Every finding on record at Vancouver Specialty and Rehab Care

Based on interview and record review, the facility failed to ensure a provider order for antibiotic treatment was implemented for 1 of 3 sampled residents (Resident 1) reviewed for professional standards of quality. The facility failed to implement an order for antibiotics, resulting in Resident 1 not receiving the prescribed treatment.Findings included.Resident 1 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (poor blood flow to the arms and legs caused by narrowed blood vessels), benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate that can cause problems with urination), and urinary retention (inability to completely empty the bladder). The Minimum Data Set, an assessment tool, dated 6/03/2026, documented the resident had moderate cognitive impairment.A provider note, dated 7/06/2026 at 07:00 PM, documented, Significant hematuria (blood in the urine) is present. Patient reports significant dysuria (pain or burning with urination), urgency (a sudden strong urge to urinate), and flank pain (pain in the side or back) Nitrofurantoin Monohyd Macro Oral Capsule 100 MG (an antibiotic used to treat urinary tract infections) Give 100 mg by mouth two times a day for UTI [urinary tract infection] for 7 Days.Review of Resident 1's July 2026 Medication Administration Record did not show an order for nitrofurantoin or documentation that the prescribed antibiotic was given.Lab results dated 07/09/2026 documented Resident 1's urine culture was positive for multidrug-resistant Citrobacter freundii complex (a type of bacteria that can cause urinary tract infections).The Hospital Discharge summary, dated [DATE], documented Resident 1 had sepsis (a serious reaction to an infection that can damage the body's organs) secondary to a urinary tract infection caused by Citrobacter freundii.On 08/18/2026 at 1:40 PM, Collateral Contact A (CC A) stated they observed urine laboratory results, dated 7/09/2026, that were flagged as critical and identified a multidrug-resistant organism. CC A stated they had not previously been aware the resident had a UTI. CC A stated they did not identify that Resident 1 received antibiotics related to the results. CC A stated the resident was subsequently hospitalized on [DATE] and diagnosed with a UTI and sepsis.On 08/19/2026 at 12:55 PM, CC B stated on 07/06/2026 he had intended for Resident 1 to receive nitrofurantoin for the UTI symptoms. CC B stated it was identified that the antibiotic order did not go through and Resident 1 did not receive the medication. CC B stated the order log had been reviewed, and the order could not be located.On 08/19/2026 at 1:56 PM, Staff A, RN, Interim Director of Nursing Services, stated the facility's normal process is for the provider to write an order on a paper order form and provide the form to either the nurse responsible for the resident or the Resident Care Manager (RCM). The nurse or RCM is then responsible for entering the order into the electronic system and placing the resident on alert. Staff A stated the facility reviews orders daily; however, if an order is not entered into the electronic system, there is no electronic order available for staff to review. Staff A stated the facility could not definitively attribute the failure to a specific staff member but had determined that a breakdown occurred between CC B's intended order and entry of the order into the electronic system.On 08/19/2026 at 2:15 PM, Staff B, RN, Risk Management, stated the facility identified that Resident 1 did not receive the nitrofurantoin documented by CC B. Staff B stated the nurse assigned to the resident on the date of the order and the RCM were interviewed, and both denied receiving a written order for the medication. Staff B stated CC B was also interviewed and could not recall which staff member he provided the written order to. Staff B stated the facility was unable to determine where the breakdown occurred in the order process. Staff B stated the written order should have been provided to the nurse assigned to the resident or the RCM for processing.Reference WAC 388-97-1620(2)(b)(ii)

Based on interview and record review, the facility failed to ensure sufficient weekend staffing as identified by the PBJ (payroll-based journal) to provide necessary care and services for 24 of 26 weekend days review for excessively low weekend staffing during the fourth quarter 2025. This failure placed residents at risk for unmet care needs and a diminished quality of life.Findings included.Record review of the PBJ Staffing Data Report, FY [fiscal year] Quarter 4, 2025 (July 1 - September 30), indicated the facility had excessively low weekend staffing.Record review of the facility's staff Hours Summary Report, and the Daily Staffing Form, showed the facility did not have the 3.4 hours of direct care per resident days, from 07/05/2025 through 09/21/2025. In an interview on 02/24/2026 at 1:32 PM, Staff A, Administrator, said they were aware of the low staffing levels during that period. Staff A said to make up for the low staffing they started using agency staff and began onboarding new employees.Reference WAC 388-97-1090 (1)

Based on interview and record review, the facility failed to ensure the binding arbitration agreement (a legally enforceable contract where parties agree to resolve disputes through a private arbitrator [an impartial third party] rather than the court system) included documentation that the facility would ensure the selection of a convenient venue that was convenient to both parties (facility and resident/resident representative) in which to carry out arbitration proceedings for 3 of 3 residents (Resident 10, 21 & 50) reviewed for arbitration. This failure placed residents at risk of not being fully informed of the arbitration process. Findings included.Record review of the facility's arbitration agreement, titled, Voluntary Arbitration Agreement, revised on 08/23/2023, did not show documentation that the residents or their representatives were provided with the opportunity to select a convenient venue to carry out the arbitration proceedings. Resident 10 was admitted to the facility on [DATE]. Record review of Resident 10's Voluntary Arbitration Agreement signed on 09/30/2024 did not show that the agreement informed Resident 10 of the opportunity to select a convenient venue for the arbitration process. Resident 21 was admitted to the facility on [DATE]. Record review of Resident 21's Voluntary Arbitration Agreement signed on 02/06/2024 did not show that the agreement informed Resident 21 of the opportunity to select a convenient venue for the arbitration process.Resident 50 was admitted to the facility on [DATE]. Record review of Resident 50's Voluntary Arbitration Agreement signed on 04/13/2025 did not show that the agreement informed Resident 50 of the opportunity to select a convenient venue for the arbitration process.In an interview on 02/24/2026 at 1:10 PM, Staff A, Administrator, reviewed the facility's arbitration agreement but was unable to show documentation that the facility would ensure a convenient venue would be selected for the arbitration process. Reference WAC 388-97-1780 (1)(2)(d)

Based on observation, interview, and record review, the facility failed to ensure staff properly donned (putting on) gloves during administration of a medication by injection (a medical procedure that involves administering medication directly into the body using a needle which allows the medication to enter the bloodstream or tissues rapidly) for 1 of 2 sampled residents (Resident 47) reviewed for injectable medication administration; and the facility failed to ensure staff properly stored and/or transported dirty laundry bins for 1 of 4 laundry bins reviewed for infection prevention. This failure placed residents and staff at risk for the spread of communicable diseases and a diminished quality of life. Findings included. Record review of the facility's policy titled, Administration of Injections, dated 03/04/2025, documented, .4. Gloves and other PPE [Personal Protective Equipment] are not required for preparing the medications, but are required for administering medications that might involve contact with blood or body fluids. Resident 47 was admitted to the facility on [DATE], discharged with return anticipated on 01/09/2026, and re-admitted on [DATE] with multiple diagnosis to include Diabetes Mellitus (a group of disorders characterized by an inability of the body to regulate its blood sugar levels), and Embolism (occurs when a blood clot breaks off and travels through the bloodstream and lodges elsewhere) and Thrombosis (formation of a blood clot inside a blood vessel) of Left Lower Extremity (leg). The Medicare – 5 Day Minimum Data Set, an assessment tool, dated 01/18/2026, showed Resident 47 was moderately cognitively impaired and was receiving insulin (a medication used to treat diabetes) injections and antiplatelet (medication that prevent blood clots from forming) medication. In an observation and interview on 02/20/2026 at 11:49 AM, Staff F, Charge Nurse/Licensed Practical Nurse, was observed administering an insulin medication injection to Resident 47 in his upper right arm. Staff F was observed to not have gloves on when she administered the injection. When Staff F was asked what the process was for glove usage during administration of injections, Staff F raised her hands up without gloves on, stating, Oh, yes, we are supposed to be wearing gloves. In an interview on 02/20/2026 at 12:17 PM, Staff B, Director of Nursing/Registered Nurse (RN) said she expected staff followed the policy they had for administration of injections. In an interview on 02/20/2026 at 12:22 PM with Staff G, Infection Preventionist/RN, when asked what the process was for administration of injections, Staff G stated staff, Should be washing hands beforehand, wearing gloves, cleansing site beforehand, and administer injections. When asked Staff G if Staff F should have been wearing gloves when she administered the insulin injection, Staff G nodded her head up and down. During an observation and interview on 02/23/2026 at 2:26 PM, four trash cans were observed in the vestibule between rooms [ROOM NUMBERS] on the wall along room [ROOM NUMBER] and about two steps in from the 200 hallway, near the exit leading to the residents' smoking area. One of the bins had two plastic bags of what appeared to be linen sticking out of the top of the barrel. Staff I, Nursing Assistant (NA), walked down the 200-hallway with a tied-up plastic bag in his right hand and placed it in one of the bins. After Staff I placed the bag in the bin, Staff I and an unidentified NA, pushed the bins outside of the door to the outside of the building. When Staff I entered the building, he was asked what was in the bins, Staff I said the bins contained dirty laundry. During an interview on 02/23/2026 at 2:45 PM, Staff I said he believed the bins were taken to the vestibule during mealtime so the bins would not be in the way. During an interview on 02/23/2026 at 2:57 PM, Staff G, said dirty linen was supposed to be bagged up and put in a big bin outside. Staff G said she expected staff to not allow the bins to be overfilled but to take them outside right away before they became overfilled. During an interview on 02/23/2026 at 3:08 PM, Staff B, said the hallway dirty bins should be moved before mealtimes. Staff B said the laundry bins should be removed before they became full and taken outside. Reference WAC 388-97-1320 (1)(a) & 388-97-1860 (1)(a) & (b)

Based on interview and record review, the facility failed to ensure the physician's orders were updated to accurately reflect the resident's choices regarding code status for 1 of 2 residents (Resident 72) reviewed for Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure that maintains blood flow and oxygenation to vital organs when the heart stops beating or breathing ceases). This failure placed the resident at risk of not having their end-of-life wishes honored and decreased quality of life.Findings included . Record review of the facility's policy titled, Communication of Code Status, dated [DATE], stated, .this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information. Resident 72 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated [DATE], indicated Resident 72 was moderately cognitively impaired. Record review of Resident 72's physician order, dated [DATE], documented, Code Status: CPR, Full treatment, avoid TF [tube feeding, method of delivering nutrients directly into the stomach through a tube]. Record review of Resident 72's [NAME] POLST (Portable Orders for Life-Sustaining Treatment, a medical form that specifies a patient's wishes for emergency and end-of-life care), dated [DATE], was marked: Do not attempt resuscitation and Allow Natural Death.Record review of Resident 72's Order Summary Report/Active Orders as of [DATE], stated, Code Status: CPR, Full treatment, avoid TF, with an order date of [DATE].In an interview on [DATE] at 11:10 AM, Staff E, Registered Nurse, said she could find a resident's code status in PCC (Point Click Care, an electronic health records used by the facility), and explained that it's usually in the top margin under the resident's name. Staff E also said she usually started her shift by looking up what the resident's POLST directed, because sometimes the PCC orders for code status were not updated. In a combined interview on [DATE] at 11:20 AM, Staff B, Director of Nursing, and Staff D, Resident Care Manager, said staff could find a resident's code status in the header of PCC when they look up a specific resident. Staff B and Staff D said the PCC code status coincides with the resident's POLST. After Staff B and Staff D reviewed Resident 72's POLST, dated [DATE], both said Resident 72's code status should have been changed to DNR (Do Not Resuscitate) in PCC. Reference WAC 388-97-0280

Based on observation and interview, the facility failed to ensure resident rooms provided enough space for comfort and privacy for 2 of 3 residents (Resident 1 & 24) reviewed for resident rooms. This failure to provide enough room could lead to a disruption of comfort and a diminished quality of life.Findings included.Resident 1 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set (MDS), an assessment tool, dated 11/21/2025, indicated Resident 1 was dependent with transfers to and from a bed to a chair (or wheelchair), and was severely cognitively impaired.Record review of Resident 1's transfer care plan, dated 11/16/2025, indicated, Uses Hoyer lift [a mechanical patient lifting device used to transfer individuals with limited mobility safely between a bed & wheelchair] assistive device to transfer. Resident 24 was admitted to the facility on [DATE]. The Admission/Medicare - 5 Day MDS, dated [DATE], indicated Resident 24 was alert and oriented. During an observation on 02/18/2026 at 1:49 PM, room [ROOM NUMBER] had three beds in the room. Resident 1 had the bed next to the window. Resident 24 was in the middle bed, and one other resident had the bed closest to the door. Resident 1 and Resident 24 were lying in their beds.During an interview on 02/18/2026 at 2:28 PM, Collateral Contact 1, said Resident 1's room did not have enough room for a Hoyer lift. She said she would like Resident 1 to be in a double room.During an interview on 02/20/2026 at 9:50 AM, Resident 24 said the nursing assistants (NA) had to move his bed to get a Hoyer lift under Resident 1's bed. Resident 24 said the NA's had to disrupt him when they had to move his bed to make room for the Hoyer lift.During an observation on 02/20/2026 at 9:56 AM, Staff J, NA & Staff K, NA moved Resident 24's bed (Resident 24 was not in his bed at the time) to get the Hoyer lift positioned near Resident 1's bed. Once Resident 1 was up in the lift they pushed Resident 1's bed towards the window (making more room to get Resident 1's wheelchair next to the bed and Hoyer lift).During an interview on 02/20/2026 at 10:25 AM, Staff J said they had to move Resident 1's bed because of the limited space to get Resident 1 out of his bed and into his wheelchair.During an interview on 02/20/2026 at 4:06 PM, Staff A, Administrator, when asked about the limited space for the Hoyer lift use in Resident 1 and Resident 24's room, Staff A said the expectation was not to create an environment that makes residents feel like they don't have their own space for comfort. Reference WAC 388-97-2460

Based on observation, interview and record review, the facility failed to maintain resident care equipment in a functional and safe manner, for 2 of 4 Mechanical Lifts (Hall 200). This failure placed residents who were dependent for transfers at risk for falls, avoidable injury, and a diminished quality of life.Findings Included. In an interview and observation on 02/19/2026 at 9:09 AM, Staff K, Certified Nursing Assistant (CNA), was observed to be pushing a Reliant Mechanical Lift (battery-powered, mobile floor lift designed to safely transfer residents from beds, chairs, toilets, or the floor) out of room [ROOM NUMBER]. Staff K said that particular lift appeared to be broken and pointed towards a broken off plastic part measuring approximately six inches by three inches in diameter, designed to encase/ cover the hydraulic pump/or motor at the center of the lift. Staff K said, there is another one down the hall. The legs keep coming together and is not safe with a heavy resident. When asked whether the maintenance department was aware of the lifts, Staff K said that they had been. Staff K said she preferred to use any other lifts if they were available. In an interview and observation on 02/19/2026 at 9:38 AM, Staff N, Resident Care Manager/ Licensed Practical Nurse, was asked to inspect the Mechanical Lifts on Hall 200 and demonstrate their proper function. Staff N observed the broken cover, and promptly took the lift off the hall, and notified the maintenance director directly. Staff N said it was the expectation for staff to report any equipment malfunctions to the maintenance department by submitting an electronic work order via Direct Supply TELS [cloud-based management system, designed to report, track, and prioritize facility repairs], although some report verbally. In an interview on 02/23/2026 at 2:03 PM, Staff K stated, They (Mechanical lifts) have not worked in a very long time. Staff K said she had not used TELS to report the malfunctions to the maintenance department and had informed them verbally. Staff K was unable to provide a time frame, or any additional information. In an interview and observation on 02/23/2026 at 3:16 PM, Staff M, Director of Maintenance, said no work orders had come in regarding Mechanical Lifts and provided a log of reported TELS work orders for the last 30 days. Staff M said the facility preferred to use TELS work orders, but some people did report work orders to the maintenance department verbally. When asked whether he was notified of concerns with Mechanical Lifts, Staff M stated, No. Staff M said he was notified today by Staff N, inspected both mechanical lifts, and deemed both unsafe. Staff M stated, they are both going into the dumpster. In an interview on 02/23/2026 at 2:03 PM, Staff A, Administrator, said staff are instructed to use the TELS to place work orders and was unaware of the any lifts malfunctioning. Reference WAC 388-97-2100(1)

Based on interview and record review, the facility failed to convey the trust account for 1 of 4 residents (Resident 112) reviewed for trust funds. This failure placed the residents and/or their representatives at risk for loss of funds.Findings included.Resident 112 had a trust account while a resident in the facility. Resident 112 discharged from the facility on 12/09/2025. Review of the facility's Trial Balance form, balance dated 02/19/2026, indicated Resident 112 had a trust account that was closed on 01/20/2026, approximately 42 days after discharge. During an interview on 02/19/2026 at 1:04 PM, Staff H, Business Office Manager, said discharged resident accounts were supposed to be conveyed within 30 days from discharge.During an interview on 02/19/2026 at 2:14 PM, Staff H said Resident 112 discharged on 12/09/2025 but they did not close the account until 01/20/2026. Staff H said it should have been closed sooner. Reference WAC 388-97-0340 (5)

Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 111). The facility failed to monitor for adverse side effects (ASE) of psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) and Opiate medication (pain medication) for 1 of 5 sampled residents (Resident 111) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side effects and a diminished quality of life. Findings included.Record review of facility's policy for psychotropic medications, undated, documented, .16. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the Attending Physician .Resident 111 was admitted to the facility on [DATE] with multiple diagnoses to include paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational, and persistent distrust, suspicion, and fear of others) and major depressive disorder (mood disorder, characterized by persistent sadness, loss of interest in activities). Record review of Resident 111's 5-Day Minimum Data Set, an assessment tool, dated 02/06/2026, documented Resident 111 was moderately cognitively impaired.Record review of Resident 111's physician orders, dated 01/30/2026, showed Resident 111 was prescribed Quetiapine Fumarate (an antipsychotic medication) oral tablet 25 MG (milligrams) by mouth three times a day. The February 2026 Electronic Medication Administration Record (EMAR) showed Resident 111 was receiving Quetiapine Fumarate as ordered. Record review of Resident 111's Electronic Health Record (EHR) did not show documentation of an AIMS test completed for the administration of Quetiapine Fumarate.Record review of Resident 111's physician orders, dated 01/30/2026, showed Resident 111 was prescribed Bupropion HCl (Hydrochloride, an anti-depressant) oral tablet 100 MG by mouth in the morning. Record review of the February 2026 EMAR showed Resident 111 was receiving Bupropion HCl every morning. Record review of Resident 111's physician orders, dated 01/30/2026, showed Resident 111 was prescribed Oxycodone HCl (pain medication) oral tablet 5 MG by mouth every four hours. Record review of the February 2026 EMAR showed Resident 111 was receiving Oxycodone as ordered. Record review of Resident 111's EHR did not show documentation of staff monitoring for adverse medication side effects while Resident 111 was receiving opiate, antidepressant and antipsychotic medications. In an interview on 02/20/2026 at 9:27 AM, Staff D, Resident Care Manager/Licensed Practical Nurse, reviewed Resident 111's EHR and said an AIMS test was not done. Staff D reviewed Resident 111's EHR and said there was no order or documentation monitoring for adverse side effects for Resident 111's opiate, anti-depressant or antipsychotic medications.In an interview on 02/24/2026 at 11:15 AM, Staff B, Director of Nursing/Registered Nurse, said she expected an AIMS test to be completed upon admission for residents taking antipsychotic medications. Staff B said she expected ASE were monitored for residents taking opiate, antidepressant and antipsychotic medications.Reference WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 5 sampled residents (Resident 6) reviewed for unnecessary medications. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included. Resident 6 was admitted to the facility on [DATE] with multiple diagnosis to include anxiety disorder (a group of mental health conditions that cause fear, dread, and other symptoms that are out of proportion to the situation) and post-traumatic stress disorder (PTSD, a mental health condition caused by an extremely stressful or terrifying event). The Quarterly MDS, dated [DATE], documented Resident 6 was cognitively intact, had anxiety disorder and PTSD, and was not taking antianxiety medications. Review of Resident 6's Electronic Health Record (EHR) showed a physician's order, dated 05/02/2025, for Buspirone HCL (hydrochloride, an antianxiety medication used to treat anxiety disorders) 10 milligrams (mg) three times a day. Review of the February 2025 Electronic Medication Administration Record showed Resident 6 was receiving Buspirone HCL 10 mg three times a day. In an interview on 02/24/2026 at 10:16 AM, Staff C, MDS Nurse/Registered Nurse (RN), said when completing the MDS, they would gather information by interviewing the resident and would look at medical records from the hospital and the facility. After looking at Resident 6's EHR, Staff C said Resident 6 was taking an antianxiety medication. Staff C said antianxiety medication use was not coded on the MDS and it should have been, stating, It looks like it was just missed. In an interview on 02/24/2026 at 10:38 AM, Staff B, Director of Nursing/RN, said it was her expectation the MDS was coded accurately to reflect medications taken by the residents. Reference WAC 388-97-1000 (2)(n)

Based on interview and record review, the facility failed to ensure residents received restorative aid (RA) services for 1 of 3 residents (Resident 10) reviewed for restorative services. These failures placed residents at risk for further decline and a diminished quality of life. Findings included .Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 01/13/2026, indicated Resident 10 was severely cognitively impaired.Review of Resident 10's Restorative Ambulation care plan, dated 10/10/2025, showed Ambulation 3x/week with FWW (front-wheeled walker) and SBA (stand-by-assist) up to 300 ft. (feet) verbal cues to promote safety. Review of Resident 10's restorative range of motion care plan (passive), dated 10/02/2025, indicated AROM (active range of motion) to BUE (bilateral upper extremity) using orange band and provided handout. PT (physical therapy/ist) to complete 1 set of 10 reps of each exercise 3-5 x/week as tolerated.Record review of Resident 10's ambulation task sheet, dated 01/25/2026 to 02/23/2026, documented Resident 10 participated twice in one day on 02/20/2026, and refused four times on 01/26/2026, 02/04/2026, 02/07/2026, and 02/09/2026.Record review of Resident 10's AROM task sheet, dated 01/25/2026 to 02/23/2026, documented Resident 10 participated twice on 02/20/2026 and refused five times on 01/26/2026. 02/04/2026, 02/07/2026, 02/09/2026, and 02/11/2026.Review of Resident 10's electronic health record (EHR) progress notes, dated 02/18/2026 at 3:20 PM documented, Patient has refused RA program on multiple occasions. RA program D/C [discontinued] at this time for lack of participation.During an interview on 02/24/2026 at 1:42 PM, Staff B, Director of Nursing/Registered Nurse, said Resident 10 refused often. Staff B said RAs should be documenting the refusal in the EHR. Staff B said it looked as if Resident 10 only participated a couple of time. Staff B said RAs should have been offering services at least three times per week. Reference WAC 388-97-1060 (2)(a)(b)

Based on record review and interview, the facility failed to ensure timely notification of the resident's representative of a significant change in condition for 1 of 3 residents (Resident 1) reviewed for change-of-condition. This failure placed the resident at risk of the representative being uninformed of the resident's change in condition and unable to participate in care decisions.Findings included .Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia (a decline in mental ability severe enough to interfere with daily life, involving memory loss, thinking problems, and changes in personality or behavior.)Record review of Resident 1's face sheet, undated, showed Resident 1 had a Power of Attorney (POA) responsible for Resident 1's health care decisions. Record review of Resident 1's progress note, dated 09/08/2025 at 6:13 a.m., showed Resident 1 sustained a new skin injury. Facility documentation showed the injury was assessed and treated by staff; however, there was no documentation verifying that the resident's representative or physician were notified as required.In an interview on 10/09/2025 at 12:10 PM, Staff B, Resident Care Manager, stated there was was no documentation to show that Resident 1's responsible party/POA was notified of the skin tear. In an interview on 10/09/2025 at 12:00 PM Staff A, Director of Nursing, acknowledged that notification was required and that there was no documentation showing it had occurred.Reference WAC 388-97-0320 (1)(a)(b)(c).

Based on interview and record review, the facility failed to provide activities of daily living (ADLs) for resident's dependent on staff assistance related to bathing for one of three sampled residents (1) reviewed for ADLs. This failure placed residents at risk for poor hygiene and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (blood flow to the brain is blocked causing brain tissue to die), hemiplegia (paralysis on one side of the body) and hemiparesis (severe weakness to one side of the body). The Minimum Data Set (MDS), a comprehensive assessment tool, dated 01/27/2025 documented the resident required substantial/maximal assistance with bathing. Resident 1's Care Plan, dated 02/24/2025, documented Resident 1 required 1 person assist with bathing/showering twice per week and as necessary. The facility bathing report documented Resident 1 had received four of eight scheduled baths or showers from 03/19/2025 to 04/18/2025. On 04/10/2025 at 1:10 PM Resident 1 said, I don't get showers twice a week. I go an entire week without a shower for some weeks. On 04/24/2025 at 12:44 PM, Staff B, Nursing Assistant, day shift, said caregivers go into the computer system and find what showers they were assigned to do that day. NA B stated that about once a week she was unable to get to all the assigned showers she was assigned to during her shift, but if she was not able to, it fell on to the next shift to complete and adds on to their assigned showers they have for the shift. On 04/24/2024 at 1:02 PM, Staff C, Nursing Assistant, day shift stated that caregivers struggle to get their assigned showers done during their shift. About three of the five days I work, I am unable to get all my showers done and have to pass them onto the following shift to catch up on. If it's on the weekend it's even less likely because there is less staff. On 04/24/2025 at 3:03 PM, Staff D, Nursing Assistant, evening shift, stated that about once a week they were unable to get all of their assigned showers done. They then let the licensed nurse and the oncoming caregiving staff know which residents they were unable to get to. On 04/24/2025 at 3:03 PM, Staff E, Nursing Assistant, Day and evening shift, stated that about once a month they were unable to get to all their assigned showers. They let the licensed staff and oncoming caregivers know which residents they were unable to get to. Staff E said that they had heard that there was a shower aid during the week but had never seen them. On 04/29/2025 at 11:47 AM, Staff A, the Director of Nursing, stated the facility had recently hired three nursing assistants and were in the process of hiring for more shower aids. Staff A stated that around mid-March to mid-April the facility had difficulty with staffing for nursing assistants due to nursing assistants quitting or not showing up for their shifts. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to provide at least eight hours of Registered Nurse (RN) coverage and supervision for 3 of 30 days reviewed. This failure placed residents at risk for not receiving needed care and supervision. Findings included . The facility's daily nurse staff postings and the Staffing Coordinator's working schedule for the 30 days prior to entry into the facility (12/06/2024 to 01/05/2025) showed the facility did not have 24 hours of RN coverage on all reviewed days. On 01/09/2024 at 1:19 PM, Staff A, Administrator, said they did not have a waiver for RN coverage. Staff A said they were recruiting for RNs and offering bonuses. Staff A said they offered incentives for staff retention. Reference WAC 388-97-1080 (3)

Based on interview and record review, the facility failed to consistently assess and implement interventions for bowel management for 3 of 4 sampled residents (76, 332 & 72) reviewed for quality of care related to constipation. This failure placed residents at risk of increased discomfort and negative health outcomes. Findings included . Review of facility policy, entitled, House Bowel P&P [Policy and Procedures], revised 10/23/2023, documented: 1. Day shift nurse run bowel report upon start of shift. 2. Day shift nurse to start bowel protocol in AM with morning med pass, document in EMAR [electronic Medication Administration Record (MAR)], place on alert charting to monitor BT/BM [bowel movement]. 3. Day shift nurse to follow up after 6 hours for effectiveness, if no results complete a bowel assessment and document in progress notes, then proceed to step 2 of house protocol prior to end of shift. 4. Day shift nurses to give report to NOC [night] shift nurses on who needs an Enema. 5. Noc shift nurses to run bowel report upon start of shift, initiate step 3 of bowel protocol at the end of the shift, document on bowel monitor, EMAR, and progress note, then pass off to Day shift via verbal report and Day shift to follow up if no BM with MD [Medical Director]. 6. All Nurses must chart on PRN [as needed] MAR that meds were given and chart the results, must make nursing progress note R/T [related to] ABD [abdomen] assessments . 7. If resident refuses bowel protocol, notify MD, place on alert charting, complete bowel assessment and document. 1) Resident 76 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 12/04/2024, documented Resident 76 was alert and oriented. Review of Resident 76's electronic medical records (EHR) indicated Resident 76 had no documented BMs for 7 days, from 12/30/2024 day shift until 01/06/2025 on the night shift. On 01/06/2025 at 11:30 AM, Resident 76 said he had been constipated for several days making his appetite poor. Resident 76 said he had reported these concerns to staff. 2) Resident 332 was admitted to the facility on [DATE]. The 5-Day MDS assessment, dated 12/31/2024, documented Resident 322 was alert and oriented. Review of Resident 332's EHR indicated no documented BMs for 12 shifts with no initiation of bowel protocol from 12/28/2024 until 01/01/2025 on the evening shift. On 01/06/2025 at 11:30 AM, Resident 332 said he was not eating well due to constipation. Resident 332 said he did not want to keep putting things in from the top when he was not moving on the bottom. 46751 3) Resident 72 was admitted to the facility on [DATE]. The Admission MDS assessment, dated 12/04/2024, documented Resident 72 was alert and oriented. On 01/07/2025 at 8:25 AM, Resident 72 said he was frequently constipated and in discomfort as a result of insufficient bowel management. Resident 72 stated, The morphine makes me constipated. What they give me every day doesn't help. The December 2024 Bowel and Bladder Elimination task sheet documented Resident 72 had a BM on 12/12/2024 at 4:24 AM and did not have another BM until 12/16/2024 at 1:59 PM, over 105 hours between BMs (over four days and 9 hours). Review of Resident 72's EHR indicated no documented BMs for over 105 hours (as indicated above) with no initiation of bowel protocol from 12/12/2024 to 12/16/2024. Review of Resident 72's EHR indicated no documented BMs for over 77 hours (over three days and five hours) no initiation of bowel protocol from 12/16/2024 to 12/19/2024. Review of Resident 72's EHR indicated no documented BMs for over 86 hours (over three days and 14 hours) with no initiation of bowel protocol from 12/28/2024 to 01/01/2025. On 01/08/2025 at 9:09 AM, Staff D, Licensed Practical Nurse, said if a resident did not have a BM by Day 3, senna (bowel stimulant) would be given. If no results, a Bisacodyl suppository; if still no results, an enema would be given to promote a BM. A bowel assessment would also be completed, and if no results the Provider would be notified. All refusal would be documented on the MAR or in a progress note. At 9:44 AM, after reviewing Resident 72's records to determine if the bowel protocol was initiated and followed, Staff E, Assistant Director of Nursing Services and Registered Nurse (RN), said the resident was given Senna on 01/03/2025, 01/06/2025, and 01/07/2025, with no progression to Step 2 of the bowel protocol. Staff E was unable to provide documentation of BMs or medication refusals. At 10:00 AM, Staff B, Director of Nursing Services and RN, said the bowel program should be initiated on Shift 9 at the start of the shift, and if no bowel movement by end of day shift, a suppository should be given. An Enema would be following the end of the night shift following the day when the bowel protocol was initiated. Staff B said she would expect a MD notification if no bowel movements were recorded. On 01/09/2025 at 9:16 AM, Staff D was unable to provide documentation of the BM protocol being initiated for Resident 72. At 1:33 PM, Staff A, Administrator, said she would expect the BM protocol to be started and documented as outlined in the policy. Staff A was unable to provide additional documentation showing Resident 72 received bowel protocol interventions. Reference WAC 388-97-1060 (1)

Based on interviews and and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was completed for 1 of 6 sampled residents (76) reviewed for Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. This failure placed residents at risk for unidentified mental health needs, unmet mental health needs and a diminished quality of life. Findings included . Per facility policy, entitled Resident Assessment Coordination with PASARR Program, revised 09/30/2024, documented, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. Resident 76 was admitted to the facility on [DATE] with diagnoses including anxiety and depression. The 5-day Minimum Data Set assessment, dated 12/22/2024, indicated Resident 76 was alert and oriented. The Level I PASARR (initial screening) was completed by the discharging hospital on 12/21/2024, and showed the resident did not require a Level II evaluation (in-depth evaluation by the state designated authority to determine the need for specialized services for the resident). The medical records showed Resident 76 had a history of anxiety and depression prior to admitting to the facility on [DATE]. On 01/06/2025 at 11:30 AM, Resident 76 was observed to be tearful and extremely anxious when the resident attempted to physically grab the surveyor's arm and requested anxiety medication from the facility staff. Resident 76 said staff had found a bag of knives that he was giving to female staff for personal protection, and now he was fearful of retaliation by staff. On 01/08/2025 at 9:20 AM, Staff H, Social Services Director, said the PASARR was generally reviewed for accuracy, after the resident was admitted . Staff H said if the PASARR was found to be inaccurate, the assessment would be completed immediately that day and sent in for PASARR Level II evaluation. Staff H said the PASARR was not found to be inaccurate until 01/07/2025. Staff H said she was unable to determine why Resident 76's PASARR was not corrected upon admission. At 2:17 PM, Staff A, Administrator, said the facility followed their policy for PASARR reviews. Staff A was unable to provide documentation to support the admission PASARR Level I had been reviewed by facility for accuracy. Reference WAC 388-97-1975

Based on interviews and record review, the facility failed to ensure preparations were made for a safe orderly discharge for 1 of 2 sampled residents (186) reviewed for discharge planning. This failure placed residents at risk for an unsafe discharge into the community and a diminished quality of life. Findings included . Resident 186 was admitted to the facility on [DATE] with diagnoses including diabetes [chronic disease that occurs when the body cannot produce or use insulin properly resulting in high blood sugar levels]. The Quarterly Minimum Data Set assessment, dated 09/26/2024, indicated Resident 186 had moderate cognitive impairment. Discharge care conference, dated 10/25/2024, indicated Resident 186 would be discharging home with spouse (also a resident at the facility). The care conference documentation did not show diabetic monitoring or management was discussed during the meeting. The electronic health record showed Resident 186 discharged home on 11/16/2024. On 01/08/2025 at 9:09 AM, Staff I, Social Services Director, said Resident 186 would have been given a glucometer from the facility to use after discharge. Staff I was unable to provide documentation showing Resident 186 had received a glucometer or had been trained on its use. Staff I said nursing staff would be the ones to document resident training on use of equipment for diabetes monitoring. Staff I said she would look for any documentation to see if teaching and training was completed. Staff I was unable to provide additional documentation of glucometer training. At 9:44 AM, Staff E, Assistant Director of Nursing Services and Registered Nurse (RN), said Resident 186 should have been given a glucometer and should have been shown how to use the glucometer prior to discharge. Staff E was unable to provide documentation of the issuance of a glucometer or training on its use. At 9:50 AM, Staff B, Director of Nursing Services and RN, said she would expect the resident would have been trained on glucometer use, and there should be documentation in the electronic health record. Staff B was unable to provide documentation of the issuance of a glucometer or training on its use. Reference WAC 388-97-0120 (3)(a)

Based on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Power of Attorney documentation for 1 of 12 sampled residents (13) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored. Findings included . Resident 13 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, dated 11/28/2024, showed the resident was moderately cognitively impaired. Resident 13's electronic medical record did not have an ADs or documentation that ADs were reviewed since March 2024. On 01/08/2025 at 1:39 PM, Staff I, Social Services, said ADs were reviewed every quarter during the care conference with long term care residents. Staff I said if the resident did not have an AD, they reviewed the AD with the resident and helped the resident complete one if needed. Staff I said Resident 13 was her own decision maker. Staff I said Resident 13 had a POLST (Physician Orders for Life-Sustaining Treatment), but no AD, Power of Attorney or guardian. At 3:32 PM, Staff A, Administrator, said ADs should be reviewed with residents upon admissions and quarterly if the resident did not have one in place. Refer to F-553 Reference WAC 388-97-0280(3)(c)(i)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 3 sampled residents (13) reviewed for right to participate in planning care. This failure placed residents at risk of not being involved in decisions about their long-term care needs and a diminished quality of life. Findings included . Resident 13 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set assessment, dated 11/28/2024, showed the resident was moderately cognitively impaired. The electronic health records (EHR) showed a care conference was conducted on 04/16/2024. The EHR showed the next care conference was conducted on 12/04/2024, almost eight months after the 04/16/2024 care conference. On 01/08/2025 at 1:39 PM, Staff I, Social Services, said care conferences for long-term residents were done quarterly or as needed. Staff I said Resident 13 had a care conference on 12/04/2024. When asked if there was a care conference prior to the 12/04/2024 care conference, Staff I said Resident 13 had a care conference on 04/16/2024. At 3:32 PM, Staff A, Administrator, said care conferences should be completed quarterly. Reference WAC 388-97-1020 (2)(e)(f)

