident wished to formulate an AD. Staff F said if residents were interested in formulating an AD, social services would provide them with an AD packet, and social services asked residents to provide a copy once they filled out the paperwork. Staff F said ADs were reviewed when scheduling care conferences, which was quarterly. Staff F said she had worked at the facility since 12/05/2022, and she did not think there was a process in place for AD's before her time at the facility. At 3:12 PM, Staff B, Director of Nursing Services and Registered Nurse, said social services was responsible for obtaining ADs upon admission. Staff B said ADs should be reviewed quarterly. Reference WAC 388-97-0300 (1)(b), (3)(a-c) 46244

Based on observation, interview, and record review, the facility failed to obtain a physician order and consent for 1 of 2 sampled residents (324) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . The facility's policy entitled Restraints, Physical/Washington State, revised 03/2016, showed, A physician's order is necessary for the use of a physical restraint. When applying restraints, the Facility will comply with the operative terms and provisions of the Washington Administrative Code. Specifically: The use of the restraint is related to a specific medical need or problem identified through a multidisciplinary assessment: the informed consent process is followed as described under WAC 388-97-0260; and the resident's plan of care provides approaches to reduce or eliminate the use of the restraint, where possible. Resident 324 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 03/07/2023, noted the resident was moderately cognitively impaired and required extensive assistance with activities of daily living. On 03/23/2023 at 10:30 AM, Resident 324 was observed lying in bed with bed mobility bars on both sides of the bed, left side of bed against the wall, and a mat on the floor to the right side of the bed. Record review of Resident 324's electronic medical record showed no documentation of a physician's order related to left side of bed against the wall and a mat to right side of bed. There was not a consent for the mat to the right side of the bed. On 03/23/2023 at 6:15 AM, Staff B, Director of Nursing Services and Registered Nurse, said there should be an order, consent, and care plan prior to the placement of any safety device. Staff B said this had been identified as a potential problem area and an audit had been started. Reference WAC 388-97-0620

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for skin impairment for 1 of 3 sampled residents (9) reviewed for comprehensive care plans related to pressure ulcers. This failure placed residents at risk for infection, unmet care needs and a diminished quality of life. Findings included . Resident 9 was admitted to the facility on [DATE]. The significant change Minimum Data Set, an assessment tool, dated on 12/12/2022, showed the resident was cognitively intact and required extensive assistance with activities of daily living. Review of Resident 9's electronic health record did not show a treatment orders or care plan to address any skin issues. On 03/23/2023 at 7:05 AM, Staff M, Certified Nursing Assistant, was observed providing incontinent care for Resident 9. Staff M said Resident 9 had several skin issues including impairments to the tailbone, upper back of thighs (left and right), under the left breast and abdominal fold. Staff M was observed removing dressings from both thighs. On 03/27/2023 at 10:40 AM, Staff O, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), said identified skin issues were placed on a skin sheet available at the nurse's station by the staff member who observed the skin issue(s). The skin sheet was reviewed by the RCM and the Director of Nursing Services (DNS). Staff O said the RCM and wound nurse documented and measured the skin impairment. The doctor was notified for orders. The resident was placed on alert status and the care plan was updated. Staff O indicated she was unable to locate treatment orders or a care plan for the skin issues identified. At 10:56 AM, Staff K, LPN and Wound Nurse, said she was not aware of any skin issues for Resident 9. At 11:48 AM, Staff B, DNS and Registered Nurse, said the care plan should have been updated. Staff B indicated she was unable to locate a care plan for the skin issues identified. Reference WAC 388-97-1020 1), (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including fingernail care for 1 of 2 sampled residents (15) reviewed for ADL care for dependent residents. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves. Findings included . Resident 15 admitted to the facility on [DATE]. The annual Minimum Data Set, an assessment tool, dated 02/02/2023, documented the resident was cognitively intact, required extensive assistance with ADLs, and was not diabetic. Resident 15's skin integrity care plan, dated 06/07/2022 and revised 01/05/2023, documented the intervention, Keep fingernails short. Resident 15's nail care task, dated 02/21/2023 to 03/21/2023, documented the resident's last nail care was on 03/14/2023 at 4:10 PM. On 03/20/2023 at 10:53 AM, Resident 15 was observed with long, yellow fingernails on both hands, the longest nails approximately 1/4 inch past the finger. On 03/22/2023 at 9:54 AM, Resident 15's fingernails were observed to still be long. When asked if his fingernails should be trimmed, Resident 15 stated, Yes. At 10:00 AM, Staff I, Certified Nursing Assistant (CNA), said CNAs were responsible for fingernail care for non-diabetic residents. Staff I said residents were assessed for fingernail trimming whenever I see them [resident's fingernails]. Staff I said fingernail care was documented in the resident's POC (Point of Care) task list. At 10:35 AM, Staff J, Licensed Practical Nurse, said nurses were responsible for trimming fingernails of diabetic residents. Staff J said she would also do non-diabetic fingernail care as well if she had the time. Staff J said she would perform nail care once a week and as-needed. At 10:42 AM, after observing Resident 15's fingernails, Staff J stated, They are pretty long. Staff J said she would trim Resident 15's fingernails now. At 1:28 PM, Staff B, Director of Nursing Services and Registered Nurse, said CNAs could trim non-diabetic fingernails and nurses performed diabetic nail care. Staff B said fingernails should be assessed as needed and during shower days, twice a week. Staff B said nail care was documented on the resident's shower sheet, a form used to track bathing in the facility. At 2:01 PM, Resident 15 was observed with clean, neat, trimmed fingernails. Resident 15 stated, You got on them. Thank you. At 2:20 PM, Staff B said documentation could be better and that was something the facility was working on, getting everyone to document the correct way. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to provide the necessary care, services, treatment, assessment and monitoring with wound care for 1 of 15 sampled residents (#1) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. This caused harm for Resident #1 when the resident was hospitalized with multiple diabetic infected and gangrenous wounds. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/12/19, showed Resident #1 was cognitively intact, independent with activities of daily living, and had no skin impairment. The admission MDS, dated [DATE], showed the resident had a [MEDICAL CONDITION]. Physician Orders, dated 06/19/19, documented Resident #1 would have skin checked weekly, and staff would complete a Weekly Wound Observation Evaluation if skin issues were identified. Physician Orders, dated 06/19/19, documented Resident #1 would have wound care to the left great toe daily and wound care to the left lateral and plantar aspect of foot every other day. Surgical Consult notes, dated 07/03/19, documented Resident #1 had non-healing left leg wounds with ulcers to the heel and midfoot. Resident #1's foot wounds were stable and required follow up in one month. After the 07/03/19 note, no further surgical or wound consult notes were provided upon request from the facility. Progress notes, dated 09/19/19, documented wound care was done to Resident #1's left great toe. No description of the wound was documented. Progress notes, dated 09/22/19, documented dressing to Resident #1's foot was dry and intact. No description of the wound was documented. Progress notes, dated 09/25/19, documented wound care to Resident #1's left great toe. The resident reported wound was resolved. No description of Resident #1's skin was documented. Progress notes, dated 09/29/19, documented wound care to Resident #1's left great toe. The resident reported wound was resolved. No description of Resident #1's skin was documented. Review of the (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 Treatment Administration Record (TAR) documented skin checks were done weekly. The TARs documented Resident #1 was getting wound care per physician orders. Progress notes, dated 10/07/19, documented Resident #1 refused wound care on left toe. Physician Notes, dated 10/15/19, documented Resident #1 foot ulcer was not completely closed but healing well. Progress notes, dated 11/04/19, documented wound care to Resident #1's left great toe. The resident reported she did not want wound care done today. Progress notes, dated 11/08/19, documented three wounds were identified on the Resident #1's foot. A diabetic ulcer to the left great toe with 100% eschar (dead tissue that sloughs off of the skin) present, left plantar measuring 1 centimeter (cm) x 1 cm, and a left medical ulcer measuring 1.2 cm x 1 cm x 0.5 cm. No additional characteristics of the wounds were documented. Record review of Resident #1's medical record showed no Weekly Wound Observation Evaluations were completed to assess and monitor the status of Resident #1's wounds including measurements and description, as physician ordered on [DATE], until measurements were documented on the 11/08/19 progress note. The plan of care, revised 11/22/19, documented Resident #1 had a wound to the left toe and left lateral foot wound. Interventions included the resident would have weekly and as needed skin assessment with treatments per physician orders. Progress notes, dated 11/28/19, documented wound care to Resident #1's left great toe. The resident reported wound care was already completed for the day. Physician notes, dated 12/06/19, documented Resident #1 foot was bandaged and the resident declined the physician's request to examine her foot. Resident #1 reported her foot continued to improve. Progress notes, dated 12/09/19, documented Resident #1's skin was dry and intact. The Skin Only Evaluation, dated 12/09/19, documented Resident #1 had no current skin issues at this time. Progress notes, dated 12/13/20, documented Resident #1 had an elevated temperature of 101.1 Fahrenheit (F). The doctor was notified and staff were to monitor the residents for signs of infection. Progress notes, dated 12/13/19, documented Resident #1's wounds remained the same. No description of the wounds were documented. Progress notes, dated 12/14/19, documented Resident #1 was not her norm and was confused with a temperature of 99.3 F. Progress notes, dated 12/14/19, documented Resident #1 declined [MEDICAL TREATMENT] and said she was feeling off. The doctor was notified and ordered labs and x-rays. The resident required oxygen for low oxygen saturation of 87%. Resident #1 was found to have an abnormal x-ray showing possible pneumonia. An antibiotic was ordered. There was no documentation showing the multiple health conditions of Resident #1 were assessed and monitored for an overall health decline including her feet. Vital signs, dated 12/15/19, documented Resident #1 had an elevated temperature of 100.1 F. Progress notes, dated 12/15/19, documented staff will check a complete blood count (CBC) to review for signs of infection. Vital signs, dated 12/16/19, documented Resident #1 had an elevated temperature of 100.5 F. Lab Results Report, dated 12/16/19, documented Resident #1's CBC showed elevated white blood cells (WBC) of 23.00 (normal range 4.00 - 11.50), showing signs of an infection. Vital signs, dated 12/17/19, documented Resident #1 had an elevated temperature of 101.2 F. The emergency room note, dated 12/17/19, documented Resident #1 was disoriented and had a decrease in responsiveness. Resident #1 was found to have [MEDICAL CONDITION] (infection of the skin) of the left foot with necrosis (dead skin tissue) and a foul smell to her toes. The Hospital Consult note, dated 12/18/19, documented Resident #1's [MEDICAL CONDITION] (an infection of the blood) due to the wounds on her left foot. Resident #1's third toe was gangrenous (dead tissue) with redness along the foot. There was a wound to Resident's fourth and fifth toes. Resident #1 reported the wound to her toes started approximately 2-3 months ago and had progressively gotten worse. On 01/29/20 at 11:41 AM, Staff F, Licensed Practical Nurse (LPN), said they should offer wound care during the day shift. If they cannot get it done on the day shift, it should be passed on to the evening shift to complete the dressing changes. At 1:09 PM, Staff C, Resident Care Manager (RCM) and Registered Nurse (RN), said he did not see the wounds and the prior RCM no longer worked at the facility and provided wound care for Resident #1. At 1:39 PM, Staff F said she had provided wound care to Resident #1 about a week prior and did not see anything unusual regarding the resident's wounds. Staff F said she did recall Resident #1 complaining of pain to her left foot. At 4:05 PM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), said if the resident refused treatment, the staff should document education was provided to the resident regarding the risk of no wound care. Staff B said weekly skin evaluations, measurement, and assessment of Resident #1's wounds were missed due to lack of oversight and should have been done. Staff B said she was not aware of necrosis in additional toes (third and fourth). Staff B said they should have identified the additional wounds to Resident #1's foot and follow up on changes to the skin condition. Staff B said they were in process of implementing a new skin care protocol. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure resident environment was safe and free from hazards when a resident received a significant burn from hot soup for 1 of 10 sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #1 when hot soup spilled on the resident and caused blisters. Findings included . Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 04/16/19, documented the resident was cognitively intact and required supervision with eating. The facility investigation, dated 06/18/19, documented Resident #1 spilled soup and had a blister on her right upper thigh measuring 4.5 centimeter (cm) by 2.0 cm by 0.0 cm in size. The blister was fluid filled and raised. There were two small red areas in the same proximity noted. The investigation showed staff were educated on proper use of microwave, not heating liquids and making sure to temp foods and fluids. On 07/01/19 at 2:45 PM, Staff A, Administrator in Training, said a nurses aide on night shift microwaved the resident's soup and gave it to her. Staff A said it was identified the staff on night shift did not have guidance on heating food and fluids. Staff A said the soup's temperature was not checked prior to giving it to Resident #1. Staff A said they had no way of knowing the temperature of the soup prior to giving it to the resident, and stated, It was significant enough to form a blister. Obviously it was above the regulation. At 3:30 PM, Staff C, Resident Care Manager and Registered Nurse (RN), said the staff were not supposed to warm food for residents as they had no way of knowing the temperature of the food. Staff C said staff should not have warmed up the soup for Resident #1. On 07/23/19 at 1:00 PM, Resident #1 said she picked up the soup and spilled it on her right front of the thigh. Resident #1 stated, It hurt like a burn and I screamed. On 07/24/19 at 4: 15 PM, Staff B, Director of Nursing Services and RN, said it was expected for staff to check the food and fluid temperature and log the readings prior to giving to the residents. Staff B said the soup temperature should have been checked prior to giving it to Resident #1. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to prevent the development of an avoidable pressure ulcer not present on admission to the facility for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This failure placed residents at risk for skin impairments, a change in health status, pain and a decreased quality of life. This caused harm to Resident #1. Finding included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), an assessment tool, dated 10/26/18, showed the resident did not have any unhealed pressure ulcer. The MDS, dated [DATE], showed the resident was cognitively intact, required extensive assist with activities of daily living, was at risk of pressure ulcer development and had one (1) or more unhealed pressure ulcer at stage 1 or higher. The resident's physician orders, dated 01/28/19, had an order to change oxygen tubing weekly every Saturday and as needed for soilage. Nurses progress note, dated 01/26/19 to 01/30/19 and 02/04/19, showed the resident was receiving oxygen therapy. A review of Resident #1's medical records showed the resident was sent to the hospital on [DATE] at 6:30 PM. Resident #1's hospital records, dated 02/05/19 at 8:00 AM, documented the following: Right ear stage 4 pressure injury measures 0.6 centimeter (cm) by 0.3 cm by 0.4 cm. Weight cartilage visible in base of wound. Large amount of white and yellow slough (non-viable yellow, tan, gray or brown tissue) noted with small amount of pink nongranular tissue. Wound edges are attached and open. Periwound with blanchable [DIAGNOSES REDACTED]. Small amount of serous drainage noted. Patient cries out when areas assessed. The (MONTH) 2019 and (MONTH) 2019 Treatment Administration Record showed documentation the resident had weekly skin check done on day shift which showed no skin issues. The resident's care plans did not address interventions to prevent skin breakdown related to oxygen tubing use. On 02/22/19 at 11:30 AM, Staff B, Registered Nurse, said residents on oxygen therapy were at risk for skin breakdown. Staff B said weekly skin checks included checking the back of the ear. Staff B said for residents receiving oxygen, the facility provides ear foam protectors. At 12:05 PM, Staff A, RN and Director of Nursing Services, said her expectation was the aides notified the nurse if they found any new skin issues of any kind. Staff A said nurses were responsible for weekly skin checks. Staff B said the nurse who did the skin assessment should be thoroughly checking the skin including the back of ears and document the findings. If there was an impairment, an investigation was started, wound evaluation should be done and the physician notified. Staff A said Resident #1 was at risk for skin breakdown. Staff A said the nurses who did the oxygen tubing change should be checking the back of ears for redness. Staff A said the facility used ear foam protectors when redness was identified. Staff B said for Resident#1, if the pressure ulcer was present to the right ear it should have been identified when the oxygen tubing was changed on 02/02/19 or when the skin assessment was done on 02/03/19. Staff A said it was hard to tell what happened and how they could have missed it. Staff A said they were in the process of changing the skin checks for residents who were on oxygen therapy. On 2/25/19 at 4:38 PM, Staff C, license nurse, said she took care of Resident #1 and completed the weekly skin assessment on 02/03/19, the day before going to the hospital. Staff C said skin checks consisted of checking the resident's heels, elbows, bottom, abdomen, head and neck, and the dressing on coccyx. Staff C said there were no new skin issues. Staff C said she checked the resident's oxygen tubing and adjusted it so it was not too tight, and checked her nostrils. Staff C stated, I think I did check her ears, and said she did not see anything alarming. Staff C said she did not see redness, and the resident did not have foam protectors. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to re-admit a medicaid resident to the facility following a pre-planned, out of state, diagnostic monitoring test for 1 of 1 sampled resident (#1) reviewed for permitting residents to return to the facility. This failure resulted in the resident remaining at the out of state hospital instead of returning to the facility for care and services for a prolonged hospital stay (over 80 days), and placed the resident at risk for increased anxiety and a diminished quality of life. This caused harm to Resident #1. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 05/10/18, indicated Resident #1 used a wheelchair and/or walker for mobility, and was independent with activities of daily living. Resident #1's care plan. revised on 02/26/18, indicated Resident #1 required occasional assistance with transfers, washing/drying hair, getting dressed, and required the use of a weighted spoon for eating. Resident #1 was at risk for falls and nutritional decline related to decreased self-feeding. Resident #1's discharge goal was to return to independent living and to establish a pre-discharge plan and identify services required to meet her needs at discharge. A 30-day Notice of Transfer or Discharge, dated 05/17/18, was given to Resident #1 with an effective date of 06/15/18. The notice listed a local hotel as Resident #1's discharge address. The documented reason for the facility initiated discharge was, Admission of guilt related to theft and forgery of checks/money belonging to protected adults living at the facility. A progress note, dated 05/21/18 at 9:08 AM, documented, Late Entry for 05/18/18: (Staff C) (admissions coordinator and Administrator in Training) and (Staff B) (Director of Nursing Services) meet with resident to discuss her 30-day notice. Resident stated that she did not admit guilt to the detective in regards to the theft of others checks. She is aware of her rights to appeal the notice and plans to do so on return from the hospital (resident had a pre-planned out of state diagnostic [MEDICAL CONDITION] monitoring study to be conducted at a specialty hospital on [DATE] through 05/25/18). Resident #1's MDS, dated [DATE], documented a planned discharge, Discharge-return anticipated. On 07/27/18 at 3:50 PM, Resident #1 said she was issued a 30-day discharge notice on 05/17/18. The resident said the facility had not discussed the facility initiated discharge with her prior to receiving the notice. Resident #1 said Staff D (Social Services Director) gave her a 30-day notice showing she would be discharged to a local hotel on 06/15/18. Resident #1 said the facility did not assist her in filing an appeal. Resident #1 indicated she had to request the phone number for the Ombuds and appeal information. Resident #1 said on 05/18/18 Staff B explained to her the facility would have a bed for her to return to after a out of state diagnostic [MEDICAL CONDITION] monitoring test was complete, even though the test was expected to last longer than the bed hold timeframe. Resident #1 said when she left the facility, she was under the impression she would be returning to the facility following her test. Resident #1 indicated the out of state hospital social worker was the first to inform her the facility denied her return. Resident #1 indicated she would have to remain in the out of state hospital until an alternate placement could be found. Resident #1 said she called Staff B on the phone after learning she was not able to return to the facility, and was told, You are not going to like anything I have to say to you, so goodbye. On 08/01/18 at 2:00 PM, Staff B stated, I told (Resident #1) you're not going to like what I have to say. Staff B said Resident #1 hung up the phone after the comment. At 12:25 PM, Staff C said she was part of the Interdisciplinary Team (IDT) that determined Resident #1 would not be permitted to return from her out of state [MEDICAL CONDITION] monitoring test. Staff C said the team discussed refusing readmission to Resident #1 after her appointment prior to her leaving on 05/21/18, but no decision was made. The decision to discharge the resident was made on 05/25/18 when the out of state hospital social worker called (Staff C) and attempted to arrange transportation for Resident #1 following the pre-planned out of state diagnostic [MEDICAL CONDITION] monitoring test. At 1:46 PM, Staff A (Administrator) said on 05/25/18 Staff C informed him Resident #1 was ready to return from her out of state [MEDICAL CONDITION] monitoring test. Staff A stated, I made the decision at that time to not allow her to come back. At 2:00 PM, Staff B indicated Resident #1 was discharged to an out of state hospital where a pre-planned diagnostic [MEDICAL CONDITION] monitoring test was conducted. Staff B said Resident #1's medical record did not contain the required documentation for facility initiated discharges. Staff B said a physician was not contacted, and there was no documentation in the resident record regarding the facility initiated discharge from the physician. Staff B indicated a recapitulation of stay was not completed. Staff B said plans to reduce transfer trauma, coordination of care after discharge, provisions for continuity of care and services required at discharge were not discussed with the resident, or with the out of state hospital. Record review of Resident #1's medical record did not contain the required documentation for facility initiated transfers or discharges. On 08/13/18, Resident #1 remained out of state, in the hospital, for 83 days after the pre-planned diagnostic test was completed on 05/25/18. Reference WAC 388-97-0120(4)(b)

Based on observation, interview and record review, the facility failed to prevent a pressure ulcer from occurring and worsening for 1 of 2 sampled residents (#11) reviewed for pressure ulcers. This failure placed residents at risk for developing and worsening skin breakdown. This caused harm to Resident #11 when she experienced pain, emotional distress, and physical and psychosocial harm. Findings Include: Resident #11 was admitted to the facility on [DATE] with multiple diagnoses. The resident's Minimum Data Set (MDS), a comprehensive assessment tool, dated 6/6/17, documented the resident had no pressure ulcers. The resident's MDS, dated [DATE], documented the resident had a stage 2 pressure ulcer, required extensive assistance with bed mobility and had severe cognitive impairment. The resident's weekly skin report and progress note, both dated 8/11/17, identified the resident had developed a new stage 2 pressure ulcer (PU). The PU was described as being on coccyx/sacral area (located at the bottom of the spine), round/oval, 1.0 cm (centimeters) in length, 0.5 cm in width and 0.2 cm in depth. The resident's weekly PU report, dated 9/22/17, documented the wound as round/oval and 2.5 cm in length, 2.0 cm in width and 0.4 in depth. The weekly PU report, dated 10/5/17, documented the resident's wound as a stage 3 PU with an increase in depth to 1 cm. A skin care plan, initiated on 8/11/18, documented the resident had a stage 2 PU on the coccyx. The resident's activities of daily living care plan showed an intervention of (Resident) is extensive assist with turning/repositioning-Assist (every 2 hours). The resident's Kardex, a tool used to communicate resident care needs to staff, showed staff were to reposition (Resident #11) at least every 2 hours when in bed, off-load, shift position every 2 hours when in (wheelchair). On 10/9/17 at 10:36 a.m., the resident was observed in bed lying on her back, grimacing. The resident said her wound area hurt so bad and the pain kills me. The resident said she tried to change positions and could not do it herself. The resident turned on her call light. At 10:38 a.m., LN C entered the resident's room and said she would give the resident her pain medication and direct the Nursing Assistants (NAs) to reposition her. At 11:40 a.m., the resident was observed lying on her back in bed. The resident was grimacing, squirming and moaning. The resident stated her wound area was killing me and couldn't turn without staff assistance. The resident said staff never came back to reposition her after LN C gave her the pain medication. At 11:45 a.m., NA A and NA H provided peri care for the resident. The resident said, Please be careful, it hurts so bad. Oh God, it hurts. At 12:07 p.m., during wound care by LN C, the resident was observed quietly moaning and repeated, Oh, it hurts. At 4:38 p.m., NA G said she was aware of the resident's PU and interventions the NAs used to prevent the wound from worsening included repositioning the resident every 2 hours, with pillows. On 10/5/17 at 8:33 a.m., 9:16 a.m., 11:27 a.m., and 1:41 p.m.; on 10/6/17 at 8:05 a.m., 10:36 a.m. and 11:50 a.m.; and on 10/9/17 at 9:23 a.m., 10:36 a.m., 11:40 a.m. and 12:01 p.m., Resident #11 was observed lying on her back in bed. No pillows or other off-lifting devices were observed on, under or around the resident. Review of the resident's records showed no documentation staff had repositioned the resident every 2 to 3 hours. On 10/10/17 at 11:26 a.m., the Director of Nursing (DNS) said staff used a resident's Kardex for information about a resident's care needs. The Kardex directed staff to reposition the resident at least every 2 hours. When asked where staff would document repositioning a resident, the DNS stated, You won't find any documentation of that. The DNS said the staff did not document when they turned a resident. The facility's failure to prevent and promote healing of the resident's pressure ulcer and follow the resident's position-related care planned interventions caused the resident's PU to worsen, and resulted in the resident experiencing pain and emotional distress. This caused harm to Resident #11. WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure acceptable pain management for 1 of 1 sampled residents (#54) reviewed for pain. Failure to provide the care and services necessary placed this resident at risk for uncontrolled pain with accompanying psychosocial harm and a diminished quality of life. Findings include: Resident #54 was admitted on [DATE] with multiple medical [DIAGNOSES REDACTED]. According to the Minimum Data Set, an assessment tool, dated 2/18/16, Resident #54 was cognitively intact and required assistance with activities of daily living (ADLs). On 7/14/16 Resident #54 had a surgical procedure and returned to the facility with a prescription for [MEDICATION NAME]-[MEDICATION NAME] (a narcotic pain medication), 1 tablet every 6 hours as needed for pain. The facility's controlled medication record documents that the facility received a total of 18 tablets for management of Resident #54's pain. In an interview on 7/18/16 at 10:00 a.m., Resident #54 stated that she had difficulties with pain beginning shortly after returning to the facility. The day after the procedure, the physician was contacted and the resident's [MEDICATION NAME]-[MEDICATION NAME] pain medication was increased from 1 to 2 tablets every 6 hours as well as a new order for [MEDICATION NAME] 1 tablet every 3 hours as needed for pain. The total number of [MEDICATION NAME]-[MEDICATION NAME] pills was not increased. The resident expressed concern over running out of pain medication and stated she had spoken to nursing staff on several occasions about contacting her physician to request additional medication prior to the weekend. She stated the staff had told her that they had requested additional pain medication but had not yet received an order. On Sunday, 7/17/16 at 6:30 a.m., Resident #54 was given her last available dose of pain medication. Later that morning, Resident #54 asked to be taken to the emergency department for treatment of [REDACTED]. At 10:30 a.m., Resident #54 left the facility via ambulance to seek pain relief at the emergency department. When Resident returned to the facility on [DATE], the staff received authorization to remove from their emergency medication kit (E-kit), 3 tablets of [MEDICATION NAME]-[MEDICATION NAME], and 6 doses of a stronger pain medication, [MEDICATION NAME]. On 7/18/16 at 10:00 a.m., Resident #54 was observed to be more subdued, less talkative and stated I hurt. The resident stated when she had received 2 tablets of the [MEDICATION NAME]-[MEDICATION NAME] pain medication, her pain level was okay. But when she received 1 tablet, the pain would reduce from a 9/10 or 10/10 to about a 5/10, which was rough. Resident #54 stated that she was counting down the number of doses left to use and was saving the [MEDICATION NAME] to use before dressing changes on the surgical site. The resident stated, This is why I was afraid to have this (procedure) done. I had put it off. Resident #54 also stated, I'll never go through this again. On 7/18/16 at 11:30 a.m., LN A was told Resident #54 believed she had a limited number of doses of [MEDICATION NAME]. The LN stated no, it's just every four hours but said she would go look at the order. A few minutes later, LN A placed a call to Resident #54's physician regarding pain medication. At 11:30 a.m., Resident #54 rated her pain at 9/10 and requested pain medication. LN A told her it would be another hour before she could receive medication for pain. In reviewing Resident #54's Medication Administration Record [REDACTED] The facility failed to manage the resident's pain in order to support the resident's highest practicable level of physical, mental and psychosocial well-being.