Based on interviews and record review, the facility failed to ensure the resident was informed about the risk and benefits and could provide an informed consent prior to administration of psychotropic medications for 1 of 5 sampled residents (332) reviewed for informed consent of psychotropic medications. This failure placed residents as risk for not being informed prior to receiving psychotropic medication and a decreased quality of life. Findings included . Resident 332 was admitted to the facility on [DATE]. The 5-day Minimum Data Set assessment, dated 12/31/2024, documented Resident 332 was alert and oriented and had no signs and symptoms of depression. Resident 332's electronic health record (EHR) showed the resident started on Trazadone for depression on 01/03/2025. The EHR did not show an informed consent including the risks and benefits was completed for the Trazadone. On 01/08/2025 at 9:09 AM, Staff D, Licensed Practical Nurse, said usually the Resident Care Managers obtain the medication consents for psychotropic medications. Staff D said psychotropic consents should be done prior to starting psychotropic medications. At 9:44 AM, Staff E, Assistant Director of Nursing Services and Registered Nurse, said Resident 332 was on Trazadone for insomnia. When asked about obtaining a consent for psychotropic medications, Staff E said usually the nurse managers obtained consents from residents or the decision makers. When asked about the resident's informed consent for Trazadone, Staff E was unable to find documentation of an informed consent for the Trazadone for Resident 332. Reference WAC 388-97-0300 (3)(a), -0260, -1020 (4)(a)(b)

Based on interview and record review, the facility failed to ensure treatments were implemented for a Stage 1 pressure ulcer (red area on the skin that does not turn white when pressed) upon admission and prevent further pressure ulcer development for 1 of 4 sampled residents (Resident 1) reviewed for pressure ulcers. This caused harm to Resident 1 when admitted with a Stage 1 pressure ulcer to the coccyx (boney structure at the bottom of the spine) and did not receive treatment or preventable measures for nine days after admission and the pressure ulcer progressed to an unstageable (base of wound is covered by a layer of dead tissue and cannot be seen) wound; and the resident developed an additional unstageable pressure ulcer to the right heel. This failure placed residents at risk for worsening of skin impairment, a change in health status and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture of the left hip and dementia. The Minimum Data Set, a comprehensive assessment tool, dated 08/16/2023, documented Resident 1 required 2-person extensive assistance with bed mobility, transfer status, dressing and toileting. Resident 1's Braden scale, an assessment tool used for assessing pressure ulcer risk, dated 08/09/2023, showed a score of 13 indicating resident was at moderate risk for pressure ulcer development. Resident 1's initial Skin Evaluation, dated 08/09/2023 at 4:37 PM, showed Staff D, Licensed Practical Nurse (LPN), identified a Stage I pressure ulcer to the sacrum (coccyx) measuring 2 centimeters (cm) in length and 2 cm in width. Resident 1's electronic medical record, dated 08/09/2023 to 08/16/2023, showed there were no orders for wound treatment and air mattress, or a care plan implemented for Resident 1's Stage 1 pressure ulcer. Resident 1's weekly Skin Evaluation, dated 08/16/2023 at 7:13 PM, showed Staff E, Registered Nurse (RN), checked a box entitled No new Skin Impairment. Resident 1's Nutrition Evaluation, dated 08/16/2023 at 7:25 AM, showed Staff G, Registered Dietician (RD), documented the resident had no skin breakdown, but several surgical incisions that increased energy needs for healing. Resident 1's weekly Skin Evaluation, dated 08/17/2023 at 2:30 PM, showed Staff G, LPN and Resident Care Manager (RCM), documented a New Skin Impairment. A Stage 1 pressure ulcer to the coccyx measuring 3 cm in length and 2 cm in width was identified during management wound rounds. Record review showed a treatment order and care plan were initiated on 08/18/2023 for Resident 1's Stage 1 pressure ulcer to the coccyx (9 days after admission with the Stage 1 pressure ulcer to the coccyx). The records showed a maintenance request form was placed for an air mattress but there was no order to direct the weight settings for the air mattress that were required to provide pressure relief. Resident 1's weekly Skin Evaluation, dated 08/23/2023 at 5:01 PM, showed Staff F, LPN, documented a New Skin Impairment, an unstageable pressure ulcer to the right heel. A progress note, dated 08/23/2023, documented physical therapy notified Staff F of a skin condition to Resident 1's right heel. The area appeared to be black and surrounding area red, non-blanchable (a condition where reddened skin does not turn white when pressed with a finger) and painful. Record review showed on 08/23/2023 a treatment order and care plan were initiated for Resident 1's unstageable pressure ulcer to the right heel. An order for the air mattress was not found. The August 2023 and September 2023 Treatment Administration Record did not show documentation of an order for an air mattress or monitoring of air mattress weight settings. Review of progress note, dated 08/31/2023 at 1:36 PM, showed Staff G documented Resident 1 was seen by the wound consultant for weekly tracking and wounds continued to deteriorate. A wound culture of the coccyx was collected. The Nurse Practitioner performed debridement (the removal of damaged tissue from the wound) with no complaints of pain. Santyl (a gel type medication used to cleanse wounds of damaged tissue) and NS (normal saline) soaked gauze covered with a foam dressing were applied to the wound. A broad spectrum antibiotic was initiated while waiting for results of the wound culture. Wound Progress Note, dated 08/31/2023, showed Resident 1 had an unstageable pressure wound to the coccyx. The resident's wound is deteriorating from last visit and covered with thick slough [dead tissue separating from living tissue]. [Resident 1] is presenting with a new deep tissue injury on her right heel . Sharp debridement provided to remove slough [on the coccyx] and restore blood flow to the wound . Wound consultant round notes, dated 09/14/2023 at 2:30 PM, showed Resident 1's coccyx wound to be unstageable with measurements of 5 cm in length, 4 cm in width, and 3.5 cm in depth. The unstageable right heel ulcer had measurements of 3 cm in length, 4.5 cm in width, and 0.0 in depth. Record review showed Resident 1 was sent to the hospital on 09/20/2023 at 1:00 AM for a change in condition. Hospital records, dated 09/20/2023, showed Resident 1 was found with unstageable pressure ulcers to the coccyx and right heel. On 10/10/2023 at 1:40 PM, Staff D said when a resident was admitted with a pressure ulcer, they would notify the provider and request treatment orders, notify care managers, and initiate a care plan. When asked about requesting a therapeutic mattress, Staff D said the RCMs would address that. At 2:45 PM, Staff C, RN and Risk Management, said if a resident came in with a pressure ulcer the expectation was to request a physician's order and air mattress right away. Staff C said a care plan was initiated and an air mattress was obtained on 08/18/2023 for Resident 1's pressure ulcer to the coccyx. Staff C said the care plan was updated on 08/25/2023 for Resident 1's pressure ulcer to the right heel, and a safety assessment was completed on 08/28/2023 for the air mattress. Staff C said there was not an order for the air mattress. At 2:50 PM, Staff B, RN and Director of Nursing Services, said her expectation, if a resident was admitted and assessed as having a pressure ulcer, would be to contact the provider, obtain treatment orders, and to request an air mattress if a pressure ulcer had been identified. On 10/13/2023 at 12:32 PM, Staff E said when No New Skin Impairment was checked on the weekly Skin Evaluation document, this did not mean there were not previous skin impairments noted. Staff E indicated she was not able to remember if Resident 1 had a pressure ulcer. Staff E said if a pressure ulcer was found on evaluation the provider would be notified and a treatment order obtained. When asked who was responsible for initiating an order for a therapeutic mattress, Staff E said she was unsure, and would notify the provider or management staff for direction. On 10/13/2023, at 1:07 PM, Staff G said the expectation for staff if a resident was admitted with a pressure ulcer was to notify the provider and RCM, initiate treatment orders, initiate a care plan, request an air mattress if the resident had a pressure ulcer on their coccyx, and initiate therapeutic boots if the resident had a pressure ulcer to the heels. When asked about an order for Resident 1's air mattress, Staff G said she remembered obtaining and care planning for an air mattress but might have overlooked getting an order. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to implement prevention and treatment strategies and failed to implement wound treatment orders for 1 of 3 sampled residents (64) reviewed for pressure ulcers (a skin wound caused by pressure preventing blood flow to the skin). This caused harm to Resident 64 when seven facility acquired Stage 4 (full thickness skin and tissue loss extending into muscle, tendon, ligament, cartilage or bone) pressure ulcers developed. This failure placed residents at risk for infection, wound development and worsening and a diminished quality of life. Findings included . Review of National Pressure Ulcer Advisory Panel position paper entitled Unavoidable Pressure Injury during COVID-19 Pandemic, dated 06/16/2020, showed, Avoidable pressure injury has been defined by CMS [Center for Medicaid/Medicare Services] as those pressure injuries that develop in [residents] for whom the [healthcare provider(s)] did not do one or more of the following: [properly] evaluate the [resident's] clinical condition and pressure injury risk factors; define and implement interventions that were consistent with [resident's] needs, goals for care, and recognized standards of practice; monitor and evaluate the outcome of the interventions; and/or revise the interventions as appropriate. Facility policy entitled Prevention of Pressure Injuries, revised April 2022, showed residents with pressure injuries must be repositioned on an individualized basis, determined by the interdisciplinary care team. The frequency for repositioning was based on the resident's risk factors and current clinical practice guidelines. Pressure redistribution and support surfaces were selected based on the resident's risk factors, in accordance with current standards. Resident 64 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralyzed arms and legs) and respiratory failure requiring dependence on life support. The admission Minimum Data Set (MDS), an assessment tool, dated 12/12/2022, documented Resident 64 was cognitively intact, was dependent on staff for activities of daily living including bed mobility, had one Stage 4 pressure ulcer and a surgical incision, and was not on a turning/repositioning program. Review of Resident 64's quarterly MDS, dated [DATE], documented Resident 64 had four Stage 4 pressure ulcers and three deep tissue injuries (an injury to underlying tissue, below the skin's surface, that results from prolonged pressure, restricting blood flow in the tissue causing the tissue to die), that three of the Stage 4 pressure ulcers were facility acquired, and Resident 64 was not on a turning/repositioning program. Review of wound provider note, dated 03/31/2023 showed Resident 64 had the following pressure ulcers: --Coccyx (low back/upper buttock)- Stage 4, 7.4 centimeters (cm) x 7.6 cm x 0.5 cm with palpable bone and exposed muscle/fascia (connective tissue). Resident admitted with this ulcer. --Left Ischium (pelvis/hip bone)- Stage 4, 4.7 cm x 3.4 cm x 2 cm with palpable bone and exposed muscle/fascia. --Right Ischium- Stage 4, 3.6 cm x 4.1 cm x 1.2 cm with palpable bone and exposed muscle/fascia. --Right Posterior Lower Leg- Stage 4, 11.7 cm x 2 cm x 0.2 cm with exposed tendon/ligament (connective muscle and tissue). --Left Heel- Deep tissue pressure injury. --Right Heel- Deep tissue pressure injury, 2.3 cm x 0.9 cm. --Right proximal heel- Stage 3. --Proximal Spine- unstageable (Full thickness tissue loss in which the actual depth of the ulcer is completely obscured), 9.4 cm x 4.2 cm, increased odor, exudate, and necrotic tissue (dead skin) with wound breakdown. --Distal Spine- unstageable, 1.8 cm x 1.5 cm. <Failure to Turn/Reposition and Failure to Manage Refusals> Review of Resident 64's impaired skin integrity care plan, dated 12/07/2022, documented Resident 64's goal of care was to have the skin heal without any signs or symptoms of infection and his skin would remain intact. Staff were to float heels (position legs so heels do not touch the bed surface) and turn frequently/reposition. Review of Resident 64's quadriplegia care plan, dated 12/15/2022, documented Resident 64 was to be Reposition/Ambulate as tolerated and at least every 2 hours. Review of Resident 64's pain management care plan, dated 12/15/2022, documented Resident 64 was to be pre-medicated for pain prior to activity to optimize participation. Review of Resident 64's behavioral care plan, dated 12/19/2022, documented Resident 64 had a behavior problem related to refusal of repositioning. Staff were to administer medications as ordered and monitor/document for side effects and effectiveness. Review of Resident 64's March 2023 Medication Administration Record (MAR) documented an order for oxycodone (pain relieving medication) 10 mg (milligram). Give 10 mg as needed for pain related to pressure ulcer of sacral region (low back), one hour prior to wound care. The MAR showed the medication was given five times that month, and three times correlated with successful completion of wound care. Review of Resident 64's behavior symptom task sheet, dated 03/06/2023 to 04/05/2023, documented rejection of care occurred twice out of 53 entries. The other 51 entries were documented as 'none of the above observed.' On 04/03/2023 at 2:37 PM, Resident 64 said he had wounds on his heels and bottom. Resident 64 was observed laying on his back in bed, arms propped on pillows. There were booties (cushioned barriers) on both feet. Resident 64's heels were not floated. On 04/04/2023 at 9:00 AM, Resident 64 was observed laying on his back with a pillow under each arm. His heels were not floated. At 11:06 AM, Resident 64 was observed laying in the same position. Resident 64 said he did not know why or how he got a new wound on his leg. At 1:08 PM and 3:00 PM, Resident 64 was observed in the same position. On 04/05/2023 at 8:04 AM, Resident 64 was observed laying on his back, a pillow under each arm and the heels not floated. At 8:12 AM, Staff F, Registered Nurse (RN), said Resident 64 did not like to turn to the right side and he preferred to turn to the left. Staff F said Resident 64's head was tilted to the left so his neck was getting contracted (stiff with limited motion) due to lack of movement and was tight now when they moved him. Staff F said Resident 64 complained of pain in his neck and other places. Staff F said they premedicated Resident 64 with oxycodone if he wanted. Staff F said Resident 64's refusals were why his wounds were getting so bad. Staff F said the Certified Nursing Assistants (CNAs) did the turning, and they asked the resident every two hours to turn. Staff F said Resident 64 had refused wound care yesterday and last night. The April 2023 MAR did not show Oxycodone was administered to pre-medicate for wound care. At 8:31 AM, Staff K, CNA, said she tried to turn Resident 64 every two hours but he had the right to refuse. Staff K said if he refused, she would reapproach three times, 15 minutes apart. Staff K said Resident 64 had not let her reposition him that day. Staff K said she asked a few times. Staff K said Resident 64 was sensitive to pain. Staff K said the bed was supposed to alternate [side to side]. At 8:48 AM, Resident 64 said he had not been asked to reposition that day, and he would if they asked. At 8:54 AM, Resident 64 was approached again and stated he had not been asked to turn that day. When asked if he refused, Resident 64 said Staff K had not asked or turned him because he had been sleeping and had not been woken up. Resident 64 said the last time he was repositioned had been on the night shift. Resident 64 said he would turn if he was asked. Resident 64 said he did not refuse turning. At 9:05 AM, Staff K and Staff D, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), was observed in Resident 64's room repositioning him. Resident 64 did not refuse. At 9:07 AM, Staff L, CNA, said in the beginning Resident 64 would refuse but now was more understanding. Staff L said Resident 64 usually allowed turning and if he did refuse it was because of no pain medication. Resident 64 would have you come back after pain medication, so did not refuse totally. At 9:12 AM, when asked how she was made aware of turning refusals, Staff F said it depended on the CNA. Staff F said the CNAs would leave then come back and Resident 64 would be approachable. Staff F said Resident 64 was better now with refusals from when he got here. Staff F said there were some CNAs he was more comfortable with and did not refuse turning for, then gave an example of a staff on the weekend shift. Staff F said Resident 64 allowed turning but not every two hours now and would allow changing with incontinence care. At 10:26 AM, Staff D said interventions to prevent and treat pressure ulcers included offloading pressure. Staff D said the CNAs rounded every two hours and repositioned when in the room. Staff D said all care staff with a license were responsible to reposition residents. Staff D said if a resident refused, the staff reapproached three times and then documented it. Staff D said they would update the care plan to make it work for the resident. Staff D said Resident 64 had, in the past for a period, refused care but was doing better. Staff D said Resident 64 did refuse because of pain with movement. Staff D said they would tell the nurse to medicate him with 10 mg Oxycodone which did help. Resident 64's biggest barrier was pain which had improved a lot. Staff D said Resident 64 was a reliable historian. When asked about staff failing to turn Resident 64 that morning, Staff D said she and Staff K went in and turned him no problem. Staff D said she would look into CNA training. When asked if the CNAs used the care plan, Staff D said she expected the CNAs to use the Kardex (task list). Staff D stated, Hard to know if they use the care plan, should be though. At 11:17 AM, Staff J, LPN, said she was the former RCM for Resident 64. Staff J said Resident 64's refusals had gotten better but not gone away. Staff J said Resident 64 refused wound care, obtaining weight, and repositioning on admit. Staff J said if he refused, the nurses explained the reasoning and 90 percent of the time a direct approach worked well for him. Staff J said Resident 64 was a lot more compliant than when he first got to the facility. Staff J said she was his nurse all weekend and he did great. Staff J said if Resident 64 was premedicated with Oxycodone, he was compliant. Staff J said Resident 64 was turned frequently, every one to two hours was standard, and he did not require more frequent turning than the standard. Staff J said the nurse or CNA was responsible to float Resident 64's heels. At 12:54 PM, during a wound care observation, two pillows were under Resident 64's neck, two pillows were removed from under his arms, a foam wedge and one other flat pillow were in the room. There were not enough pillows in the resident's room to float both heels and turn the resident on his side while supporting his painful and stiff neck. At the end of wound care, staff positioned Resident 64 on his side. His legs were not floated. At 2:01 PM, Staff B, Director of Nursing Services and RN, and Staff C, Director of Quality Assurance and LPN, said they expected residents to be turned every two hours. When asked what 'frequently' meant on the care plans, Staff B said staff should reposition as frequent as possible. Staff B said it was not possible every 2 hours, so a range of 1.5-2.5 hours was acceptable. Staff B said she expected staff to approach residents (to turn) even when sleeping. <New Skin Injuries> Review of Resident 64's skin assessment, dated 04/02/2023, documented Resident 64 sustained a new pressure ulcer to his left lower leg. The wound was described as dark red/purple and and measured 6 cm x 1 cm. The shape of the wound was described as line. On 04/05/2023 at 12:54 PM, during a wound care observation, the left lower leg dressing was removed which was stuck to the skin. Staff F used wound cleaner to moisten the skin and dressing to separate them. As the bandage was peeled back, the skin from the lower half of the wound peeled back with the dressing. Staff F said the wound was now open. Resident 64's urinary catheter bag was observed hanging off the bed on the left side allowing the tubing to run next to the left lower leg. The skin injury was of similar shape and size as the catheter tubing. When adjusting Resident 64, a new red baseball size area was observed on the left hip. Staff K said the area was new. Staff F applied skin prep to the area. <Failure or Delay in Implementation of Wound Orders> 1) Review of Resident 64's electronic health records (EHR) documented a wound care order, dated 03/16/2023, which included leaving both heels open to air. Review of Resident 64's wound provider note, dated 03/24/2023, documented a foam dressing was to be applied to both heels daily and as needed during wound care. Review of Resident 64's EHR showed the order was updated on 04/04/2023, 11 days after the order was written. 2) Review of Resident 64's wound provider note, dated 03/10/2023, documented a change in wound care orders for the Stage 4 pressure ulcers to the coccyx, left ischium and right ischium. The order was to apply Hydrofera blue, a medicated foam, to the base of the wound. The previous order for Dakin's (a liquid wound treatment) soaked gauze packing, was not continued. Review of Resident 64's wound provider note, dated 03/17/2023, documented a change in wound care orders for the stage 4 pressure ulcers to the coccyx, left ischium and right ischium. The order was to apply Vashe (a liquid wound care treatment) to soak gauze and pack into base of the wound. The order for Hydrofera blue was not continued. Review of Resident 64's wound provider note, dated 03/24/2023, documented Recommend Vashe treatment. However, the facility team provided Hydrofera blue . Review of Resident 64's March 2023 MAR documented the facility failed to discontinue the Dakin's solution and start the Hydrofera blue until 03/16/2023, six days after the order changed. The MAR documented the facility failed to implement the Vashe soaked gauze packing completely and instead continued the Hydrofera blue. On 04/05/2023 at 10:26 AM, Staff D said the RCMs accessed a program to get the new wound orders because all the notes were uploaded. Staff D said if the wound provider gave a verbal order, they could put it in right away but usually they waited for the notes to be uploaded to put orders in the EHR. Staff D said wound rounds were on Friday, so by Tuesday they typically aimed to have orders updated. At 11:17 AM, after looking at Resident 64's wound orders in reference to the missing Vashe treatment, Staff J said she did not know why it was not given. At 2:01 PM, Staff B and Staff C said it was the RCMs' responsibility to update the orders as soon as they were uploaded into [an online program]. Staff C said she expected the RCMs to look for new orders on Monday. Staff B said she expected the staff to follow orders unless the house provider had an alternative. <Improper Air Mattress> Resident 64's Skin Integrity Care plan, dated 12/15/2022, documented Resident 64 required an air mattress related to a pressure ulcer. The goal was for Resident 64 to remain free of complications including skin breakdown. Staff were to monitor and document for side effects and effectiveness including skin breakdown. Review of Resident 64's skin grid, dated 12/21/2022, documented weekly skin assessments for a second facility-acquired pressure ulcer to the spine which started as a deep tissue injury and progressed to an open wound. Review of Resident 64's EHR showed an order, dated 03/09/2023, for House Air Mattress. Type: Medicure Settings: 720 (internal air pressure of the mattress). Check to ensure functioning of air mattress every shift. If any issues notify administration. There were multiple discontinued orders for mattresses including orders without pressure settings. Review of Resident 64's wound provider note, dated 03/24/2023, documented after the facility changed the air mattress, Resident 64's wounds started to show improvement. On 04/05/2023 at 11:17 AM, Staff J said staff switched out the air mattress because the old one was not pressure relieving correctly and was caving in the middle. Staff J said it was the same type of mattress, just a different one and was now less painful for the resident. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure residents were free from sexual abuse for 1 of 17 sampled residents (#1) reviewed for abuse. This failure placed residents at risk for psychological harm, pain and a diminished quality of life. This failure caused harm to Resident #1 when she experienced sexual abuse, pain, embarrassment and attempted to leave the facility. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 10/12/19, documented Resident #1 was moderately cognitively impaired and required extensive assistance with activities of daily living. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #2 was cognitively intact. A late entry social services progress note, dated 10/14/19, documented Resident #1 had a relationship with Resident #2. Resident #1 said she did not want to get all touch feely. A nurses progress note, dated 10/20/19 at 6:42 PM, documented Resident #1 stated, He touched me and it hurts there now. The note showed staff had asked Resident #2 multiple times to be separate from Resident #1. Resident #2 continued to follow Resident #1 after she expressed to be left alone. The facility investigation report, dated 10/20/19, documented Resident #1 was overheard by staff stating Resident #2 touched her genital area and it was hurting. The investigation documented Resident #2 had penetrated with his fingers and caused pain to Resident #1. Resident #1's statement showed sexual contact was not consensual and caused pain. Resident #2 was placed on 1:1 (one staff to one resident). Resident #1's care plan, initiated 10/21/19, documented demonstrates a need for companionship/affection with other residents as evidenced by hand holding and kissing. Resident #2's care plan, initiated 10/21/19, documented demonstrates a need for companionship/affection with other residents as evidenced by hand holding, kissing (and) verbalizing that they are in a relationship. On 10/28/19 at 2:03 PM, Resident #2 said he penetrated Resident #1's genital area with his finger. Resident #2 stated, I had long nails. I could have scratched her. At 3:00 PM, Resident #1 said Resident #2 reached in her pants and touched her genital area. Resident #1 said she told Resident #2 to stop, but he did not. He went further and penetrated with his finger and she was scratched. Resident #1 stated, It was rough. Resident #1 said she grabbed Resident #2's hand and pulled it out as it was hurting. Resident #1 said she felt disrespected, embarrassed and said she felt discredited. Resident#1 said she did not consent to sexual contact and did not want to be touched. Resident #1 stated, It was hard for me. On 11/07/18/19 at 11:50 AM, Staff P, Nursing Assistant, said she noticed Resident #1 stayed in her room more after the incident. At 12:45 PM, Resident #1 said she attempted to leave the facility as she felt she should have not said anything regarding the incident. Resident #1 said she felt anxious, embarrassed and upset with the incident and did not want to stay at the facility any longer. Resident #1 said she was afraid to sleep at night and she no longer felt safe at the facility. Resident #1 felt Resident #2 was getting all the attention as he had 1:1 with him all the time. At 1:15 PM, Staff C, Social Services Assistant, said staff notified Social Services Resident #1 and Resident #2 were observed kissing and had a romantic relationship. Staff C said Resident #1 and Resident #2 were approached to ensure both parties had consent to the intimate relationship. Staff C said Resident #1 said she did not want to be touched. At 4:00 PM, Staff B, Director of Nursing Services, said she had observed on multiple occasions Resident #1 and Resident #2 holding hands and later was made aware of the two residents being affectionate in the hallway. Staff B said the relationship was consensual prior to the incident occurring. Staff B said Resident #2 had a [DIAGNOSES REDACTED]. Reference WAC 388-97-0640(1)

Based on observation, interviews and record reviews, the facility failed to ensure a physician order [REDACTED].#1) reviewed for physical restraints. This failure placed residents at risk of frustration, decline in function, not having their preferences honored and a diminished quality of life. This caused psychosocial harm to Resident #1 when he told the facility he did not want the wanderguard and it was placed anyway. Findings included . Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Safety Device Data Collection and Evaluation, dated 08/29/19, documented the use of a wanderguard on Resident #1's electric scooter to treat medical symptom variable level of alertness. The evaluation did not identify the wanderguard as a physical restraint and did not show past alternatives/interventions attempted. Resident #1's At risk for unsafe operation of electric scooter care plan, initiated 08/27/19, documented the following: -Wanderguard on w/c (wheelchair) to remind him to remain in safe environment when operating his electric scooter. -Resident #1 may operate his electric scooter outside with supervision. A physician's orders [REDACTED].#1's medical symptom. Resident #1's medical record did not contain a signed consent for the use of the wanderguard and did not contain attempts made for least restrictive interventions attempted prior to placing the wanderguard. Resident #1's progress notes, dated 08/28/19 through 09/05/19, did not show follow up and the resident's response to the wanderguard. On 08/29/19 at 1:59 PM, Resident #1 said a wanderguard was placed two days ago on his electric scooter, and he was unable to go outside with his electric scooter. The resident said he told Staff H, Registered Nurse (RN), he did not want the wanderguard. Resident #1 said Staff H said she had to place it as she was directed by upper management. Resident #1 said he did not sign a consent for the wanderguard to be placed. Resident #1 said he was mad, angry and upset when the wanderguard was placed. Resident #1 stated, I feel humiliated. The wanderguard was observed attached to the left side of the resident's electric scooter. At 2:55 PM, Staff C, Resident Care Manager (RCM) and RN, said a wanderguard was placed on Resident #1's scooter as a reminder for him not to go outside in his electric scooter. At 3:30 PM, Staff E, RN, said she was not aware the resident had a wanderguard, but she could see why it was placed, he leaves the facility a lot. At 4:15 PM, after not being able to locate Resident #1's signed consent for the wanderguard, Staff F, Quality Improvement Nurse, said a Safety Device Information should be completed and Staff C was working on it. At 4:35 PM, Staff G, RCM and RN, said he felt no least restrictive options were attempted prior to the wanderguard being placed. Staff G indicated the resident was being restricted from going outside. On 08/30/19 at 11:05 AM, Resident #1 said no one had asked him if he needed the wanderguard. The resident stated, It's making me mad. At 3:52 PM, Staff H, RN, said Resident #1 refused to have the wanderguard placed. Staff H said she placed the wanderguard on 08/27/19 after Staff C spoke with the resident. Staff H said Resident #1 felt like the facility was trapping him and taking away his rights. At 5:03 PM, Staff D, Anonymous Staff, said Resident #1 was seen crying and was requesting to have the wanderguard removed. Staff D said the resident was being restrained as the doors locked when the resident got close to them. On 09/05/19 at 10:10 AM, Staff C said the wanderguard was the least restrictive intervention for Resident #1. Staff C was unable to provide a signed consent. Staff C said she discussed risks and benefits with the resident, but did not complete one. Staff D said she should have documented interventions attempted prior to placing wanderguard. Staff D said it was expected for wanderguard orders to be obtained right away and said an order should have been obtained prior to placing the wanderguard. At 11:16 AM, Resident #1 stated, I cannot go outside. I am like a kid now. Resident #1 said he would like the Wanderguard removed. Resident #1 stated, I feel like I am an infant who cannot be trusted. I feel disrespected. At 12:00 PM, Staff B, Director of Nursing Services, said it was expected for staff to obtain a physician order [REDACTED]. Staff B said it was expected a risk and benefit to be completed, and said it was not done. Staff B said the resident does not need to sign a consent for the wanderguard. Staff B said the wanderguard was the least restrictive interventions for Resident #1. On 09/06/19 Resident #1's representative said the facility did not discuss with him other options attempted or the risk and benefits prior to placing the wanderguard on the resident's electric scooter. Reference WAC 388-97-0620(1)

Based on observation, interview, and record review, the facility failed to provide care and services which promote and enhance privacy and dignity of 1 of 4 sampled residents (#59) and 1 of 1 dining room reviewed for dignity and resident rights. This failure placed residents at risk for diminished dignity and a lack of homelike dining experience. This caused harm to Resident #59 when her privacy curtain was not closed and the resident's body was visible to residents and visitors in the hallway. Findings include . Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/09/18 at 11:28 AM, the resident was observed lying on her bed, wearing only a shirt and brief. The resident was visible from the hallway and privacy curtain open. Multiple staff members were in the hallway and no one entered the resident's room and pulled her privacy curtain to prevent view of the resident from the hallway. At 5:01 PM, the resident was observed lying on her back in bed wearing only a shirt and brief. The privacy curtain was open. On 07/10/18 from 11:17 AM to 11:24 AM, the resident was observed lying on her back in bed. The resident was wearing a shirt and a brief. The resident's brief was pulled down past her knees. The resident was exposed and visible from the hallway. Two (2) Nursing Assistants (NAs), the Records Management (RM) staff, and the Administrator (ADM) walked by the resident's room without closing the privacy curtain. A male resident in a wheelchair looked into Resident 59's room from the hallway as he passed. A male visitor walked past the resident's room. Resident #59's Care Delivery Guide (Kardex), a tool used by staff to direct resident care, documented to pull curtain partially closed when leaving (resident) room, allows (resident) privacy, prevent complaints from other residents. On 07/11/18 at 3:33 PM, NA F said she read the resident's care plan and Kardex, but was unfamiliar with Resident #59's care. NA F said in general, residents' curtains should be drawn and their doors closed to promote resident privacy. On 07/12/18 at 9:20 AM, Licensed Nurse (LN) F, a Resident Care Manager, said the expectation was for staff to draw residents' privacy curtain closed. LN F stated, We need to preserve (Resident #59's) dignity and that of other residents and visitors. At 9:40 AM, the Director of Nursing Services (DNS) said her expectation was that all staff should maintain the resident's dignity by drawing the curtain and/or continually trying to redirect the resident. <Dining> On 07/09/18 at 12:09 PM, lunch was observed being served in the dining room. The tray cart had trays that each held 2 plates. The plates were delivered as they were pulled from the cart. Residents sitting at the same table were not served at the same time. On 07/12/18 at 7:47 AM, breakfast was observed being served in the dining room. The tray cart had 2 plates on each tray. The plates were delivered as they were taken out of the cart. Residents sitting at the same table were not served at the same time. At 8:30 AM, NA D said there was not a process in place to ensure residents at a table were served at the same time. NA D said they served the plates as they came out of the cart. On 07/13/18 at 8:30 AM, the DNS said the facility had been working on getting a mapping of where residents sit in the dining room so the trays came out together and residents could eat together. Reference WAC 388-97-0180(1-4)

Based on interviews and record review, the facility failed to ensure residents were free from verbal and mental abuse from staff for 1 of 6 current residents (#1) reviewed for abuse. This failure placed residents at risk for potential abuse, 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 02/20/18, indicated the resident was moderately cognitively impaired, had no behaviors, and needed extensive assistance for bed mobility and toileting. The MDS showed the resident was occasionally incontinent of urine and always incontinent of bowel, and did not show diet restrictions. An Incident Investigation, dated 02/17/18, documented the resident reported he used his call light at 11:00 PM. The nurse (Licensed Nurse (LN) 4, a registered nurse) answered his call light, and told him he needed to tell her everything that he needed now because the resident was using his call light too much, and staff would not be coming back in to answer his light. If the resident used his light again, LN 4 would tell the aides not to come in. The resident requested a snack and LN 4 told him, No, you cannot have snacks at night. You don't need to eat. LN 4 told the resident it was past his bedtime and he needed to go to sleep. The resident said he did not use his call light the rest of the night, and he wet himself because his urinal had fallen onto the ground. The resident said after LN 4 got off, he did use his call light. LN 4 was suspended pending the investigation. A witness statement, dated 02/19/18, Nursing Assistant (NA) 1 documented she felt bad for the resident, tried to get the resident a snack and the nurse told her no. The resident had asked NA 1 for a peanut butter and jelly sandwich. The nurse said he could not have any more, so I went back and told the resident. The resident said he did not eat his dinner because it was cold, and he was still hungry. NA 1 said she felt bad for the resident. NA 1 said the nurse told her not to go back in there as much when his light is on because it's a behavior, and he probably did not need anything. A witness statement, dated 02/19/18, documented LN 3, a Registered Nurse, indicated she worked the same shift as LN 4. LN 3 said LN 4 told Resident #1 that he needed to tell her what he needed while he was in his room because the staff cannot be going into his room all the time and that the resident cannot be calling the facility when he does not get his call light answered. LN 4 told the resident the staff had other residentd they had to care for, and they cannot do that if they were always in his room. The Incident Investigation, dated 02/17/18, noted the allegation was not substantiated. On 03/01/18 at 3:14 PM, Resident #1 stated, I asked for a snack and the nurse told my aide I can't have any more and I was hungry. The nurse told the girls not to answer my call light and she told me to tell her everything I wanted right then, that they wouldn't be answering my call light. I felt terrible and scared to use call light and ended up wetting myself because my urinal had fallen and I couldn't get it. At approximately 5:00 PM, the Director of Nursing Services said there was a Disciplinary Action Report, dated 02/21/18, that documented LN 4 received a resident rights violation and noted a possible psychological harm. When asked about the findings on the Incident Investigation, dated 02/17/18, as unsubstantiated, the DNS said the findings were wrong. Reference WAC 388-97-0640(1)