Based on observation, interview and record review, it was determined the facility failed to operationalize its policies and procedures for protection of residents, and for the prevention, identification and investigation of abuse, and/or mistreatment. The failure of the facility to assure all was being done within its control to recognize and prevent 1 of 2 Residents (#50) from being the recipient of sexualized behavior by a male resident (#90) placed the resident(s) at harm for continued unwanted sexualized advances. Findings include: Resident #50 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Interview for Mental Scale (BIMS) score was '0' due to the resident being unable to complete the assessment. Resident #90 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set MDS indicated the resident's Brief Interview for Mental Scale BIMS' score was 3. Record review done on 07/13/16 indicates on 03/01/2016 Resident #50 was standing at the station 2 nurse's station and Resident #90 was observed to walk up behind Resident #50 and took her hand and guided it toward his groin area. This incident report further indicated, Resident #90 was most likely attempting a sexual maneuver involving Resident #50. Record review done on 07/13/16 of Resident #90's progress notes indicated on 03/17/2016 a health status note, Resident #44 came from outside through the double door near Central Supply room and caught Resident #90 attempting to unzip his pants in front of Resident #50. Record review done on 07/13/16 of Resident #50's progress notes indicated on 05/29/2016 a health status note, Resident #90 was noted putting hand around Resident #50. Resident #50 was brought back to her room, encouraged to stay by station 2 nurse's station. Was concerned and crying about whether she was in trouble. Record review done on 07/13/16 of Resident #50's progress notes indicated on 06/19/19 a health status note, Reported to this nurse resident was found with male resident (Resident #90) in another room. Record review done on 07/22/16 of employee statements indicated on 07/18/16 at 4:10 p.m. Licensed Nurse (LN) G wrote, Other Staff (OS) from ARC visits Q MTW (every Monday, Tuesday, Wednesday) when OS, arrives she finds Resident #50 in hallways or activity room. On 07/11/16 at approximately 6:30 p.m., Resident #50 was observed by State Surveyors to be in the hall, near the station 1 nurse's station alone and with no staff in sight. On 07/15/16 at 12:50 p.m., Resident #90 was observed walking past Resident #50's room and look into her room. A staff was observed in the hall to walk past the resident and not continue to walk with the resident and ensure he left the area safely. On 07/14/16 at 8:43 a.m.; Resident #22 indicated she has observed some behaviors between Resident #50 and Resident #90. Resident #22 indicated that she asked Resident #50, has he (Resident #90) ever touched underneath what you're wearing? and the resident indicated that Resident #50 answered, Oh yes. Resident #22 indicated that several of us are watching him. Resident #22 stated, We have told a couple of staff, so there are 3-4 staff watching Resident #90, but he sits there and smiles. On 07/14/16 at 12:01 p.m., Resident #43 indicated that approximately one month ago she and two other residents (#42 & #22) were in the activity room along with Resident #50 and Resident #90. Resident #90 began grabbing at Resident #50's hands and arms and saying, Why don't you love me, we need to get married. Resident #43 stated, It got so bad that Resident #22 went over and got her (Resident #50) and brought her to a different table. Resident #43 indicated that Resident #90 will grab and touch Resident #50's arms and hands anytime he can and at any available opportunity. Resident #43 stated, We all feel like we're responsible to protect Resident #90, she is a grown woman, but really like a child in her mind. I don't feel secure with Resident #90. If Resident #50 is there, we watch where he (Resident #90) goes and we watch her. Resident #43 indicated that during this incident she reported it to the Activities Assistant (AA). The resident indicated that staff was not in the room during the incident. Resident #43 indicated that following this incident an aide told her, whatever you do, watch out for him, just whatever you do, watch out for him. On 07/15/16 at 10:06 a.m., Resident #42 approached the state surveyor asking to talk, he stated, They gotta do something about Resident #90. Resident #42 further indicated that Resident #90 will tell Resident #50 that he loves her, has a house for her, and wants to marry her. The resident indicated that Resident #90 will wait for staff to leave then will do it; however, enough residents are in there (the activity room) and they will watch him. Resident #42 indicated an incident recently got so bad that Resident #22 had to go get Resident #50 and move her away. On 07/15/16 at 10:17a.m., Activities Assistant (AA) indicated that Resident #90 will often use the word darling in response to Resident #50. AA indicated that Resident #90 has only recently been coming to activities, and that Resident #50 has always come to activities. AA indicated there is a trend in Resident #90 wanting to sit next to Resident #50. When asked if any incidents have been reported to her, AA reported that some residents had reported that there was an incident that had happened and she just reported it on to the charge nurse, LN E, that there was an issue during activities. On 07/15/16 at 10:37 a.m., Social Services Director (SSD) indicated that she had not heard any worry since her time of being employed at the facility, since the middle of May. SSD indicated she wasn't aware of any sexually inappropriate behaviors for Resident #90. On 07/15/16 at 10:50 a.m., LN E indicated that Resident #90 has taken a liking to Resident #50. LN E indicated there is a care plan to keep a close eye on Resident #50. On 07/15/16 at 11:35 a.m., the Director of Nursing (DNS) indicated that Resident #50 and Resident #90 talk but it is almost like they are friends. They will walk down the halls almost like they are friends. The DNS indicated that recently someone overheard Resident #90 ask Resident #50 to marry him; however, it was a busy area and was difficult to fully hear the conversation. The DNS indicated that she had forgotten to log the incident on 03/17/16 in the state reporting log or report this to the Complaint Resolution Hotline, involving Resident #90 unzipping his pants and was unaware of any event on 06/19/16 of both Resident #50 and #90 being in a room together. Record review done on 07/13/16 of the facility's state reporting log from 01/18/2016-07/18/2016 indicated two logged incidents regarding Resident #50, one related to a fall, and one on 03/03/16 related to another allegation of abuse regarding another resident that has since discharged . Record review done on 07/13/16 of Resident #50's care plan indicated that the resident is a vulnerable adult, and has a guardian for her protection. Monitor closely to ensure that she does not violate anyone else's space, likewise, monitor to ensure that no one violates her space, rights or comfort level. Record review done on 07/13/16 of Resident #90's care plan indicated that the resident may need direction to express sexual needs appropriately. Furthermore, allow patient to talk about missing intimacy, and respond appropriately, if patient expresses sexual needs inappropriately gently redirect to his bedroom for privacy. Monitor interactions with female residents. Monitor resident's location Q (every) 15 minute checks through 3/7/2016.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest physical, mental and psychosocial well-being for 3 of 6 residents (# 1, 2 & 4) when they failed to monitor a cholecystostomy tube (a tube for draining the gallbladder), failed to ensure compression stockings were applied as ordered and failed to monitor psychosocial well-being for a person at risk. These failures caused harm to resident #1 who experienced pain and emergency hospitalization when his unmonitored tube migrated into the abdominal cavity; placed resident #2 at risk for not being monitored for psychological well -being and caused resident #4 to have unnecessary risk of skin breakdown. Findings include: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 03/12/14, the resident was alert and oriented but was dependent on staff for activities of daily living (ADLs). According to hospital records accompanying the resident at the time of admission to the facility, the resident had a history of [REDACTED]. A cholecystostomy tube had been surgically placed to drain gallbladder secretions into a closed drainage system (an accordion like device) on the outside of the body. No orders on how to manage the tube or secretions were obtained on admission or during the remainder of the resident's facility stay. According to facility treatment administration records (TARs), nurses were directed by nursing order to "Empty & burp accordion drain to gallbladder every shift and as needed." The nursing order was completed as directed between 02/27/14 and 03/14/14. On 03/11/14, a nursing note reflected "Adhesive holding pt (patient) chole (cholecystostomy) tube undone with tube noted to be partially dislodged roughly 2 cm (centimeters). Patient denies pain or sob (shortness of breath). Tube secured with tape and MD (physician )notified with verbal orders to wait until MD can see in the a.m. so that he my decide a proper course of action. WCTM (will continue to monitor) closely." On 03/14/14, 3 days later, the next entry regarding the tube reflected a nursing note "Cholecystostomy tube cut two inches posterior to site per MD order with patient tolerating well. Taped to patient's skin. Awaiting further orders for CT (CAT scan) and subsequent removal or replacement of drainage tube. WCTM closely." On 03/14 /14, an attending physician note indicated "It was hoped the {fistula} would stop draining and the fistula would heal, such that the tube could be pulled (removed)." There was no evidence the tube was monitored or assessed between 03/14/14 and 03/19/14, or for 5 days. According to TAR records and nursing progress notes, no further monitoring was completed regarding the cholecystostomy tube during that time. The TAR reflected directions for emptying the accordion drain were discontinued on 03/14/14. Nursing notes did not mention the tube or the insertion site. Monitoring of the tube, drainage and insertion site ceased. On 03/19/14, 5 days after the tube was cut, nursing notes reflected "Patient co (complains) of severe abdominal pain, 10 out of 10 unrelieved by pain medication, history of aortic aneurysm, cholecystostomy, severe abdominal pain, upper right quadrant. Diaphoretic (sweating). Send out to ER (emergency department) for evaluation and treatment per MD." The note did not address whether or not the tube was in place. On 04/08/14 at 09:10 a.m., the Staff Development Coordinator stated "I help out with admissions and help the nurses to check orders. It a resident comes in with a tube or piece of equipment we are unfamiliar with, I do research, find the policy, inservice staff, check competencies and ensure staff know how to provide care. I was on vacation last week so I was not aware of {resident #1} until now. I know about the situation now, because I am helping with the investigation. I am training staff currently on care of residents with 'tubes'. We have a policy on 'Closed Drainage System'. We should always have a physician's orders [REDACTED]." At 09:25 a.m., LN A stated "On 03/14/14, the MD decided the tube was in place and not draining. The tube had been attached to the accordion drain, but the MD thought the tube was scarred into the resident because it would not budge when he tried to remove it. Under the Doctor's direction, I cut the tube to about 2 inches from the resident's skin and taped it down. It was a small drainage tube which opened into the abdominal cavity. We did not document or monitor the tube after that. The overall plan was to pull or replace the tube. Truly, I did not think the tube was going anywhere because we couldn't remove it. When the resident started complaining of abdominal pain on 03/19/14, the tube was gone. I do not know where it went. I guess we should have monitored the tube." 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS, dated [DATE], the resident was alert and oriented with some memory problems. She required extensive assistance with ADLs. According to facility documents, on 03/14/14 at 10:00 a.m., a nursing assistant (NA) providing care to the resident reported to the Director of Nursing (DNS) that he had "lost his temper with the resident when the resident was making several requests and insisting that everything get done quickly." He further stated he had told the resident "If you weren't so demanding more people would want to take care of you." The NA immediately realized his words and tone were inappropriate and apologized to the resident. The NA then reported his behavior to the DNS. The NA was suspended and an investigation ensued. Chart documents written between 03/10/14 and 03/20/14 did not reflect any monitoring of the resident's psychosocial well-being. On 04/07/14 at 04:10 p.m., the Social Services Director (SSD) stated I was not involved with {resident #2} when the incident with the NA occurred. I did not follow up and I was not involved. We did have a care conference last week, but nothing about that incident was mentioned." On 04/08/14 at 09:05 a.m., the DNS stated "I placed that resident {#2} on alert between 03/14/14 and 03/17/14 for psychological harm for adverse reaction, and asked the staff to document any reaction or signs and symptoms of depression. I don't see where any documentation was completed. The nurses are supposed to monitor residents on alert every shift. I guess I need a way to make sure what I ask for gets done." 3) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According the the MDS dated [DATE], the resident was alert, but not able to advocate for self. The resident was dependent on staff for ADL care. The resident was identified as being at risk for skin breakdown. On 02/16/14, a new physician's orders [REDACTED]. According to the TAR records, the resident had stockings on during 49 mornings of the 53 total number of days during the time frame of 02/14/14 through 04/06/14. TAR records reflect the stockings were removed on 25 evenings during the same 53 day time frame. On the dates reflecting the stockings were not removed, it was not known if the stockings were left on overnight, placing the resident at unnecessary risk for skin breakdown. On 04/07/14 at 03:30 p.m., the resident was observed to be wearing the compression stockings while up in the chair. On 04/08/14 at 12:10 p.m., LN B stated "I monitor the TARs at least weekly to make sure the nurses are providing care as it should be provided. I don't know how I missed the compression stockings. I expect the nurses to put the stockings on in the mornings and remove the stockings in the evenings and to document their actions."