Based on interview, and record review, the facility failed to recognize their interventions were ineffective to protect vulnerable adults and consider different alternatives for 3 of 6 sampled residents (#34, 62 & 59) reviewed for abuse. The facility failed to initiate alternative interventions and/or reevaluate the effectiveness of interventions and to provide consistent monitoring for Resident #34 who had known ongoing sexual behaviors toward residents. This failure placed residents at risk to be unwilling participants in sexual encounters, not providing appropriate interventions for sexual needs and mental anguish. This failure resulted in harm to Resident #34, #62 and #59. Findings include: Resident # 34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 7/26/17, indicated the resident had severe cognitive impairment. The medical chart documented the resident had a known history of pursuing male residents into their rooms engaging in kissing, hugging, and physical sexual contact. This behavior had continued to escalate with no new interventions in place except 15 minute checks, redirection, and reminding the resident she was married. A progress note, dated 1/27/17, indicated Resident #34 needed to be monitored for inappropriate behaviors towards male residents. The resident's care plan, dated 1/30/17, documented resident kissing others and will go into other rooms, stop signs in place to remind not to enter rooms .staff to remind resident that she is married and to redirect as needed. A progress note, dated 3/18/17, showed Resident #34 was found in Resident #62 room displaying inappropriate behaviors, kissing. Resident #62 stated he did not like it. The nurse encouraged Resident #62 to try and discourage Resident #34 from doing it again. This incident was not investigated by the facility. (Resident #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 9/4/17, indicated the resident was alert and oriented, did not have behaviors, required extensive assistance activities of daily living including mobility, dressing, eating, and toileting; and had range of motion limitations with both upper and lower extremities.) During an interview on 8/29/17, Resident #62 stated, It happened two times and then she got caught. The facility put a stop sign on my door and she would stop by and say I love you and blow kisses, everyone knows about her. On 8/29/17 at 3:19 p.m., when asked about the incident between Resident #34 and Resident #62 on 3/18/17, the Director of Nursing (DON) stated, .No incident report. I would have expected a call. A progress note, dated, 3/27/17, documented the resident was placed on alert for inappropriate behaviors with visitors and placed on 15 minute checks. The incident was not logged on the Accident and Incident log and an investigation was not completed. A progress note, dated 6/4/17, documented Resident #34 was found kissing Resident #59. Residents were separated and put on 15 minute checks. RCM notified. An investigation, dated 6/4/17, documented Resident #34 was placed on 15 minute checks after kissing Resident #59. Resident #34 was reminded she was married and only high 5's were appropriate. (Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], indicated the resident had severe cognitive impairment, able to make needs known, had physical and verbal behaviors, and required supervision with activities of daily living.) On 7/25/17, a fax was sent to the doctor noting Resident #34 was found kissing another resident, both were placed on 15 minute checks and placed on alert charting for psychosocial harm. An investigation, dated 7/25/17, documented the resident had hugged and kissed another resident in the hallway before dinner. Other residents saw the resident kissing him. The facility concluded it was not inappropriate. The investigation showed it was unsubstantiated and no further action was required. On 8/11/17, during the night shift, Residents #34 and Resident #59 were found engaged in oral sex and fondling. The residents were separated and the licensed nurse (LN) was alerted. The residents were placed on 15-minute checks. The physician and both resident's family and power of attorneys were notified. The investigation for the 8/11/17 incident documented this was a pattern of behavior for Resident #34. A progress note, dated 8/13/17 documented Resident #34 was trying to mingle with Resident #59 by sitting outside his room, following him and trying to get him to go to her room. Resident #34 was continued on 15 minute checks and was redirected multiple times throughout the day. A social service note, dated 8/14/17, documented the social worker met with Resident #34 related to the sexual activity over the weekend. The resident was placed on 15 minute checks over the weekend. It was decided the resident would be placed on 1:1 supervision and be re-evaluated to determine resident needs after the investigation. On 8/14/17, when interviewed by social services, Resident #59 denied having sexual contact with another resident. A progress note, dated 8/16/17, documented Resident #59 admitted to the sexual incident happening and was a willing participant in the activity. On 8/16/17 at 1:10 p.m., the DON said Resident #34 and #59 were put on 15 minute checks and indicated it was night time so they probably didn't have enough staff to put the residents on 1:1 (constant supervision). They put Resident #34 on 1:1 on Monday. The plan is to keep on 1:1 going forward we don't have a choice other than to do that. We have tried multiple times for placement and is denied. At 1:15 p.m., the Social Services Director (SSD) stated, She should have been put on 1:1 immediately. We were not notified until Monday morning and DON was on vacation. The acting DON was notified. At 4:14 p.m., the Administrator (ADM) stated, I didn't know until Monday morning. I asked what happened and what was done immediately. They were put on 15 minute checks, and then we decided 1:1. They made a judgement I guess .I would expect a phone call when something like that happened, but they didn't call me. Review of Resident # 34's medical record from 1/1/2017 through present, multiple entries in progress notes related to inappropriate sexual behavior, care plans indicate known history of pursuing male residents and visitors. The facility's failure to identify their current interventions were ineffective and consider alteratives, and thoroughly assess to put alternative interventions in place to meet the needs of individual residents, placed residents at risk for abuse. Residents did not have individual interventions put in place to assist with behaviors. This failure allowed ongoing, known behaviors of Resident #34 to continue, placed residents and visitors at risk for unwanted behaviors, and resulted in sexual encounters which may or may not have been wanted by other residents. Interventions put in place were ineffective and not reevaluated for alternatives to address sexual behaviors. This caused harm to Resident #34, #62 and #59 and potentially other residents. Reference: WAC 388-97-0640 (1)

Based on observations, interviews, and record reviews the facility failed to identify, immediately report and thoroughly investigate incidents of abuse, neglect and mistreatment to protect and prevent residents from similar incidents for 4 of 23 sampled residents (#56, 8, 43 & 34) reviewed for abuse. This failure placed residents at risk for abuse, exploitation, diminished quality of life and psychosocial harm. This caused harm to Resident #34 and #43. Findings include: The facilities abuse policy, dated December 2016, noted, Thoroughly investigate all alleged violations and retain documents showing that all alleged violations are thoroughly investigated. Prevent further potential abuse, neglect, exploiration, or mistreatment while the investigation is in process. Require center staff, which includes employees, consultants, contractors, volunteers and other caregivers who provide care and services to resident on behalf of the center, to report immediately to the Executive Director, without fear of retribution, all incidents of abuse, exploitation, mistreatment, or neglect of a resident. Identify events, such as resident-to-resident altercations, bruising of residents, occurrences, patterns, and trends that may constitute abuse, neglect, exploitation, mistreatment, injuries of an unknown source, and misappropriation of resident property. 1) Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 7/12/17, indicated the resident was severely cognitively impaired and required extensive assistance with dressing, toileting and personal hygiene. A nursing note, dated 6/4/17, documented, (Resident #56) was in dining room with husband (Resident #59), and husband was seen putting hand up (Resident #56's) shirt. (Resident #56) was pushing his hand away and stated, 'no.' A nursing note, dated 6/9/17, documented, CNA informed this nurse the resident had 'bed controller in her vagina.' When this LN (Licensed Nurse) asked resident, 'Did you place the bed controller in your brief,' 'I don't know, maybe,' was the resident's response . A nursing noted, dated 6/16/17, documented, Resident was taken to spouse's room to visit with (family). When family left, they left them in room alone with door shut. This LN heard her spouse yelling and removed her back to her room. On 8/23/17 at 3:11 p.m., the Director of Nursing Services (DON) said she was unaware of the incident that took place on 6/9/17. At 6:00 p.m., the DON said the Resident Care Manager did not know about the incident and they were starting an investigation and the resident did not remember anything. On 8/28/17 at 10:38 a.m., an updated incident log did not include an incident regarding Resident #56 on 6/9/17. At 11:34 a.m., the DON said she had just not logged it and provided a log now including the incident involving Resident #56 on 6/9/17 with findings, reasonably related to condition, and actions taken, no further action and staff training/counseling. At 12:22 p.m., when asked about the status of the investigation for Resident #56, the DON said, I'm still working on it; all I have is the SSD's (social service directors) note. I can't get staff to call me back and without their interviews, I don't have anything. The DON indicated LN I (a floor nurse) wrote the note. At 12:30 p.m., when asked about the findings and actions documented on the log, the DON stated, We did education. She's not going to remember the incident at her age. She may have been fiddling with it, but I don't think it was staff related because she had gone to bed and only people in the room were the people that were changing her and they found it in her brief. That's just my opinion. The POA (Power of Attorney) and MD weren't notified because it wasn't really an incident. I just got in touch with (LN I) and she said the bed control was in her brief, not in her vagina. The incident report conclusion, dated 8/28/17, noted, The resident was interviewed by DON and (social services) but does not recall event. RN who wrote the original note stated that the bed control was in her brief, not in her vagina. That it was discovered during a brief change and that only staff had been in her room since she went to bed and staff discovered the reported to her. She did not notify MD or POA as she did not think it necessary .Resident is very demented, confused and it is very likely that she placed it in her brief herself .There is no reason to believe that anyone else placed a bed control in her brief. At 2:23 p.m., when asked who found the resident with the foreign object, the DON stated, It was either NA N or NA O (Nursing Assistant), who no longer works here. At 2:35 p.m., the SSD stated they had not tried to contact NA O and they were attempting to contact NA N. On 8/29/17 at 10:15 a.m., when asked what incidents are reported to the state hotline, the DON said, If abuse or neglect is suspected- unless a resident says they did it and they're oriented and tell you, then I don't have to report it. At 11:53 a.m., NA N said she was not the NA that found the foreign object. At 4:57 p.m., when asked which NA discovered the foreign object, LN I stated, I don't remember. Ask them to check the schedule. When asked about where the foreign object was found, LN I stated, It was in her brief. When asked about her nursing note, LN I said, I must have stated it wrong. It was in her brief, not inside of her. When asked if she reported it to the DON, POA, or MD, LN I stated, No, I didn't think it was anything so I didn't call them. I put it on the 24 hour report and passed it on to the day nurse and I haven't heard anything else about it until now. She has dementia and I just assumed she did it. She is right in front of the nurses station. No one had been in there. When asked if she had eyes on the resident the whole night, LN I stated, More or less. Her door is usually closed because we try to keep her husband from going in the room. She's always being monitored that he doesn't go in there. When asked whether this should have been reported to the hotline she said, I guess if you don't know how it got there. I should have reported it. The facility did not start an investigation until over two months after the incident. The investigation consisted of statements from the nurse and resident on 8/28/17, approximately two and a half months after the incident. No other resident's were interviewed. The NA that found the foreign object was not identified or interviewed. The incident was not reported to management per policy and the incident was not reported to the state hotline. The investigation did not rule out abuse and/or neglect. 2) Resident #8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact and participated in health care decisions. On 8/22/17 at 3:22 p.m., when asked if a staff, a resident, or anyone else at the facility had abused her, Resident #8 stated, (NA I) is very unprofessional. She is saying I caused her to fall. She's been treating me different. This is my home and you should treat me better than that. I feel that (NA I) does not need to be a caregiver. She's going to hurt somebody else. At 3:45 p.m., Resident #8 said she had told staff about it and not management. At 3:53 p.m., the Administrator (ADM) was notified of what Resident #8 had said. The incident report, dated 8/2/17 at 4:15 p.m., included a witness statement by NA K, I did witness a small confrontation between the resident and (NA I). (NA I) began to question (Resident #8) in an argumentative way. (Resident #8) would let me know that she doesn't want (NA I) ever in her room and that she makes her 'uptight'. She has told me these types of phrases/confessions more than a handful of times. A witness statement by NA J noted, (NA I) never answered (Resident #8's) call light. (NA I) bragged about how when (Resident #8's) call light was on, she would walk to the doorway and smile and wave at (Resident #8) and then walk away laughing. (NA I) stated, 'You kick me out of your room once and I'm never returning.' NA I's disciplinary action report, dated 8/23/17, documented, Resident reported to a state surveyor that she was verbally abused by (NA I) and this made her cry and caused psych/social harm to resident. During investigation, others also reported that they had witnessed inappropriate conversations with this resident. Multiple mandatory reporters were aware of alleged abuse and did not report to the state agency hotline nor anyone in their chain of command, and failed to follow their facility's abuse policies and procedures. 3) Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], documented the resident required extensive assistance with activities of daily living including incontinent care and was moderately cognitively impaired. The resident had a POA in place. The Mood and Behavior care plan showed the resident preferred to stay in bed and nap during the day, enjoyed reading and talking about books, was awkward in social situations and had a history of [REDACTED]. Care Conference notes, dated 7/27/17, documented the resident's behaviors were decreasing, the resident was pleasant and getting along with staff, and was focused on books. Record review of a physician's note, dated 8/1/17, documented, patient was pleasant, alert, comfortable. No issues brought today. Continue with current care plan. On 8/8/17 at 3:50 a.m., nursing notes documented LN J was called into the resident's room by NA P and reported finding a pencil in the resident's vagina during a brief change. LN J evaluated the resident for injury, notified the physician, DON, and POA. On 8/8/17, a progress note documented the Social Service Director (SSD) met with the resident to discuss the incident of the previous night. There was no documentation to show the SSD asked if the resident felt safe, and if someone had approached or touched her in an inappropriate way. There was no documentation to show the resident's roommate or other resident had been interviewed regarding potential abuse or safety concerns. There was no documentation to show other staff had been interviewed. The August 2017 Accident/Incident logs showed there was no documentation of the incident on 8/8/17 with Resident #43. On 8/23/17 at 3:10 p.m., LN B, who had worked at the facility for six years, stated, I have never known this resident to have any sexual behaviors, just verbal behaviors. On 8/28/17 at 3:20 p.m., NA P stated she had found the pencil in the resident's genital area when she went to change her brief. At 6:31 p.m., LN J stated she had been outside the resident's room at her med cart when the aide came to get her. The first thing I did after it came out was to check for injury. Then I called the DON, and she told me what I needed to do. When asked if the resident had ever had any behaviors like this, previous to this incident or since, LN J stated she was not aware of any. The resident had a habit of talking in a crude way but I never saw any actions or even heard of any actions. When asked if the resident had said she had done this to herself, LN J stated, No, she just said I'm bad. On 8/29/17 at 12:16 p.m., LN B stated the resident read books all the time. LN B stated he had never known her to use a computer or use any kind of pen or pencil to write with, and said she was a two person assist to get out of bed. At 4:16 p.m., the SSD stated, I just asked what they were looking for. It never occurred to me that (Resident #43) hadn't done it, because I had been told she admitted to it. I went on that premise. When asked if this resident had ever had any sexual behaviors in the past, the SSD stated, No, just verbal behaviors. When asked about the care conference on 7/27/17 documenting the resident was having less behaviors and then this incident occurred, the SSD said she hadn't thought about it. On 8/23/17 at 3:11 p.m., the DON stated she was aware of the incident. The DON said the state was not notified because it was (Resident #43) that did it. I do 90% of all the logging on the accident/incident logs. When asked if this incident had been logged, the DON stated, I'm not even sure what I would have logged it under. After review of the logs, the DON stated, The resident was not on the log. Resident #43 had never been known to have any sexual behaviors. She had been known to cuss and say inappropriate things. A care conference on 7/27/17 documented decreasing behaviors. On 8/8/17 a foreign object was found in the resident's vagina. No one logged it or reported to the state. A thorough investigation, including interviews with other residents and other staff, was not completed to rule out abuse. 4) Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was severely cognitively impaired and did not have behaviors. The resident's medical record had multiple entries of the resident having sexual behaviors with male residents (pursuing male residents into their rooms, kissing male residents and having sexual contact with a male resident.). The resident's care plan included interventions to redirect the resident out of resident rooms, remind her it is wrong to kiss or do anything with other residents as she was married, and only high 5's were appropriate. Progress notes documented incidents of inappropriate behaviors. The resident's chart documented multiple incidents of inappropriate behavior (kissing, hugging, physical sexual contact) including 1/30/17, 3/18/17, 3/27/17, 6/2/17, 6/4/17, 7/25/17, 8/11/17, and 8/13/17. Interventions continued to be 15 minute checks, 1:1 supervision, redirection, and reminding the resident she was married. A social service note, dated 8/14/17, documented SS met with Resident #34 regarding sexual behavior over the weekend. Over the weekend, it was decided Resident #34 would be put on 1:1 supervision and be reevaluated to determine resident needs after the investigation. On 8/16/17, the DON said, The residents were put on 15 minute checks and it was probably night time and they probably didn't have enough staff to put them on 1:1. They put Resident #34 on 1:1 on Monday . On 8/16/17, the Administrator said, I didn't know until Monday morning. I asked what happened and what was done immediately. They were put on 15 minute checks and then we decided 1:1. They made a judgment I guess .They didn't call me. On 8/16/17, the Administrator provided a follow up report and documented Resident #34 had severe cognitive impairment. The resident had a history of [REDACTED]. It appears the resident had a sexual drive and it may be enhanced with the impulsivity of her diagnosis. Record review of Resident #34's medical record does not show documentation of the resident's sexual desires being discussed with the resident and/or resident's representative. The facility had not thoroughly investigated the nature of Resident #34's sexual behaviors and had not considered alternate interventions to address the individual needs of this resident. The facility had documentation of multiple incidents of inappropriate behavior which were not investigated to determine the root cause of the Resident #34's behaviors and alternate interventions to change the outcome of the resident's behaviors. The facility failed to consistently complete investigations of inappropriate behavior, and failed to thoroughly investigate incidents to rule out abuse. Refer to F-223 Reference: (WAC) 388-97-0640 (5)(6)(a-c)

Based on observation, interview, and record review, the facility failed to ensure medically-related social services were provided for 1 of 2 sampled residents (#34) reviewed for behavioral assessments for resident specific interventions. This failure placed residents at risk for individual interventions not being completed for meet resident needs and a delay in attaining or maintaining the highest practicable level of physical, mental and psychosocial well being. This caused harm to Resident #34. Findings include: Resident # 34 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a documented history of pursuing male residents into their rooms engaging in kissing, hugging, and physical sexual contact. This behavior had continued to escalate with no new interventions in place except 15 minute checks, redirection, and reminding resident she was married. The resident's chart documented numerous incidents of inappropriate behavior (kissing, hugging, physical sexual contact) from January 2017 to August 2017. Interventions continued to be 15 minute checks, redirection, and reminding the resident she was married. A social service note, dated 8/14/17, after an incident of sexual contact with another resident, the social worker met with Resident #34 related to the sexual activity over the weekend. The resident had been placed on 15 minute checks over the weekend. The resident was placed on 1:1 (continuous) supervision and would be reevaluated to determine resident needs after the 8/11/17 incident investigation. On 08/16/17 at 1:15 p.m. the Social Services Director (SSD) stated, She should have been put on 1:1 immediately. We were not notified until Monday morning and DNS was on vacation. The acting DON was notified. The facility's failure to provide medically related social services for Resident #34's sexual behaviors resulting in the resident continuing to pursue other residents in the facility. This placed residents at risk for engaging in unwanted sexual contact. The facility was aware of Resident #34's sexual behaviors and did not identify specific interventions to address the resident's sexual needs and continued to use interventions that only worked temporarily. From a reasonable person's approach, this would cause harm to Resident #34 and the other individuals she pursued. The facility failed to provide social service support to Resident #34, and other residents, to develop interventions to address sexuality and preferences. Reference: (WAC) 388-97-0960 (1) Refer to F-223 and F-225