Based on observation, interview, and record review, it was determined the facility failed to define and implement interventions consistent with the resident's needs and stated facility policies and procedures regarding pressure ulcer prevention for 1 of 3 sampled residents (#31) reviewed for pressure ulcers. This failure caused harm to resident #31 when the resident developed 2 facility-acquired pressure ulcers, one of which increased in size and depth, and developed an infection. Findings include: According to the facility's definitions contained in the "Prevention and treatment of [REDACTED]. skin) fat visible; and a Stage 4 is full thickness tissue loss with exposed bone, tendon, or muscle. An Unstageable pressure ulcer is full thickness tissue loss in which the base of the ulcer is covered by slough or eschar (a scab) in the wound bed.The policy stated, "successful treatment of [REDACTED]." Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 04/15/13, indicated the resident was severely cognitively impaired and required extensive two-person assist for bed mobility and transfers. The MDS indicated the resident had two Stage 2 pressure ulcers that developed after admission and three Stage 4 pressure ulcers, initially observed 8/8/11. On admission the resident's Braden skin assessment (an assessment tool used to identify a resident's risk for developing pressure ulcers) indicated the resident was at high risk. The resident continued to be assessed at high risk for developing pressure ulcers during her stay in the facility. Pressure ulcers on the resident's coccyx, right gluteal fold and left gluteal fold were initially observed on 8/8/11 and have continued to be present. Licensed Nurse (LN) A reported the resident had been on Hospice but her condition improved significantly and she was discharged as she no longer met the criteria. On 4/18/13 the Hospice medical doctor charted, "Patient has amazingly hit a new period of stability again. Her sacral wound is somewhat improved and, while she has developed foot ulcers, they are not acutely infected." The doctor determined the resident no longer qualified for Hospice and was discharged on [DATE]. While the resident was on Hospice the "Weekly Pressure Ulcer Report", dated 2/6/13, indicated an initial observation was made of an Unstageable pressure ulcer over the resident's right foot bunion area measuring 4 centimeters (cm) x 4.5 cm x 0.1 cm. New Stage 2 pressure ulcers measuring 2 cm x 0.5 cm x 0.1 cm over the resident's left foot bunion area and 2.5 cm x 1 cm x 0.1 cm on the left great toe were observed. Two Stage 2 pressure ulcers were observed on the resident's left toes, measuring 0.5 cm x 0.5 cm x 0.1 cm and 1.0 cm x 0.5 cm x 0.1 cm. The consulting wound care nurse charted on 2/6/13 "Resident has been steady in healing even small skin issues apart from the 3 major nonhealing wounds but over the past few days has declined in wellbeing and has deterioration of current wounds and development of multiple blisters, one of which further deteriorated into unstageable with slough. These tissue changes are consistent with end of life though resident has a history of rallying despite medical assessments. Recommend keeping her pressure reducing boots on 24/7." On 4/15/13 the visiting Hospice nurse charted "Both bunion sites on feet have exac (exacerbated) - deeper/larger and draining. She is at risk for further breakdown - follow up with foot protector foam or other proper treatment as needed." The resident's skin care plan, revised 3/28/13 and 4/9/13, stated goals for the resident as "no complications of the current pressure ulcers of the coccyx and left and right gluteal fold." The resident's left and right foot pressure ulcers were not addressed in the care plan. A second goal indicated staff would have interventions in place to prevent altered skin integrity. Care plan interventions for the resident's feet included: identifying potential causative factors; pressure relieving/reducing mattress, chair cushion, and positioning pillows to protect the skin while in bed; repositioning frequently when in bed; and protective socks and boots to be applied when up in wheelchair. The consulting wound nurse's recommendation of wearing pressure reducing boots continuously was not included in the care plan. The resident's lower extremity contractures and bony areas of the feet rubbing together were not identified as a potential causative factor. An inservice for the licensed nurses titled, "Skin Function, Risk Factors, and Prevention Measures" was held on 2/23/13. The nurses were instructed to turn and reposition residents every 2 hours, use positioning devices to prevent contact between bony areas and use appropriate pressure reducing devices to reduce the risk and/or prevent skin breakdown. The inservice did not provide specific direction as how to prevent foot ulcers. Observations of the resident's positioning were made as follows: On 4/29/13 the resident was observed lying on her right side in the same position at 1:00 p.m., 2:10 p.m., 3:15 p.m., and 4:10 p.m. The bony areas of the resident's feet were lying on top of each other. Positioning pillows and pressure reducing boots to prevent contact between bony areas were not observed to be present. On 4/30/13 the resident was observed lying on her right side, the bony prominences of the feet together, throughout the day. Positioning pillows and pressure reducing boots to prevent contact between bony area were not observed to be present. From 10:00 a.m. to 1:00 p.m. on 5/2/13 the resident was observed lying on her right side in a fetal position. The bony areas of the resident's feet were together. She was placed in a sitting position for lunch. After lunch the resident was placed on her left side with the bony areas of her feet touching. Positioning pillows and pressure reducing boots to prevent contact between bony areas were not observed. On 5/2/13 the resident's weekly pressure ulcer assessment indicated the area over the right bunion had progressed to a Stage 4 pressure ulcer. On 5/6/13 the resident was observed sitting in her wheelchair from 10:45 a.m. to 2:00 p.m. The resident was then observed lying on her left side. The resident was observed in the same position with her feet pressing against each other, at 4:15 p.m. and 5:10 p.m. Positioning pillows and pressure reducing boots to prevent contact between bony areas were not observed to be present. On 5/7/13 at 10:24 a.m., LN A stated the resident should be turned a minimum of every 2 hours to prevent pressure ulcers from forming or worsening. LN A reported that the aides were responsible for turning the resident. She was unsure if the aides documented when the resident was turned, "the aides just remember when the resident was turned." LN A stated the nurses were responsible for assessing the resident if the aides observed concerns. On 5/8/13 at 11:10 a.m., Nursing Assistant (NA) K reported the aides were only able to chart the time a resident was turned. She stated she just has to remember what side the resident was positioned on. The aides were also to notify the nurses for any skin concerns observed. The aides were not given specific directions for protecting the resident's feet. The aides documentation of resident #31's positioning were as follows: On 4/29/13, the resident was repositioned at 4:58 a.m., 5:03 a.m., 1:52 p.m., (9 hours without turning), 5:02 p.m. and 8:49 p.m.(3.75.hours without turning). On 4/30/13, the resident was repositioned at 12:42 a.m., 5:39 a.m.(5 hours without turning), 9:33 a.m., 11:01 a.m., 1:48 p.m., and 9:05 p.m.(7 hours without turning). On 5/1/13 the resident was repositioned at 12:04 a.m., 1:12 a.m., 3:31 a.m., 4:15 a.m., 9:11 a.m., (5 hours without turning), 1:58 p.m., 3:21 p.m., 9:58 p.m.,(6.5 hours without turning) and 11:40 p.m. On 5/2/13 the resident was repositioned at 1:05 a.m., 3:15 a.m., 5:39 a.m., 10:07 a.m., (4.5 hours without turning), 1:26 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m. On 5/3/13 the resident was repositioned at 12:17 a.m., 4:11 a.m., (4 hours without turning), 5:12 a.m., 10:05 a.m.(5 hours without turning), 12:24 p.m., 5:15 p.m., (5 hours without turning), and 9:42 p.m.(4.5 hours without turning). On 5/7/13 at 8:50 a.m., the wound care specialist contracted by the facility stated he had not been treating resident #31 but interventions for preventing skin breakdown were generally consistent from resident to resident. He stated that residents should not remain in the same position for several hours at a time and positioning to protect bony areas was a standard of practice. At 11:27 a.m., resident #31's medical provider assessed the pressure ulcer over the right bunion as infected and antibiotics were prescribed. The doctor stated the resident "needed to be turned no less than every 3 hours." The surveyor's observations of the resident were shared with the doctor. The doctor stated lying in the same position for more than 3 hours could certainly contribute to further breakdown. The facility's failure to reposition the resident regularly and provide positioning devices to prevent contact between the resident's bony prominences resulted in 2 facility-acquired pressure ulcers. This failure resulted in harm to the resident when one ulcer increased in depth and became infected. Refer to F281 .

Based on observation, interview and record review, it was determined the facility's governing body failed to provide effective oversight for the implementation of policies regarding the management and operation of the facility. The governing body's failure allowed the facility staff to provide chronically inadequate care to residents, including failure to identify and/or respond to residents needs effectively; and allowed the facility staff to complete inadequate or failed to complete investigations to rule out abuse and neglect. Over a period of 3 months the governing body failed to take action necessary to ensure the facility was in compliance with state and federal licensing and certification standards. This failure, as evidenced by the results of 3 abbreviated surveys and the current full survey resulted in 4 harm level citations. Findings include: Between 2/21/13 and 5/8/13 there have been three abbreviated surveys and one re-licensing survey resulting in 27 citations for regulatory violations. Since 3/1/13 the facility has continued to be out of compliance at harm level. During this current survey, sub-standard care was found at: F-314 Treatment/Services to Prevent/Heal Pressure Ulcers at G level & F 493 Governing Body - Facility Policies/Appoint Administrator at G level. The facility has existing non-corrected violations and remains out of compliance for: F-226 Develop/Implement Abuse/Neglect Policies (2/12/13) at D level; F-279 Develop Comprehensive Care Plans (3/25/13) at E level; F-282 Services by Qualified Persons/per Care Plan (3/25/13) at D level; F-353 Sufficient 24 Hour Nursing Staff per Care Plan (3/1/13) at F level; and F-514 Resident Records-Complete/Accurate/Accessible (3/1/13) at E level. The facility's governing body failed to ensure the facility was operated in a manner to effectively implement plans of correction to sustain [MEDICATION NAME] compliance. This failure failed to ensure compliance with state and federal regulations as well as meet the health and safety needs of the residents residing in the facility. .

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for 1 of 9 residents (#4) when they failed to monitor or recognize changes in the Resident's condition. This failure caused harm for the resident when when the need for acute medical treatment was delayed. Findings include: According to the American Nurses Association, Scope and Standards of Practice, 2011, " according to standards of care, a licensed nurse shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. " Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident went to the hospital on 9/17, then re-admitted on [DATE]. The Resident had no feeling below the waist and had to use a Foley catheter (a tube to drain the bladder) for urine. According to the Minimum Data Set (MDS), an assessment tool, the Resident was normally alert and oriented but was dependent on staff for activities of daily living. The Resident received routine insulin (a medication to control blood sugars) and a sliding scale type of insulin that could be adjusted, depending on the Residents blood sugar readings. Sliding scale insulin was to be administered for blood sugars over 130 mg/dL. The order was changed to give slightly less sliding scale insulin starting on 3/12 at 4:30 p.m. The Resident was to have blood sugar checks (CBG's) done 5 times per day. Resident record review reflected the Resident with an elevated blood sugar, poor appetite, decreased fluid intake, decreased urine output and complaints of "not feeling well" beginning with the day shift (6:00 a.m. until 2:30 p.m.) on 3/12/13. Additionally, the Resident was constipated, with no bowel movement recorded on 3/6, 3/7, 3/8, 3/9, 3/10, & 3/11. The Resident was "moaning" on several occasions during the evening shift (2:00 p.m. until 10:30 p.m.) of 3/12 and the night shift (10:00 p.m. until 6:30 a.m.) of 3/13. The Resident was given a suppository on the day shift of 3/12 for no bowel movement, but there was no assessment recorded. The Resident was not assessed on the evening shift of 3/12. The Resident was not assessed on the night shift of 3/13. Vital signs were not recorded. Pain medication was not administered. The physician was not notified of the changes in Resident condition until 8:00 a.m. on 3/13. Blood sugar checks were elevated despite the Resident not eating. Blood sugars were recorded as follows: 3/12 at 7:00 a.m. = 318 mg/dL sliding scale insulin given as ordered, "did not eat breakfast" 3/12 at 11:30 a.m. = 317 mg/dL "sliding scale insulin not given", orders were for 12 units of [MEDICATION NAME] Insulin, "did not eat lunch", 3/12 at 4:30 p.m. = 224 mg/dL "sliding scale insulin not given", orders were for 5 units of [MEDICATION NAME] Insulin, "not eating, constipated", 3/12 at 8:00 p.m. = 186 mg/dL "sliding scale insulin not given", orders were for 3 units of [MEDICATION NAME] Insulin, 3/13 at 3:00 a.m. = 107 mg/dL sliding scale insulin not required Urine output was recorded sporadically for the prior week, with no usual pattern established. The Resident had a catheter (a tube used to drain the bladder). On the day shift of 3/12 the Resident's urinary output was 400 cc (milliliters). On evening shift of 3/12, no urine output was recorded. On the night shift of 3/13, a urinary output of -0- was recorded. No assessment was completed to determine if the catheter was positioned correctly or was open to drainage. On 3/13/13 at 8:15 a.m., according to nursing notes, Resident #4 was sent to the hospital emergently for signs and symptoms of septic shock (an overwhelming infection) with a "Blood pressure of 70/40, pulse 130, temperature of 99.7 and swelling and redness of the genital area." On 3/25/13 at 3:25 p.m., the Director of Nursing stated "I am continuing to investigate, but I don't think we did anything wrong." See F 309 for detailed interviews and explanations of the Resident's deteriorating condition.

Based on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable level of physical, mental and psychosocial well-being when they failed to complete a timely assessment and respond to reported concerns for 1 of 9 residents (#4) whose overall condition was in decline. This failure resulted in unnecessary pain and delayed treatment for [REDACTED]. All staff interviews were completed on 03/22/13 and 03/25/13. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident went to the hospital on 9/17, then re-admitted on [DATE]. The Resident had no feeling below the waist and had to use a Foley catheter (a tube to drain the bladder) for urine. According to the Minimum Data Set (MDS), an assessment tool, the Resident was normally alert and oriented but was dependent on staff for activities of daily living. The Resident received routine insulin (a medication to control blood sugars) and a sliding scale type of insulin that could be adjusted, depending on the Residents blood sugar readings. The Resident was to have blood sugar checks (CBG's) done 5 times per day. According to facility records, Resident #4 saw his physician on 3/11/13 for possible insulin adjustment. The Resident was planning to discharge to the community and the physician had wanted to ensure the Resident's diabetes was in the best possible control. While the Resident was at the office, the Resident was found to be sluggish and was found to have a low blood sugar. Paramedics were summoned to the doctor's office and administered treatment to the Resident. Paramedics recommended hospitalization , but the Resident declined because he wanted to proceed with discharge plans. The physician decided to order a more extended monitoring of the Resident's diabetes later in the month. The Resident returned to the facility with orders to reduce the amount of insulin to be given and to continue to check CBG's 5 times a day. During interview, Licensed Nurse (LN) F stated "I worked the day shift on 3/11, 3/12 and 3/13. My shift is from 6:00 a.m. to 2:30 p.m. On Monday, 3/11, he {Resident #4} went to the doctor with blood sugars out of control. The Resident {#4} would sometimes have blood sugars as low as 30 {mg/dL} and as high as 200-300 {mg/dL}. The Doctor wanted to keep the Resident's blood sugars under 130 {mg/dL} and had changed the sliding scale insulin coverage to a lower level. The next day, 3/12, the resident didn't feel well and was staying in bed. At about 1:30 p.m. {on 3/12}, the Nursing Assistant {NAC M} reported to me that the Resident was still not feeling well. I checked in the computer and I saw the Resident had not had a bowel movement for 5 or 6 days. I listened to his abdomen and I noticed his bowel tones were sluggish. This had happened a couple of times in the past. He was getting medications that cause constipation, plus he has [MEDICAL CONDITION] {no feeling in legs} from a spinal cord injury. He couldn't feel anything from the waist down. I gave him a suppository and told the evening shift nurse. He did not have a bowel movement on my shift." CBG (blood sugar checks) records for the date of 3/12 show the blood sugar at 7:00 a.m. was 318 mg/dL and at 11:30 a.m. was 317mg/dL. Medication administration records (MARs) show sliding scale insulin was administered as ordered at 7:00, but was not given in response to the 11:30 a.m. blood sugar: "Resident refused to eat lunch {on 3/12}, insulin not given." Nursing notes written on 3/12 speak to communication with the physician's office about upcoming appointments. The notes do not provide any information as to the Resident's over all well being or why he might not be feeling well. There was no information available regarding whether the Resident's abdomen had been assessed. There was no information available regarding whether the Resident's vital signs had been checked. There was no information available regarding if any consideration had been given to why the Resident's blood sugars were high when he was not eating. During interview, Nursing Assistant (NAC) J who had worked the evening shift on 3/12 stated "I started my shift about 3:30 p.m. on 3/12. The day shift NAC told me that he {Resident #4} had received a suppository because of no BM in quite a few days and to check him because the resident wouldn't be able to tell if he had a BM or not. I checked on him 3-4 times that shift, but it was about 9:00 p.m. before his bowels moved. When I changed his linen, I leaned him on one side, then when I turned him the other way, I noticed there was not much in the catheter bag, the mattress was wet {indicating leakage} and I noticed that his genitals were red and swollen. I told the nurse {LN G} about my observations. She told me she would check on him. Also, the resident seemed like he might be in pain because he was restless and moaning which I also told the nurse about. He also seemed really, really tired." Nursing notes written by LN G at the end of the evening shift on 3/12 reflected "Res {Resident} not hungry this shift due to constipation and had large BM following suppository for same. Low output {urine} at end of shift due to poor fluid intake but feeling better after BM. Continue bowel meds and monitor. Push fluids." MAR (Medication Administration Records) records indicated the Resident's blood sugar at 16:30 {4:30 p.m.} was 224mg/dL and the blood sugar at 20:00 {8:00 p.m.