Based on interview and record review, the facility failed to re-admit 1 of 2 sampled residents (#1) reviewed for transfer to the hospital. Resident #1, a medicaid resident, was not admitted back to the facility after the resident was ready for discharge from the hospital and readmission to the facility. This failure led to the resident being transferred to another hospital instead of returning to the facility for care and services. This failure caused harm to Resident #1 when he had a prolonged hospital stay and a diminished quality of life. Findings include: Resident #1 is a long term care resident of the facility and has been living in the facility for [AGE] years. Record review documented Resident #1 was admitted to a local general hospital on [DATE] for kidney stones. Record review showed the resident was transferred on 12/20/16 from a local general hospital to a specialty hospital. Patient Report, dated 12/28/16, documented, It is likely (the resident) will need a very prolonged wean with unclear likelihood of success, and would like to return to facility, I think would be reasonable given his long term need. Patient Report, dated 1/5/17, documented the resident was unable to discharge back to SNF as the facility does not have a bed (specialty bed) we have here for the patient per team. On 1/12/17, at 1:15 p.m., Respiratory Manager (RM) stated, We have one (specialty bed) like in the hospital. Not sure if he is coming back. Respiratory wise we can meet his needs. We have 4 total residents between 8 vents (ventilators) and 6 trachs ([MEDICAL CONDITION]). At 2:07 p.m., the Administrator (AD) stated, Our Medical director (MD) refused to care for him, concerns about their ability to care for him and not willing to be his medical director. This started last week. We have a meeting set up for today. The challenge is infection control. He does not follow infection control policies. There are barriers. Our MD wanted us to have mental health services and pain specialist in place and available when he is ready to come back. He can come back and the medical directors are willing as long as there are specialists involved. We have a meeting today. Clinically he is ready in the hospital. We did not send anything to the state because we couldn't consider admitting due to the barriers. Might have received paperwork but didn't pursue because of barriers. I did receive a call on 12/29/16 that Resident #1 was ready for re-admission. When asked if other resources were pursued to find another provider to follow Resident #1 in the facility, the AD stated, No, we thought we could get through the barriers. At 2:11 p.m., the Regional Clinical Director stated, We are taking him (Resident #1) back today if he is ready. On 1/17/17, at 10:00 a.m., the AD emailed, An order was placed with a vendor yesterday, but the local office somehow did not receive it. He is talking to the local office now about that specific bed. I will keep you updated. At 10:36 a.m., RN Case Manager (RNCM) stated, He is returning to the facility, they were expected to discharge him yesterday. On 1/18/17, no update has been received that Resident # 1 has readmitted to the facillity. Resident #1 remained in the hospital 21 days past the day the hospital was ready to discharge, on 12/29/16.

Based on observation, interview, and record review the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to ensure each residents ' safety and well-being. The facility failed to immediately take action when an automatic emergency power transfer switch box was found on 11/4/16 to contain water. The administration failed to recognize this situation as an immediate need to address and correct this issue to protect the emergency power supply and resident and staff safety. This facility houses up to 19 ventilator and [MEDICAL CONDITION] dependent residents for whom emergency power is critical to their well-being. The facility ' s failure to immediately address the leaking roof above the electrical room revealed a lack of oversight of major environmental systems placing residents and staff at risk and was determined to represent an immediate jeopardy. The facility was informed of this on 12/19/16. Findings Include: An inspection by the state fire marshal on December 6, 2016 revealed water in the emergency power supply switch. The facility was informed this was an Immediate Jeopardy situation on December 6, 2016. On December 7, 2016 the state fire marshal determined that a 2nd immediate jeopardy situation existed related the leaking roof over the facility ' s electrical room housing many electrical boxes including the emergency power transfer switch. Up until this discovery by the state fire marshal of the safety hazards posed by water leaking into the electrical room and specifically into the emergency power transfer switch box, the administration had taken no emergent action to correct this life safety issue. At 5:42 p.m. interview 12/6/2016 with Respiratory Manager (RT) of the ventilator unit revealed that the current residents on the ventilator unit were 19 which consisted of 10 residents on ventilators and 6 residents with just tracheostomies. She indicated that the ventilators had internal batteries and there were also back up batteries available. The RT manager expressed concern regarding the unsafe emergency power transfer switch and stated she didn ' t know there was an issue until this week. She stated having a working generator which the emergency power switch would turn on, was a requirement of the respiratory therapy company ' s contract. An interview on 12/10/16 at 12:25 p.m. with the maintenance director revealed that a service person from(NAME)Cat, a generator company, came out in early November to go over the testing of the generator with him. When the panel box to the transfer switch was opened, there was water in the bottom of the switch box. The Product Support Manager from(NAME)Cat stated not to test that switch to the generator until the leaking roof was fixed. The roof leak into the electrical room and the switch box was shown to the administrator and the senior executive director the same day(NAME)CAT service person was in the facility. Interview on 12/16/16 at 10:16 a.m. with the Product Support Manager (PDS) from(NAME)Cat stated he went to the facility on [DATE] to show the maintenance director how to do Fire Marshal Testing. When he opened the transfer switch box, it had water in it. He then told the maintenance director that he was not going to do anything until the leak was fixed. The administrator was present at the transfer switch box and told PDS that it would be fixed by the following Monday and to send a technician out to inspect the switch to make sure it wasn ' t damaged and then perform a test then. A tech from Cat(NAME)went to the facility as requested. Nothing had been fixed and he was sent away. PDS reported he heard nothing else from the facility until the Fire Marshal contacted him on 12/6/16. In an interview with the administrator on 12/14/16 12:00 p.m. he stated that he was notified 11/4/16 about the transfer switch and was taken down to look at the transfer switch. We put plastic and covered the areas and called roofing companies. In an interview with the Senior Executive Director (SED) she stated, I put a Purchase Request (PR) on 11/19 and then goes to review and then on 12/8 it was produced. We can ' t control vendors. The generator wasn ' t the issue. The transfer switch was the issue. With Thanksgiving holiday and snow we wouldn ' t put anyone on an icy roof for safety reasons. I feel we had things in place to be prepared for anything. The facility was aware of the transfer switch safety concern on 11/4/16. The administration failed to recognize the seriousness of the unsafe transfer switch and did not immediately take steps to fix the issue promptly to ensure resident and staff safety. This represents an immediate jeopardy in the administrator requirement of federal nursing home regulations. Please Refer to the Life Safe Code reports for more information dated 12/6/16 for K-tag 918 related to the electrical issues found to be at immediate Jeopardy level of Harm. Also refer to Life Safety Code Report date 12/7/16 related to the roof leak into the electircal room K 932 also cited at Immediate Jeopardy harm level.

Based on Interview, Observation, and Record Review, it was determined the governing body failed to ensure effective oversight of the administration of the home ensuring safe operation to include the provision of a safe environment. Administrative employees of the corporation were aware of a roof leak in the electrical room of Pacific Specialty allowing water to access a critical emergency power supply transfer switch and failed to take immediate action to correct the unsafe situation placing residents and staff at risk. The failure of the governing body to ensure safe operation of this facility was determined to represent an immediate jeopardy. The facility was informed on 12/19/16. Findings Include: When the Administrator (ADM) and Senior Executive Director (SED) became aware of water in an emergency power transfer switch box responsible for the automatic transfer of power to the facility's emergency generator should the facility lose power, they failed to take immediate action. On 12/6/16 at 6:35 pm when the administrator was asked when he was notified of the unsafe transfer switch, he indicated, on 11/4/16 he and the SED were taken down to look at it at that time. During interview on 12/14/16 at 12:00 noon when the administrator was asked when corporate was notified of the unsafe transfer switch ADM stated, I don ' t know how that works . or when the SED ' s direct supervisor was notified. We put plastic over the areas and called roofing companies. In a timeline document created 12/14/16 submitted to the department, the Senior Maintenance Director for the area communicated with Executive Director of Facilities Management at corporate by phone in the latter part of November 2016. On 12/14/16 at 1:04 p.m. the Senior Executive Director (SED) stated, We called the regional maintenance man somewhere between 11/4-11/9 some stuff went to executive director of facilities. I put a PR (purchase requisition) in on 11/19 and then it was produced 12/8. We can ' t control vendors the generator wasn't the issue. It was the transfer switch. With Thanksgiving holiday and the snow, we wouldn't put anyone on an icy roof for safety reasons. I feel we had things in place to be prepared for anything. Neither the facility's on-site administrative team nor the corporate representatives responded with any sense of urgency to water leaking into the electrical room including into the emergency power switch box. It was not until the state fire marshal observed the water damage in the electrical room that the facility took immediate action to correct the hazardous conditions. Refer to F 490 Administration and Life Safety Code K 918 and K 932 dated 12/6/16 and 12/7/16 respectively which were cited at Immediate Jeopardies for further information about the hazardous conditions created by a roof leak in an electrical room.

Based on interview and record review, it was determined the facility failed to ensure medically-related social services to include supporting a resident's right to make decisions concerning his health care and who he wanted as a surrogate decision maker were provided to 1 of 4 current sampled residents (Resident # 2) . Neither Resident #2 nor his family were notified or involved in the decision to petition for guardianship which resulted in the Resident #2 feeling retaliated against and causing psychological harm. Findings include: On 6/13/16 at 10:08 a.m. Resident # 2 and family member via phone call reported a guardianship petition had been filed for the resident by the facility. The family member stated, {Resident} was served with papers from the guardian ad litem. Social Service Director initiated the guardianship. We were not notified of the guardianship. The Guardian ad litem is going to court today to have an attorney appointed to us and do a psychological evaluation. The family member stated, I feel this is complete retaliation. Both Resident #2 and the family member reported that the facility is not communicating with either of them. Resident #2 stated, I don ' t feel l can say anything anymore. At 10:46 a.m. SSD stated, We meet as an IDT to determine if we should petition for guardianship, write up a petition and send to attorneys, then send to guardian ad litem then notify the resident. When asked what the criteria is to determine if a guardianship is warranted, SSD stated, It ranges all over, if there is no supportive family and resident is cognitively unable to make own decisions, no POA, no guardianship, etc. then we will petition for guardianship. When asked about Resident # 2 ' s criteria and reason for petitioning for guardianship, SSD stated, We had pondered for a while, notes from psychologist, as well as the PASRR auditor. We have had an increase where the resident ' s cognition varies, reporting differences, recommendation from the MD for pain or inability to sleep and family member has sabotaged anything that we have done. When asked about Resident # 2 ' s cognition SSD stated, Yes his BIMS score is 13. (BIMs score is a quick measurement of one ' s cognitive functioning with 15 being the highest score. The resident rated close to the top range of cognitive functioning.) I would say the more detailed, his cognition varies. He would tell us one thing and tell his family member another. What his idea is of the truth is unknown. I have tried to build up a trust and felt that he goes to his family member for support and they are so overly vocal and override what he says. We petitioned for Guardian ad litem, to investigate whether a guardianship is warranted, prior to that did not have a conversation with the family member or resident there wasn ' t anything in place to take his rights away. It is just to see if a guardianship is needed. When asked if Resident # 2 was upset, SSD stated, I did not talk to him after, my assistant did and he was on alert. On 6/24/16 at 10:20 a.m. Director of Clinical Services, when asked about criteria to petition for guardianship she stated, When the resident is not able to make their own decision or have a cognitive impairment, or no one to assist, or if not in best interest. This goes through DON {Director of Nursing}, SSD {Social Service Director}, ED {Executive Director} and the legal department. Families and residents would be notified of initiation of guardianship. Depending on [DIAGNOSES REDACTED]. When asked about the petition for guardianship for Resident # 2, the Director of Clinical Services stated, I was not aware that the process had started, I turned it over to the Regional Director of Operations (RDO). I have been asking those same questions from SSD where the process is at. At 11:15 a.m. Investigator met with Resident # 2 with family member present. Both were upset related to the way the facility went about doing the guardianship. They felt that facility did this to get back at them because family member advocates for the resident. When there is a concern the family member talks to them about it and they don ' t like it. Resident # 2 was tearful when he said that he calls his family member and that she is his support and who else is he supposed to call. Both expressed feeling that the guardianship was retaliation for voicing concerns about care issues. Resident #2 states he is in constant fear of retaliation. At 11:40 a.m., SSD when asked about process for guardianship stated, The Interdisciplinary Team (IDT) meets to see if appropriate steps to take for guardian when there is no other form of legal POA. The SSD types up a petition and explaining reason for guardianship and then we send to an attorney to petition the courts. When asked if there was a conversation with resident and family member regarding petition for guardianship, SSD stated, The IDT felt it would cause psychosocial harm if he was told prior and we felt it would protect him by telling him when the guardian ad litem was present to discuss the process with him. We followed up and put him on alert and he said he was fine. When asked if family member is involved, SSD stated, Oh yes she comes to care conference. We scheduled them on wound care days so she can attend. They have a close relationship and he will revert things to her. His main support is her. When asked about other residents who may need guardianship, SSD stated, We typically talk with the family member or an anchor person and help them petition for guardianship. At 12:05 p.m. DNS stated, when asked about criteria for guardianship, If the family is not involved, or unsafe making his or her decisions, or unable to make decisions or unsafe if they are cognitive impaired, I would talk to social services and she would initiate the process. We would have an IDT meeting to discuss if we should apply for a guardianship. It would depend on a case by case basis. Based on the psychologist ' s notes there were some cognitive deficits, and an unhealthy relationship with his family member. The IDT felt it was best to apply for guardianship. When asked if he had seen any interaction with the resident and family member DNS stated, I round in resident ' s room. I have not seen any interaction first hand. The PASSR dated 1/25/15 recommended discussion with family or DPOA for guardianship. On 7/6/16 at 10:09 a.m. during phone interview with Psychologist, he stated, I met with patient on 3/2/16. I met with just the patient. Staff reported to me the unhealthy relationship with family member. I rely on staff report. I have not witnessed firsthand any unhealthy relationship with the family member. I cannot base this on my own observations. I rely solely on nursing and social services information. On 7/7/16 at 4:00 p.m., interview with Resident # 2 and family member on the phone the resident was very upset regarding the way the administrator came in and talked with him yesterday. The administrator told him that they were going to have a care conference with him, the administrator, social service and guardian ad litem. The resident told the administrator that he needed to talk to his family member. According to Resident #2, the administrator stated, You are your own person. We don ' t need to talk to her. Resident #2 told administrator that there will be no care conference and that they could talk to his lawyer. Resident #2 was very tearful and stated, I just don ' t know what to do anymore. No matter what I do they don ' t care. The family member said the resident called her very upset. They mentioned that they have asked to have the correct size of catheters and was told they are not ordering any more that he goes through too many, and he would have to go in a brief. Resident #2 stated, I just want caregivers and nurses that know me and how to take care of me, or at least train others so they know what to do, and they just give me new caregivers that don't know anything about me, and I will have to just deal with it. Resident #2 stated, I feel they are retaliating against me and my family because she advocates for me, who else am I supposed to go to. On 7/11/16 @ 4:45 p.m. an outside resource familiar with situation stated he is directly involved with the resident and his family regarding the facility. He stated, There is a history of very substantial complaints at the facility and retaliation against resident and family member regarding the guardian ad litem petition. I have seen resident very escalated at the time I was there, but more out of frustration in general No matter how he tries to get assistance timely, it doesn ' t happen. I have not personally talked with the facility as I feel it has gone past the point of mediation.

Based on observation, interview and record review, the facility failed to maintain confidentiality of 14 of 32 sampled residents ' specific personal and medical information. For Residents # 54,, 12, 16, 79, 14, 92, 45, 78, 28, 51, 31, 72, and 57 who were identified by name in a resident sample list that accompanied two state inspection reports. The facility is required to post the inspection reports but the list of sampled residents and staff is to be kept confidential and not to be posted. The facility posted the names of the residents involved in an annual survey and 3 of 3 sampled residents in a complaint investigation. By posting resident names with the inspection reports, the facility did not uphold the right of these residents to have all personal and medical information maintained in a confidential manner. Findings Include: On May 31, 2016 2:40 PM State inspection reports were observed by the investigator posted by the facility as required. Along with the State inspection reports were the resident sample lists for inspections dated 9/28/15 and 12/15/-12/16/15. The resident sample list for these 2 inspections included resident names and identifying numbers. By reading the state report which identified resident by numbers only, one could reference the sample list of residents which allowed the reader to see what residents were being referenced in the inspection reports. The Administrator when asked who posts the surveys in the survey binder he stated I do when I receive them. When asked about their policy with confidentiality of the residents by posting the inspection reports and the resident sample lists with the resident ' s name and sample numbers, he stated, I don ' t know, I ' ll ask my boss . He retrieved the inspection/survey book and stated I put the survey report in here . The Regional Clinical Director of Operations was called by the administrator and put on speaker phone. She stated never, we never post identifying information. The administrator found the page with the resident ' s names and identifiers, pulled it out, and put it under the desk. Residential Care Services received photos taken 5/29/16 @ 2:18 p.m. taken by a visitor. The survey book that had confidential resident lists, annual survey dated 9/28/15 with 32 resident names listed. The survey book also contained a complaint investigation dated 12/15/15 with 3 resident names listed. On 6/13/16 at 11:15 a.m. the visitor and the resident they visited expressed concern with resident ' s name being listed for everyone to see in the survey book. The visitor and resident felt there was retaliation for voicing concerns about care issues. At 3:00 p.m. when asked about the confidential resident list being in the survey binder on display Administrator (ADM) stated, ' That ' s on me, there aren ' t any in there now.