} was 186mg/dL. According to the MAR, the Resident's "sliding scale insulin held {not given} - not eating-constipated ". No vital signs were recorded in the chart for the evening shift. Nursing notes did not reflect why the Resident was not eating, whether an assessment of the low urine output had been completed or why the Resident's blood sugar remained high despite poor food intake. During interview, LN G, the evening shift nurse on duty on 3/12, stated "I work the evening shift from 2:00 p.m. until 10:30 p.m. I was told in report on 3/12 that he {Resident #4} had received a suppository on day shift. As far as I know, the Foley catheter was patent {functioning}. He had no appetite that evening he said he felt full and was waiting to have a BM." When asked what assessment she had completed for Resident #4 on the evening of 3/12, LN G replied "I checked his blood sugar and gave his medications. I was aware of the low urine output. I did not assess the resident on the evening of 3/12. I didn't think it was necessary." An agency/temporary staff nurse worked during the night shift between 10:00 p.m. and 6:30 a.m. The chart did not contain information to explain what was happening with the Resident from the end of the evening shift on 3/12/13 until the beginning of the day shift on 3/13/13. No vital signs were recorded. No pain medication was administered. A CBG was recorded as being 107 mg/dL at 03:00 a.m. During telephone interview, the agency nurse stated "I noticed the Resident {#4} was arousable and responding to verbal stimuli on 3/12 when I came on duty for the night shift. I was not aware of any changes through the night. I checked his blood sugar at 3:00 a.m. I heard him moaning, but he didn't seem to be in pain." Nursing notes in Resident #4's record written on 3/13 showed "Around 7:30 a.m., noticed res {Resident} very confused and looks pale. Res moaning off and on. While positioning noticed lower abd. {abdomen}, penis and scrotal area swollen and red. Foley cath {catheter} in{place} but no output in Foley bag. Foley cath irrigated with NS {mild salt solution} but no return flow. BP {blood pressure} 70/40, pulse 130, Temp {temperature} 99.7. MD {Doctor} notified and received order to transfer res to hospital." During interview, Nursing Assistant (NAC) K stated "My shift starts at 6:00 a.m. I went into check on {Resident #4} right away on the morning of 3/13 because the off-going aide told me he was moaning all night and seemed to be in pain. I remember his condition on the morning of 3/13 because he was very different from usual. When I first saw the Resident right after I got here, his color was gray. I took the vital signs and the blood pressure was very low, the pulse was high, he had a temperature. When I went to pull the resident up in bed, I saw his private area was very swollen. I immediately went and got the day nurse, then he got sent out to the hospital." During interview, LN F stated "The agency nurse reported in morning report on 3/13 that he {Resident #4} had been moaning and groaning all night and had a low blood sugar. When I went into his room about 7:30 that morning, he didn't look right. He looked confused and more pale. When we went to move him up in bed, I saw his testicles. His penis and testicles were very swollen, maybe about 6-8 inches across. And he had no urine output. We sent him to the hospital about 8:15 a.m." According to staff interview and resident record review, the facility day nurse LN F did not assess the Resident on the day shift on 3/12, despite the Resident not feeling well and having elevated blood sugars and extreme constipation. LN G did not assess Resident #4 on the evening shift of 3/12 despite receiving information from the day shift regarding blood sugar problems, bowel problems and resident complaints of not feeling well, and despite receiving NAC reports of swollen genitals, apparent pain and low urine output. During the night shift of 3/12 to 3/13, an agency nurse unfamiliar with the resident was on duty. There was no indication the night nurse assessed the resident or evaluated the resident's vital signs. On the morning on 3/13, the agency nurse reported the resident had been moaning during the night shift, but no interventions were recorded. The night shift nursing assistant reported on the morning of 3/13 that the resident had been moaning during the night shift. By the time the day shift Licensed Nurse assessed the resident on the morning of 3/13, the resident was experiencing signs and symptoms of acute infection and required emergency transfer to the hospital. The Resident experienced unnecessary pain and a delay in treatment because of lack of assessment for at least 3 shifts. On 3/25 at 3:25 p.m., the Director of Nursing stated, "We heard from the Physician that Resident {#4}was found to have a type of gangrene. I am continuing to investigate, but I don't think we did anything wrong. The Resident was found to have Fournier's Gangrene and had to have radical surgery. He was transferred to the burn unit for extensive skin grafting. He will be there for several months." Refer to F 279, F 281 & F 282

Based on observation, interview and record review, the facility failed to ensure care and services were provided for the highest well being for 1 of 18 residents (#29) when the resident's ongoing pain was not addressed. The resident experienced weight loss, behaviors (anxiety and frequent refusal of care) and decreased mobility which may not have occurred if pain had been recognized and managed resulting in harm to the resident. Findings include: Resident #29 was admitted on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also legally blind. The resident was dependent on staff and required extensive assistance with activities of daily living. The resident had memory problems, but was able to express needs and concerns. According to the re-admission nursing assessment, completed on 01/17/2012, Resident #29 was not experiencing pain. Nursing notes did not reflect pain. Pain was not identified on the Minimum Data Set (MDS), an assessment tool. Further pain assessment was not completed. On 01/26/12, however, the plan of care listed pain as a problem. The care plan stated, "Resident has acute and chronic pain as evidenced by complaints of pain and a decrease in functional level." Possible interventions included "Monitor and report pain, administer [MEDICATION NAME] as ordered and monitor for effectiveness, schedule pain medication administration prior to treatment/activities known to contribute to pain as applicable." A review of the medication administration record (MAR) showed Resident #29 had orders for [MEDICATION NAME] (a mild pain reliever) to be given on an "as needed" basis. The resident had received 5 doses between 01/17/12 and 5/20/12. The resident received no other medication for pain or discomfort. According to the MAR and behavior monitoring records, the resident also received [MEDICATION NAME] (a [MEDICAL CONDITION] medication) for "anxiety and frequent refusal of care." Nursing assistant records show the Resident refused bathing or refused to get out of bed several times each month. When the Resident refused care and was re-approached later or on another day, quite often the care was noted to be accepted. An analysis of the reasons for care refusal was not found. The resident additionally received [MEDICATION NAME] (an anti-depressant) and [MEDICATION NAME] (for appetite stimulation). Occupational Therapy notes refer to pain as the reason given by the resident for refusing to get out of bed into the wheelchair. During the week of 05/01/12 through 05/08/12, notes stated the resident had "Pain in left shoulder (acute and chronic) and left neck pain and pain to buttocks area." Mental health followed Resident #29 weekly to assist with depression and adjustment. Notes written on 02/02/12 stated "Shoulder pain." Notes written on 02/16, 03/29, 04/19, and 04/26/12 reflect "Wheelchair causes pain and creates reluctance to get up." Notes written on 04/26, stated "Resident feels no longer needs [MEDICATION NAME]." Notes, recorded on 05/02, documented "Resident with some irritation noted. He continues to report his wheelchair causes pain that makes it difficult to be motivated to get out of bed." Weight records showed the Resident with difficulty in maintaining weight: 02/01/12 - 216 pounds 03/01/12 - 207 pounds 03/11/12 - 201.8 pounds 03/25/12 - 212 pounds 04/29/12 - 213.5 pounds 05/07/12 - 201.5 pounds The Resident was placed on Ensure as a supplement and [MEDICATION NAME] to help with appetite. No information was found regarding whether pain was affecting the resident's ability to eat. On 5/20/12 at 9:05 a.m., Nursing Assistant (NA) A stated, "The resident does complain of pain on occasion, especially when up. Sometimes the resident refuses care when in pain, but he is real good about letting us know." On 05/20/12 at 10:50 a.m., Resident #29 stated, "I am in pain pretty much all of the time in one spot or another. My left shoulder hurts a lot, especially when I try to move. My back hurts when I get up in the chair. I have a lot of stomach pain. I can get crabby and irritable when I am in pain. Sometimes it affects my appetite, but not always. I have told a lot of the staff about the pain I am having. Anybody that works with me pretty much knows I am in pain." Refer to F-272, F-312, F-329, F-428

Based on observation, interview and record review, the facility did not meet professional standards of practice when a Licensed Nurse discontinued a physician's orders [REDACTED].#4). Findings include: According to the American Nurses Association (ANA), the public has a right to expect nurses to demonstrate professional competence throughout their careers. The nurse is individually responsible and accountable for maintaining professional competence. The nursing profession's responsibility to shape and guide any process for assuring nurse competence. The employer is responsible and accountable to provide an environment conducive to competent practice. Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers and other key stakeholders. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was to wear a hard plastic-type back brace (thoracolumbarsacral orthosis, TLSO) when out of bed to provide stabilization and support to the fracture in her spine. At the time of admission, Resident #4's chart showed intact skin with no open areas and not being at risk for skin breakdown. By 02/24/11, skin breakdown was noted to the buttocks and to both heels. Nursing progress notes reflected a "reddened area on left buttock, blister on left heel and reddened area on right heel." The left buttocks was assessed as a non-pressure reddened area, the left heel was assessed as a 1.0 cm purple area, and the right heel was assessed as being a Stage II blister. Weekly skin assessments were completed and the buttocks area was declared "resolved" on 03/16/11. On 03/19/11, nursing progress notes reflected the Resident to have "a large pressure area 6 x by 3.5 {centimeters}purple blue along upper coccyx and across the lower back where the brace aligns". A 2.0 cm x 1.0 cm open area was noted on the right buttock within a bruised area covering the lower back and left buttock which was discolored, bruised, with loss of superficial skin measuring 6 cm x 3.5 cm at the base of the back brace. The licensed nurse assessed the cause of the deep tissue injury on the back to be related to the constant pressure and ill fit of the back brace. However, the Director of Nursing disagreed with this assessment and on 03/21/11 wrote "Resident was observed with the bruising on the sacral/buttocks related to the TLSO brace sliding down and pinching skin between brace and seat of wheelchair. TLSO brace had never fit well, either riding too high or too low, despite adjustments. Summary: "Open areas left and right buttocks and bruising related to pinching of skin secondary to brace. Plan: continue barrier care, low air loss alt press mattress. Limited time out of bed." On 04/13/11, a telephone order was written in the physician progress notes [REDACTED].{Resident #4} to wound clinic.' An "X" was drawn through the order with the following statement written to the side of the order: "Void per DNS." On 04/14/11 during interview, several licensed nurses who wished to remain anonymous stated, Resident #4's "open area on her coccyx was caused by pressure of the ill fitting TLSO brace. The Residents coccyx, lower back breakdown is now at least a Stage III pressure ulcer. If the Director of Nursing had allowed us to use the proper treatment, we might have been able to prevent the Resident from having such a big problem with her skin." On 04/15/11 during interview, the Director of Nursing stated she was familiar with Resident #4's wound and had seen it many times. She stated the wound was not a pressure area and was not staged because the wound was "shearing" "not pressure." She stated it started as deep tissue trauma from the brace. She stated "We kept watching it, but we never called it pressure because it was an abrasion caused by the shearing force of the TLSO brace". When ask whether she had stopped the Resident's referral to the wound clinic earlier in the week, she replied "We have the expertise here to take care of wounds, the Resident did not need to be seen by the Wound Care Clinic." See also F 314

Based on observation, interview and record review, the facility failed to accurately recognize and assess risk factors, failed to define and implement interventions and failed to monitor, evaluate and revise approaches to maintain intact skin for 1 of 5 residents (#4) reviewed for pressure ulcer prevention and appropriate treatment. This failure resulted in harm for Resident #4 when the resident developed skin breakdown after admitting to the facility and did not receive proper treatment for [REDACTED]. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #4 was to wear a hard plastic-type back brace (thoracolumbarsacral orthosis, TLSO) when out of bed to provide stabilization and support to the fracture in her spine. At the time of admission, Resident #4's chart showed intact skin with no open areas and not being at risk for skin breakdown. On 02/17/11, the nursing admission assessment stated "multi bruising on arms due to hospital treatments, IV's, shots,. Left side bruising from full abdomen, unable to turn to see back." On 02/17/11, a nursing admission note stated ...No decub ulcers." On 02/17/11, the Braden scale assessment to determine skin at risk for breakdown completed on admission showed a score of 18 (a score of 12 or less represented a high risk for breakdown). The following scores were obtained *Sensory perception = 4 = No impairment *Moisture = 3 = Occasionally moist, requiring linen change once per day *Activity = 2 = Chairfast, ability to walk severely limited *Mobility = 3 = Slightly limited *Nutrition = 3 = Adequate *Friction and Shearing = 3 = No apparent problem Total Score = 18 On 02/17, an admission plan of care was developed to address the Resident's needs. This plan included wearing the TLSO brace when only out of bed. The plan called for "preventive skin care." The admission plan of care also called for inspecting area "above and below splint for signs or irritation, redness or chafing at least daily, pad borders with tape if irritation is demonstrated." On 02/24/11, skin breakdown was noted to the buttocks and to both heels. Nursing progress notes reflected a "reddened, blanchable area on left buttock, blister on left heel and reddened area on right heel." The left buttocks was assessed as a non-pressure reddened area, the left heel was assessed as a 1.0 cm purple area, and the right heel was assessed as being a Stage II blister. Treatments were initiated for the assessed areas and the care plan was updated to reflect "float heels, place wedge behind Resident's back to keep her off buttocks". Nursing notes reflected the Resident moved about in bed and frequently turned herself onto her back. Nursing notes did not reflect whether or not the fit or location of the TLSO brace presented a source of pressure or risk of pressure to the lower back area. Weekly skin assessments were completed and the buttocks skin area was declared "resolved" on 03/16/11. On 03/19/11, nursing progress notes reflected the Resident to have "a large pressure area 6 x by 3.5 {centimeters}purple blue along upper coccyx and across the lower back where the brace aligns". A 2.0 cm x 1.0 cm open area was noted on the right buttock within a bruised area covering the lower back and left buttock which was discolored, bruised, with loss of superficial skin measuring 6 cm x 3.5 cm at the base of the back brace. The licensed nurse reported her findings through the alert charting system. The licensed nurse also assessed the cause of the deep tissue injury on the back to be related to the constant pressure and ill fit of the back brace and took measures to pad the borders of the TLSO and contact the manufacturer of the brace. On 03/21, the Director of Nursing (DNS) assessed the wound and wrote a progress note: "Resident was observed with the bruising on the sacral/buttocks related to the TLSO brace sliding down and pinching skin between brace and seat of wheelchair. TLSO brace had never fit well, either riding too high or too low, despite adjustments. Summary: "Open areas left and right buttocks and bruising related to pinching of skin secondary to brace. Plan: continue barrier care, low air loss alt press mattress. Limited time out of bed." An undated, unsigned note was found stapled into the Resident's chart which stated: "Open areas left and right buttock are non pressure - Do Not Stage them. Do Not call them pressure." On 03/23/11, weekly skin assessments show the right buttock with a 2.0 x 1.0 centimeter open area within a bruised area and the lower back and left buttock with a 6.0 x 3.5 centimeter discolored bruised area with a loss of superficial skin at the base of the brace. Weekly skin assessments were completed by the DNS and Resident Care Manager (RCM) with the licensed nursing staff deferring wound care and assessment to them. On 03/28/11, a nursing note stated "wound to bottom brown/black eschar, RCM and DNS to follow. " On 04/04/11, a nursing note written by a nurse manager stated "nurse on floor concerned with open wound to coccyx, sacrum, right and left buttocks. This nurse examined areas. The wound to the right buttock was 3.0 x 5.0 cm with surrounding tissue beef red, slough in the center of the wound bed, dry with no drainage. Sacral/coccyx wound extending to right and left buttocks 8.5cm x 4 cm with slough. MD notified and new orders for treatment obtained." The plan of care was updated. On 04/07/11, a nursing note written by the DNS stated "Resident with pressure on right heel.. Resident also with open areas on right buttock 2.0 x 0.5 cm and low back 6.0 x 3.5 cm secondary to brace. Areas covered with thin layer of slough." On 04/13/11, when the wound continued to deteriorate, a telephone order was written in the physician progress notes [REDACTED].{Resident} to wound clinic.' An "X" was drawn through the order with the following statement written to the side of the order: "Void per DNS." On 04/14/11 during interview, several licensed nurses who wished to remain anonymous stated, Resident #4's " open area on her coccyx was caused by pressure of the ill fitting TLSO brace, with the staging being equal to a Stage III pressure ulcer. If the DNS had allowed us to use the proper treatment, we might have been able to prevent the Resident from having such a big problem with her skin." A note written on 04/14/11 by the attending nurse practitioner in Resident #4's chart stated "Deep tissue wound to low coccyx. Wound wet with grey slough. Will send to the Wound Clinic for evaluation and treatment." On 04/15/11 during interview, the DNS stated she was familiar with Resident #4's wound and had seen it many times. She stated she had written the note to not stage the wound because the wound was "shearing" "not pressure." She stated it started as deep tissue trauma from the brace. She stated "We kept watching it, but we never called it pressure because it was an abrasion caused by the shearing force of the TLSO brace". When asked about the wound clinic referral on 04/13, she stated "We have the expertise here to take care of wounds, the Resident did not need to be seen by the Wound Care Clinic." On 04/15/11, during interview, Resident #4 stated "My behind started hurting right after I got here. It was from the brace not fitting. The nurses were checking on my back and the brace people came and adjusted the brace. Nothing really helped so I had my family bring in a "donut' (a foam cushion) for me to sit on. That really helped to relieve the pressure on my bottom, but they won't let me use it anymore." The facility had systems in place to prevent pressure ulcer development as well as extensive wound care protocols. Facility Licensed Nurses had received extensive training on pressure ulcer prevention and pressure ulcer care. See also F 281

Based on document review and interview the facility failed to ensure residents were free of significant medication errors for 1 of 7 sampled Residents (#3) reviewed for medication administration. The failure of the facility to ensure the resident's medication patch was removed prior to the placement of a new one caused resident harm which required emergency medical attention. All interviews took place 12/17/2010 Findings include: Resident #3 (former resident) was admitted to the facility 11/20/2010 with [DIAGNOSES REDACTED]. Resident had physician orders [REDACTED]. According to the medication specifications for [MEDICATION NAME] the previous day's patch must be removed before applying a new patch. Possible side effects and signs of overdose include weakness, dizziness, and [MEDICAL CONDITION]. On 12/07/2010 Resident #3 collapsed at the nursing station. Resident was assessed as being non responsive with her eyes closed. Her blood pressure was 161/84 and her heart rate was 63. She did open her eyes but was not focusing. Blood sugar was checked and it was 94. Oxygen saturation on room air was 98%. Emergency assistance (911) was called and Resident was taken to the emergency department for further evaluation. In the emergency department a urinalysis was completed to rule out a urinary tract infection. The urinalysis was negative. Resident #3 also had an EKG which showed no significant change. When assessed it was noted the resident had 4 [MEDICATION NAME]es on her body dated 11/30, 12/2, 12/5 and 12/6. The emergency department removed the extra patches and notified the facility. Resident #3 was discharged back to the facility with the [DIAGNOSES REDACTED]. Review of resident #3 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation the old patch was removed or not found. When interviewed, LN A,B, & C stated before applying a new patch they would remove the old one. They said if one was not found they would have another nurse help them look for it. They would document they could not find the old patch on the MAR.