Based on observation and interview, it was determined the facility failed to ensure 2 of 2 current sampled residents, 2 of 2 resident family, and 6 of 9 current staff were free from willful intimidation, and feeling afraid and upset from an atmosphere described as the good ole boys club. This failure resulted in expressions and observations of intimidation, crying, and verbalizing fear. Findings include: 1) On 12/15/2015 at 12:40 p.m., Resident #3 stated the Director of Nursing Services (DNS) rules by fear and intimidation. The resident and Resident #3's family member stated they do not go to management (i.e. Administrator (ADM)/DNS) anymore because nothing changed. Resident #3's family member stated he has been disrespected and the DNS does not listen. The family member stated when he had asked for the nurse to contact the DNS regarding Resident #3, the nurse stated she was unable to do that because she would get in trouble for contacting the DNS. Family member stated, When I have gone to (ADM and/or DNS), I get dismissed. 2) On 12/15/2015 at 2:27 p.m., Resident #2 stated, I feel like I've been intimidated and threatened. Every time we bring up concerns, they tell me I need to look for another place. Staff says they are bullied and everyone walks on egg shells around here. Staff tell me they are afraid. Resident #2's family member stated the nursing staff demeanor changes when the DNS is present. The family member said the staff are afraid of the DNS. On 12/15/15 and 12/16/15, 6 of 9 facility staff were interviewed and repeatedly indicated the following: It's just the good ole boys club around here. The ADM and DNS rule by intimidation and look down on women. Staff feel intimidated by the ADM and DNS. The DNS was not approachable and could be intimidating. Staff feel an uncomfortable atmosphere in the building. Staff were observed to be fearful, tearful and shaking. Staff were observed to be uncomfortable, worried look, shoulders hunched, when talking about the DNS. The atmosphere expressed by residents caused Resident #3 and 2 to feel afraid and intimidated by the DNS and ADM. This intimidation has caused residents and staff to feel that they cannot voice concerns because of fear of retaliation.

Based on interview and record review, the facility failed to provide a catheter change treatment for [REDACTED]. This failure resulted in Resident #1 experiencing pain and bleeding for approximately 18 hours requiring a transfusion. Findings: Resident #1 has been a resident of the facility since 2007. Resident #1 has chronic [MEDICAL CONDITIONS] and is unable to move his body. On 6/26/15 according to Staff #1, Residemt #1's suprapubic catheter was leaking. Licensed Staff #2 proceded to change the catheter. Licensed Staff #2 stated in his nurses's note that Resident #1 was agreeable to his changing the catheter and experienced no pain only a little discomfort. After reconnecting the drainage tube, Licensed Staff #2 wrote that there was some urine draining but mostly blood. Licensed Staff #2 also noted that throughout the remainder of the shift, his urine did clear some but was still blood-tinged. According to Licensed Staff #3's nurses' notes on the next morning (6/27) at 0800, Resident #1's catheter was leaking, blood clot noted . noted urine mixed with blood coming out . in large amount and fresh blood noted on the catheter. Licensed Staff #3 replaced the catheter with little discomfort to Resident #1. On the following shifts, amber colored urine is noted. On 7/27/15 interview with Resident #1, revealed that he did not want his catheter changed when Licensed Staff #2 approached him about it. He said that he would wait til tomorrow for his regular nurse to change it. Resident #1 stated that it hurt so bad when he changed it. I couldn't stand the pain. He told me he had done lots of them, but it really hurt when he did it. It started bleeding after he did it. Resident #1 was able to verbalize his refusal of the catheter change and had no other way to protest since he is unable to move his body. Additionally, Resident #1 has chronic [MEDICAL CONDITION]. On 6/30/15 Resident #1 had debridement of his decubitus ulcers and returned to the facility with a brief soaked in blood. His physician had noted back in December 2014 that his chronic [MEDICAL CONDITION] worsened with the [MEDICATION NAME] of his decubitus ulcers. On the 7/1/15 hospital admission, the doctor wrote On Friday, 5 days PTA-RN (who was not his usual RN) changed his catheter-apparently traumatized on way out and on way in with new catheter. Bleeding was profuse from suprapubic cath and urethral meatus-cath changed again on Sat by usual RN and bleeding now only from meatus. CT of abdo and pelvis ordered to further eval for underlying cause as simple change should not cause this much bleeding. Hemaglobin was 7.4 g/dl on hospital admission. (Normal hemaglobin for men is 14 - 18 g/dl) Resident #1 received a transfusion of blood. CT scan showed no new health changes.

Based on observation, interview and record review, it was determined the facility Administration failed to monitor and effectively administer services to attain and/or maintain residents' highest level of function and optimal well-being and to ensure residents were treated with dignity and respect for 10 of 26 sampled residents (#'s 1, 5, 6, 8, 12,13,14, 23, 24 & 25) and discharged residents (#'s 20 & 21). This failure caused harm to Residents #1 & 5 and to discharged Residents #20 & 21. Failure to assess for sufficient qualified staffing and address staff knowledge to meet resident needs placed residents with individualized and special care/treatment needs at risk for failure to reach the highest level of function and optimal quality of life. Findings include: 1) Refer to 42 CFR 483.10(b)(11) F-157 NOTIFY OF CHANGES (INJURY/DECLINE ETC.) For facility failure to immediately inform the resident's legal representative and/or interested family members of changes in the conditions of Residents #'s 5, 19 & 20. 2) Refer to 42 CFR 483.10(f)(2) F-166 RIGHT TO PROMPT EFFORTS TO RESOLVE GRIEVANCES For facility failure to promptly address and resolve grievances for Residents #'s 5, 22 and 10. 3) Refer to 42 CFR 483.13 (c) (2) F -226 Develop/implement Abuse/neglect Polices, the facility ) The facility failed to implement written policies and procedures to prohibit mistreatment, abuse and neglect for current sampled residents (#'s 23, 24 & 25) who resided in various locations throughout the facility and reviewed for abuse. This failure created the risk of harm due to the facility failed to identify, protect, investigate, prevent and/ or immediately report allegations of abuse. This failure placed residents at risk for further abuse. 4) Refer to 42 CFR 483.15(a) F-241 DIGNITY AND RESPECT OF INDIVIDUALITY For facility failure to ensure Resident #12 & #6 were treated with dignity and respect during staff interactions and personal care to prevent embarrassment and diminished self esteem to these residents and all residents in the facility. 5) Refer to 42 CFR 483.15(f)(1) F-248 ACTIVITIES MUST MEET INTERESTS/NEEDS OF EACH RESIDENT. Resident #1 was harmed when the facility failed to provide meaningful activities. 6) Refer to 42 CFR 483.15(g)(1) F-250 PROVISION OF MEDICALLY RELATED SOCIAL SERVICES. Resident #1 was harmed when the facility failed to ensure social services were provided to assist the resident to attain his highest level of function. 7) Refer to 42 CFR 483.25, F309-Provide Care/Services for Highest Well-Being - related to wound care resulting in resident harm. Resident #'s 1 & 5 and discharged Resident's #'s 20 & 21 were harmed when the facility failed to provide the necessary care and services for skin care, chest pain and urinary infections to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. 8) Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores. Resident #1 was harmed when the facility failed to ensure Licensed Nurses (LN's) provided skin/wound management to provide prompt medical evaluation to prevent pressure ulcer development and deterioration in his condition. 9) Refer to 42 CFR 483.25 (e)(1), F-317 No Reduction in Range of Motion Treatment and Services unless Unavoidable. Resident #1 was harmed when the facility failed to provide restorative services which resuled in a decline in mobility. 10) Refer to 42 CFR 483.25(h) F-323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES Resident #1 was harmed when the facility failed to ensure supervision was provided to prevent injury. 11) Refer to 42 CFR 483.25(m)(1) F-332 FREE OF MEDICATION ERROR RATES OF 5% OR MORE For observed error rate of 32% for Residents #'s 8, 13 & 14 who received medications hours after scheduled times and/or not according to manufacturer's requirements/pharmacist recommendations and not in accordance with accepted standards of practice.This failure placed all residents in the facility at risk of harm from unsafe medication administration. 12) Refer to: 42 CFR 483.30(a)(1)&(2), F353-Sufficient Nursing Staff - For facility failure to ensure sufficient qualified staff members provided care and services in accordance with accepted professional standards of practice for performing tube feedings, assessments, care planning, treating residents with dignity and respect, accommodation of needs, quality of care, medication administration, pain management, pressure ulcer care/treatment and services.

Based on observation, interview and record review, it was determined the facility failed to have sufficient numbers of qualified staff to provide and supervise care for residents with complex health care needs and to ensure residents were treated with dignity and respect for 10 of 26 sampled residents (#'s 1, 5, 8, 12,13,14, 23, 6, 24 & 25) and discharged residents (#'s 20 & 21). This failure caused harm to Resident #1 and #5 and harm to discharged Residents #20 & 21. This failure placed all residents at risk of not attaining and/or maintaining the highest practicable physical, mental, and psychosocial well-being in accordance with resident assessments, care plans and professional standards of practice and impacted their well-being and quality of life. Findings include: 1) Refer to 42 CFR 483.15(f)(1) F-248 ACTIVITES MEET INTEREST/NEEDS OF EACH RESIDENT Resident #1 was harmed when the facility failed to ensure the resident was engaged in meaningful activities of choice. 2) Refer to 42 CFR 483.15(g)(1) F-250 PROVISION OF MEDICALLY RELATED SOCIAL SERVICES. Resident #1 was harmed when the facility failed to ensure the resident received assistance to maintain his highest level of physical, mental and psychosocial well-being and to promote consistent efforts to meet the residents medical and social service needs when he demonstrated depression and a change in mood and behaviors. 3 Refer to 42 CFR 483.25, F309-Provide Care/Services for Highest Well-Being - related to wound care resulting in resident harm. Resident #1 and discharged Residents #20 & 21 were harmed when the facility failed to provide prompt, necessary care and services to help them attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and comprehensive care plan. 4) Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores, Resident #1 was harmed when the LNs failed to provide skin/wound management to provide prompt medical evaluation to prevent pressure ulcer development and deterioration in condition. 5) Refer to 42 CFR 483.25 (e)(1), F-317 No Reduction in Range of Motion Treatment and Services unless Unavoidable. Resident #1 was harmed when the facility failed to provide restorative services to prevent a decline in mobility. 6) Refer to 42 CFR 483.25(h) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES Resident #1 was harmed when there was an avoidable accident by being left alone with hot coffee and without supervision. 7) Refer to 42 CFR 483.25(k) F-328 TREATMENT/CARE FOR SPECIAL NEEDS Resident #5 was harmed when the facility failed to ensure qualified staff performed tube feedings and administered medications via the correct tube port to prevent repeated hospitalization s and re-insertions and other complications. 8) Refer to 42 CFR 483.25(m)(1) F-332 FREE OF MEDICATION ERROR RATES OF 5% OR MORE For observed error rate of 32% for Residents #'s 8, 13 & 14 who received medications after scheduled times and/or not according to manufacturer's requirements/pharmacist recommendations and not in accordance with accepted standards of practice and placed all residents at risk of unsafe medication administration and for avoidable documented medications errors for Resident #'s 6, 16, 28, 29, 30 and discharged Resident #19.

Based on interview and record review, it was determined the facility failed to ensure proper treatment/care for residents with feeding tubes for 1 of 1 current sampled residents (#5) reviewed for enteral feedings. This failure caused harm to Resident #5 and placed all residents with feeding tubes at risk of not receiving adequate specialized services to prevent complications. Findings include: Resident #5 was admitted to the facility in November 2014 with multiple medical conditions including diabetes, breathing problems, [MEDICAL CONDITION] and stroke with right-sided contracture. He had a combination stomach/small intestine feeding tube (gastrojejunostomy -- GJ) with two ports, one for medications and one for liquid/nutritional feeding. He was alert and oriented and could make his needs known through gestures. Review of the clinical record and Resident Concern Reports (RCR), revealed the resident experienced multiple complications and return hospital visits for a plugged feeding tube with replacement in April and again in May. According to the hospital records dated 4/4/15 the resident was found to have a plugged feeding tube and aspiration pneumonia (lung infection that develops usually after stomach contents enter the lower airways and is a high risk complication for those with feeding tubes). Hospital record physician's notes dated 5/16/15 indicated a repeat visit for a clogged J-port of the GJ feeding tube due to medications and required replacement again. Hospital records indicated: All pills go in the G (gastric-stomach) port. Do not use the J (jejunostomy-small intestine) port for meds. On 5/19/15 at 3:30 p.m., Resident #5's family member was interviewed as the resident was in the hospital again being treated for [REDACTED]. S/he said the resident had to have the feeding tube replaced in April and again in May because the nurses did not know which port was used for nutritional feeding and which one should be used for medications. She said she had to stop one nurse from using the J-Port for medications during one of her recent visits. On 5/20/15 at 6:00 p.m., the Director of Nursing (DNS) said she was aware of the incident when the family member stopped the nurse from administering medications in the wrong port. The DNS said the facility had taken steps to label the ports so nurses would know to use the G (gastric) port only for medications.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate supervision was provided to 1 of 3 sampled residents (#1) reviewed for accidents. This failure caused harm to the resident when he suffered 2nd degree burns from hot coffee. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple medical conditions that included a traumatic event resulting in paralysis of his arms and legs. He was totally dependent on staff for all care and services and used a soft-padded call device with his chin. During interview on 5/20/15 at noon, the resident was in bed. He indicated he had been at the hospital. Review of an investigation report dated 3/21/15 at 5:15 p.m., a nursing assistant (NA) had given the resident hot coffee with three ice cubes in the resident's preferred cup with a straw. Staff heard the resident yelling for help. Staff found coffee was back-flowing out of the straw and onto his neck and right side of his chest. The resident returned from the hospital emergency room after receiving treatment for 2nd degree burns to the area and required special burn cream (Silvadene) and daily dressing changes. The facility determined This was an unforeseeable accident-- there was absolutely no evidence of abuse or neglect. The record failed to indicate how the resident was supervised before or would be supervised after the accident to ensure the resident's safety.

Based on interview and record review, it was determined that Resident #1 of 3 sampled residents for restorative therapy, did not receive continuous restorative care to his contracted arms. This failure caused Resident #1 to lose his ability to move his arms that he had upon admission to the facility and caused his shoulders to be painful. Findings include: Resident #1 was admitted on [DATE] for healing of a Stage 3 pressure sore on his tailbone. Resident#1 had fallen off a patio and fractured his spine. He was a quadriplegic as a result of the fall with limited movement of his arms. According to interview of the resident and his mother he could bring one hand up to his mouth. And he claimed that his shoulder pain came from non movement of his arms by therapy. He was offered Physical and Occupational Therapy but refused due to pain and his perception that they were rough handling him. So he was put on a Restorative program that he refused depending on who was providing the service. Interview of other residents (#2 & #3) on the restorative program, revealed that it was not consistently provided by the facility. Resident #2 stated that (restorative therapy) has been hit and miss for a long time now and and my R leg is not doing well - it lacks strength to walk. According to Resident#1's mother, he does not receive it consistently once a day as ordered/care planned since admission. They tell her they will do it and he tells her that they didn't do it and he is in pain. His mother says that the restorative aide is pulled from her work to fill in for short staffing or to assist with dining. Interview of the one restorative aide in the program, Staff #A, stated that she works 4 days on and 2 days off and that there has been a shortage of aides on the floor to which she has been pulled to fill in. She stated that on 5/12/15 the Director of Nursing had made Resident #1 a priority patient to be receiving restorative daily. At this time Staff #A is providing 5 days a week until another restorative aide can be hired. According to University of Washington (UW) Spinal Cord Clinic, upon discharge Resident #1 was able to roll side to side in the bed with maximum assist; Feed at least 10% of his meal successfully using wrist support cuff (able to eat a whole banana himself); tried using a wash mitt with a little help to wash his face and needed maximum help to wash his eyes; with arms supporting, sit for 1 minute on edge of a mat with max assist as one arm does not stretch out straight. There was no documentation in his chart that any of these skills were being provided. Observation of Resident#1 on 5/11/15 reveals that he can not move his arms himself and can no longer bring his arm up to his mouth. He is being fed his meals, he has contractures of his shoulders, elbows and wrists that have not improved since his admission but rather have declined. He no longer can roll side to side without shoulder pain.

Based on observation, interview and record review, it was determined that the facility failed to provide appropriate activities for 1 of 7 residents (#1) who was bed bound and depressed. As a result Resident #1 watched TV and visited with family when they visited and was on the call bell when alone. Findings include: Resident #1 was admitted on [DATE] for healing of a Stage 4 pressure sore on his tailbone. Resident #1 was placed in an air bed for wound healing laying on his back mostly as he refused to be turned due to pain in his shoulders. Resident #1's activities care plan included family visits, TV, radio and pet visits with his dog. There were no defined in-room activities except those mentioned above when he became bed bound. In interview, Resident #1 said that no one comes into his room to talk or play games or discuss current events. Interview of Resident #1's family member revealed that family visits are considered by the facility as his entertainment and activity. Family members state they can't come on a daily basis so all he has is his TV for management of his boredom. A family member also feels his depression isn't improving. According to his wound clinic orders he is not to be up in a wheel chair so he can not participate in any group activities out of his room. Resident#1's care plan had not been updated to ensure facility in room activities. Observation of his room revealed a TV and some family pictures but no radio or other types of activities and he is in a private room. There were no posters on the wall to depict Resident#1's personal interests in life. The room seemed dark except for the light above the sink to the left of the resident's bed. The resident did say he needed decreased stimulation to reduce his anxiety. The window blinds were closed or just partially open. All other walls and the ceiling were without any decorations or posters. According to a family member he is constantly calling her when he can't reach his call light or when no one answers his call bell signal or if he has complaints about his care delivery. There was no documented discussion between activities and physical therapy or restorative to provide a physical activity for his right hand and arm in order to promote the movement that he was admitted with. Since admission Resident #1 has declined in his ability to bring his hand close to his mouth. There were no interdisciplinary meetings that included the activities department to determine how to stimulate his participation in his care and services and impacts his depression.

Based on observation, interview and record review, it was determined the facility failed to aggressively provide medically related social services for 1 of 7 sampled residents (#1) who was resistive to care due to pain and anxiety. This failure placed the resident at risk of not being able to attain or maintain the highest level of everyday physical, mental and psychosocial well-being and promoted inconsistent care to meet the resident's individual needs. Findings include: Resident #1 was admitted to the facility on [DATE] following a traumatic event that left him paralyzed in his arms and legs. He was to receive care to heal one Stage 3 pressure ulcer on his tailbone. Resident #1 had refused mental health services required under the PASRR II regulation for his depression. According to his Mood and Behavioral Symptoms care plan, Resident #1 was identified as depressed with sad mood, feels bad for self and health situation, and his mood fluctuates throughout the day, with tearfulness and angry outbursts. There are no medically related social service interventions on the care plan other than his referral to mental health which he declined on admission. Even though Resident#1's behaviors were identified, finding ways to support his individual needs were not determined or implemented. In interview, Resident #1 still displayed these behaviors and also perseverated on negative thoughts. Interview with social services on 5/11/15 revealed that because he refuses services he has not received any interventions from social services. Though he refused counseling three times from the same provider there was no pursuit of any other provider whom he might have felt more comfortable relating to. There was no contact made with other resources such as peers/support groups who have had similar medical issues. According to interview of a family member, he has an established relationship with one of the ambulance drivers since meeting him for his trips to the wound clinic who would visit with him and he also developed a relationship with one of the male aides. Resident #1 is in a private room and does not come out due to his not being up in a wheelchair. When asked if social services (SS) provided him with visitors they (SS) countered that he had family that visits. Re-assessments of his medically related social issues were routinely done (quarterly) but with no updated or new interventions . There were no social service notes that reflected any interactions with Resident#1 to get to know him and learn how to motivate him. There were no documented discussions with him to assist him in making decisions about his care, or how to reach goals for his healing, nor was grieving recognized as an intricate portion of his depression and refusal of care. Thus no grief counseling was offered or provided by social services. There were no interdisciplinary meetings among the professional departments spear headed by social services to determine how to work with his refusal of care and services and his depression which impacts his participation, through motivation and personal skills. But antidepressant medication changes were made over time as the remedy for his depression. .

Based on observation, interview and record review, it was determined the facility failed to provide necessary care and services to 1 of 4 sampled residents (#1) and to 2 of 4 discharged residents (#s 20 & 21). This failure resulted in harm to Resident #1 as evidenced by the increase in avoidable pressure ulcers, pain and delayed treatment and poor wound healing of his original pressure ulcer and depression. Harm occurred when staff failed to recognize the need for timely treatment of [REDACTED].#20 and 21. These failures placed all residents at risk of harm. Findings include: 1) Resident #1 was admitted [DATE] for healing of a Stage 3 pressure ulcer on his tailbone according to his admission Minimum Data Set (MDS, an assessment tool). Resident #1 is paralyzed from a traumatic event. Resident #1 has no chronic or unstable medical conditions and no nutritional deficits. Resident #1 was observed in bed lying on his back with his feet touching the bottom bed frame. The mattress was air and sand filled and it was observed to be not more than a couple inches wider than Resident #1. Resident #1 had stated on interview 5/11/14 that he had a fear of falling off the bed when being moved. Resident #1 stated that he was afraid of turning on his side and had shoulder pain when he did and insisted on a staff person holding him just off the top of the bed when getting his dressing changes. Because of shoulder pain he often refused to be positioned off his bottom according to nurses' notes. According to the Interdisciplinary Goals from his care plan from the University of Washington (UW) Spinal Cord Injury Clinic dated 9/4/14, he was able at the time of his discharge to the facility to roll side to side with the assist of two people. Their (UW) goal for him at the facility was to advance to rolling side to side with some help and the use of a railing. On his admission MDS, Resident #1 was interviewed about his pain. His responses were that he was in almost constant pain at an intensity level of 7 out of 10, that limited his sleep and activities of daily living. He was on a scheduled pain medication regimen as well as when needed additional pain medication. Resident#1 complained that he didn't always get his pain medication on time. Often he would have to wait up to two hours for him to get it. In May 2015 his pain intensity for his as needed pain medication was either a 9 or 8 out of 10 on the medication sheets. Most often it was for arm & shoulder pain. According to the May medication records, he received routine pain medication in the AM and HS (hour of sleep). Since the facility uses a flexible medications pass with a four hour window from 6:00 a.m. to 10:00 a.m. for morning and 8:00 p.m. to 12::00 a.m. (HS) schedule, it is difficult to know how regulated his pain was if he were to receive medication at 6:00 a.m. and then not until as late as midnight. Resident #1 stated there were nights he did not get his HS medications until 2:00 in the morning. This was verified by Resident #1 on 5/11/15 as he told the Director of Nursing Services (DNS) that he didn't get his bedtime medications until 2:00 a.m. that morning. Resident#1 stated that he didn't like being repositioned when in shoulder/arm pain. During interview, one family member stated that he had not been given his pain medication before leaving in the ambulance for one of his recent wound care clinic appointment that occur on Thursday afternoons. Both Resident #1 and a family member stated that not getting his routine restorative exercises daily caused his arms and shoulders to hurt. When he had movement of his arms and shoulders, he had less pain but for the last 2 months restorative exercises were offered sporadically. Resident#1 had a cheek press call bell that often slid down the pillow case and out of his touch area. He would call his family and tell them that he couldn't use his call bell. They in turn would call the facility to have it attended to. Both family and Resident #1 reported that it would take hours at times to get someone to finally come in and adjust it. Resident #1 stated that it scared him to not be able to use his call bell. Refer to F 323. 2) discharged Resident #21 was readmitted to the facility from the hospital on [DATE] with multiple medical [DIAGNOSES REDACTED]. The resident was alert and oriented, made all of her own care decisions and required extensive assistance from staff for all daily living tasks. Review of the physician's note date 4/3/15 indicated the resident was working diligently with therapy .recently off the ventilator and [MEDICAL CONDITION] (3/31/15) .pleased with the resident's progress. <PAIN; THIGH WOUNDS FROM HOYER LIFT> On 4/15/15 the night shift note (no time) indicated the resident was found to have a bruise on her left inner thigh and right outer thigh .she states the Resident Care Manager (RCM) was notified about it during the day shift and he (nurse) thinks it is from the Hoyer (mechanical lift) sling . There was no documentation of an assessment or that the physician was consulted. On 4/22/15 day shift (no time) noted the resident refused to get up because just thinking of getting up with the use of the Hoyer already gives me pain, I don't want to get up too much. There was no documentation of an assessment of the thigh injuries and increased pain. The physician's note dated 4/23/15 indicated the resident had an acute exacerbation of some chronic redness in her legs .apparently started in the last 24 hours. The note indicated the resident had a history of [REDACTED]. She currently has a rash and is most bothersome between the legs and upper thighs, and it is most sensitive when her legs are touched. So far, the staff have not tried any topical applications for this. On 4/25/15 day shift (no time) the record indicated the resident was medicated for complaints of thigh pain at a level 8 of 10. No assessment was found in the record. On 4/26/15 on day shift (no time) the resident continues to complain of pain in thighs secondary to wounds she believes are caused by the Hoyer straps .feels the pain is traveling and spreading on her thigh. The staff member noted the wound on her left inner thigh had worsened and the edges have turned black .Dr. was called and orders to send to the emergency room (ER) for evaluation. The Resident's last quarterly assessment dated [DATE] indicated the resident's pain level was usually 3 out of 10. Review of the resident's MAR for April 2015 revealed an increase in narcotic pain medication ([MEDICATION NAME] 10 mg) from 1 time per day on 4/1, 2, 3, 8, 9, 10, 11, 15 and 16, 2015 to being medicated 3 and 4 times each day from 4/19/15 through 4/26/15 for pain in left lower extremity (LLE), right leg, right hip and thigh pain at level 8 out of 10. Hospital records indicated the resident was admitted on [DATE] at 3:00 p.m. with initial [DIAGNOSES REDACTED].wounds have surrounding black tissue. The physician's drawing of the wounds indicated an area on the outside of the right thigh and inside the left thigh .with a description of painful, swollen, red, bruised .likely secondary to the Hoyer lift .these wounds were determined not to be secondary to [MEDICAL CONDITION], but instead, non-infected wounds likely from the Hoyer lift .these wounds had been ongoing for approximately 1 month prior to admission to the hospital. The resident suffered harm when the facility failed to assess, monitor and intervene upon finding bruising to the resident's thighs to prevent the wounds from worsening to the point of ulcers that were bleeding and black tissue surrounded the areas. This caused a delay in treatment of [REDACTED]. <URINARY TRACT INFECTION [MEDICAL CONDITION] On 4/10/15 Resident #21 complained of burning with urination. Staff documented a strong odor present. A urine sample for culture and sensitivity was collected per catheterization (tube inserted into bladder to collect urine) at 7:15 p.m. and the laboratory called for pick-up. This note did not identify any skin issues to the area or to the resident's thighs as later noted on 4/15/15. Review of a Resident Concern Report (RCR) submitted to the facility on [DATE] by the resident, indicated she had a urine sample (for culture and sensitivity) taken a week ago (4/10/15). The Resident Care Manager (RCM) told her she would need Keflex (Antibiotic) for the UTI. She stated the day shift Nursing Assistant (NA) said the RCM told her it was not needed because the NA gave her Cranberry juice to help. The resident said she was not told to drink Cranberry juice. She was told on 4/17/15 the urine sample was a poor specimen and the provider decided not to treat. The next note dated 4/19/15 on night shift (no time) documented the resident was confused and agitated .she stated she was upset because no one changed her brief since 11:00 a.m. and the NA reported she (resident) was talking to herself around midnight. Her urine has a strong odor .urinalysis (UA) was done on 4/10/15 .will do another UA because labs are unavailable. On 4/19/15 another UA was ordered for culture and sensitivity due to c/o dysuria (painful urination) and some confusion the previous shifts. On 4/20/15 on the night shift (no time) an attempt to collect a urine sample via catheterization was not successful. The resident was admitted to the hospital on [DATE] and found to have a UTI--treated with a course of antibiotics. The resident suffered harm when the facility failed to assess, monitor and intervene upon discovering continued signs and symptoms of UTI even when the resident voiced concern about not getting the antibiotic after waiting a week. This failure caused nearly a 3-week delay in treatment for [REDACTED]. During the resident's hospitalization she was treated for [REDACTED]. 3) discharged Resident #20 was admitted to the facility in November 2014 with multiple medical conditions including current heart failure, heart and lung disease, [MEDICAL CONDITION] with rapid venticular response (RVR) and diabetes. Review of a Resident Concern Report (RCR), documented by the Social Services Director (SSD) on 3/18/15, indicated the resident complained of chest pain and difficulty breathing. The resident was upset that when she reported this to two nursing assistants (NA), they did not get help for her. She said the girl nurse did because I was calling out for help. The SSD explained how anxiety can make someone feel . A note of the incident, attached to the RCR review, indicated that at approximately 9:30 a.m., a NA reported to the nurse that the resident's heart is racing. There were no nursing notes (NN) in the record between 3/11/15 to 3/19/15. On 3/19/15 (no time) the record indicated the facility transported the resident to a scheduled gynecology appointment for vaginal bleeding noted in the February physician's assessment. The NN indicated on this day (no time), the facility received a call from the gynecology office that the resident was being transferred to the emergency room (ER) for evaluation related to low blood pressure and shortness of breath (dyspnea). The NN dated 3/20/15 (no time) indicated the resident was admitted to the hospital's Intensive Care Unit (ICU) for [MEDICAL CONDITION] (rapid irregular heart beat), urosepsis (life-threatening condition when the urine infection spreads into the blood stream), RVR (rapid ventricular heart rate) and to rule out a [MEDICAL CONDITION] (MI-[MEDICAL CONDITION] infarction). The documentation continued: Has elevated Troponin (protein found in the blood when the heart muscle has been damaged) .She also had blood in her urine and was made a do not resuscitate (DNR) in the hospital. On 5/28/15 at 3:30 p.m., during interview with the family member, she said she was contacted by the gynecology office and the hospital ICU regarding the resident's critical condition. The family member wanted to know how come it took the facility so long to get her medical attention and why she wasn't notified immediately for all of the care issues the resident suffered including the complaints of chest pain and shortness of breath prior to being sent to the gynecologist's office. .

Based on interview, observation and record review, it was determined that the facility failed to promote clinical wound healing for 1(#1) of 3 sampled residents with pressure ulcers. This failure resulted in the development of 9 additional avoidable pressure ulcer for Resident #1. Findings include: Resident#1 was admitted [DATE] with one Stage 3 pressure ulcer on his tailbone according to his Minimum Data Set (MDS) assessment. Resident #1 is a young male who has paralysis from a traumatic event. Though Resident#1 was identified as at risk of developing additional pressure ulcers because of his resistance to care and repositioning, he was not at risk through having unstable medical conditions. Resident #1 was assessed on admission and quarterly by the Minimum Data Set (MDS) as being a total assist with bed mobility, dressing, transfer, locomotion, eating, bathing and personal hygiene. Total assist means that two staff are required to assist the resident in the accomplishment of these tasks. Underlying issues that may affect his function were identified as changing cognitive function, pain, communication problems, mood decline, also weakness, limited range of motion, poor coordination, poor balance and visual impairment; and depression and contractures. According to the admission MDS, Resident #1 had his pressure ulcer condition assessed to be at risk for additional pressure ulcers. The goal of the care plan for his pressure ulcer-functional status was improvement of his current pressure ulcer and minimizing risk for the development of more pressure ulcers. He was admitted with a Stage 3 measuring 6.5x 3.9 x 3.0 centimeters. This admission was for wound care healing before returning to inpatient rehabilitation in Seattle. The facility determined that the nurses would assess location, size, stage, presence and type of drainage, presence of odor, and condition of surrounding skin and note whether granulation tissue (required for healing) is present and the wound is healing or not, every Monday on a skin sheet. Care to be provided was listed as: air bed in place, turning schedule 1 - 2 hours, weekly skin audits, daily skin checks by NACs during personal care, good protein nutrition and hydration. On Resident #1's next quarterly assessment (MDS 12/17/14) there was recorded one unhealed stage 3 or 4 measuring 2.5x 3.0 x 2.0 which showed healing as the size was decreasing along with granulating tissue. No skin sheet audits that showed the size, stage, type of drainage, presence of odor or condition of surrounding tissue since his admission were provided when asked for on 5/11/15 & 5/12/15. Licensed Staff C showed me all the places he said they would be but there were none in any of the binders or the resident's chart to be found. When asked for the Wound Clinic notes on 5/11 & 5/12/15 the facility did not present them. Resident #1 started weekly pressure ulcer treatments at the hospital wound clinic on 10/9/14. On initial treatment at the wound clinic, the (#1) pressure ulcer was Staged at a IV as tailbone was exposed in the wound. It now measured 5.0 x 2.0 x 3.7 centimeters (cm). On 10/23/15 a new Stage II was on his Right (R) heel (#2). On 11/6/14 the R heel was healed. On 12/11/14 a third pressure ulcer at a Stage II developed on his Left (L) buttock and Pressure ulcer # 4 on R buttock was developing as an unstageable deep tissue injury. Through the month of December 2014 the pressure ulcer #1 still had exposed tailbone during wound treatments Staged as a IV. Yet the MDS only accounted for one pressure ulcer at Stage III level. On 12/18/14 the wound clinic made a request for a Clinitron bed for Resident #1. According to the Certified Wound Specialist Nurse at the wound clinic the Clinitron bed is meant to be used for patients with a severe stage 3 or 4 pressure ulcer that is having difficulty healing. Generally, if a patient has a pressure ulcer like this it means that they can't really move much on their own, so no worries about them getting in and out of bed. The way the bed works is that the very fine sand inside the mattress gets blown around inside by air when the bed is inflated. This is supposed to help heal the pressure ulcer. The only bedding you are supposed to have on this bed is a flat sheet (fitted sheet is too small) to be able to get the full effect of the beds purpose. Between March 5 and March 12, 2015 Resident #1 received his Clinitron bed that was ongoing requested by the wound clinic for three months. Also during the month of December the nurses were having difficulty changing the wound vac dressings on his tailbone ulcer and this is noted in the wound clinic documents as a cause for worsening of the ulcer condition and lack of healing. On 2/5/15 wound clinic notes a Stage II developed on his left heel (pressure ulcer #5). Even though the pressure ulcer on his L buttock healed 12/18/14, a new pressure ulcer developed on his L buttock from his sitting up in his bed at 30 to 45 degree elevation of his head that puts pressure on that area of the lower back. Pressure ulcer #6 developed 2/19/15 on his R lateral leg at superficial level along with a new #7 also appearing on his L buttocks. On 3/17/15, Resident #1's quarterly MDS assessment showed 2 Stage 3 pressure ulcers and one Stage 4 pressure ulcer with the measurements of the unhealed stage 3/4 as 6.5 x 4.0 x 2.0. Granulated tissue also was checked as being present. Where these pressure ulcers are located is not in the assessment. Resident #1 was put on a Wound VAC since his clinic admission and improper placement of the dressing with pressure leaks caused one of the new pressure sores on his buttocks, but nursing staff at the facility were not all aware of how to change the dressing to the wound vac. As a result in 2/4/15 the care plan noted to hold the wound vac until the next day when he went to the wound clinic. Resident #1 stated that some of the nurses wouldn't do his dressing change because they didn't know how. The last time before it was discontinued a nurse could not get it back together to fit tight so it didn't leak. According to interview of the Wound Clinic Nurse, KCI the wound vac company offered training on the wound vac dressing changes. During the month of April the facility had problems again being able to change the wound vac dressings to his pressure ulcer and as a result the misplacement of the foam part of the dressing caused damage to the skin, wound bed and swelling to the tailbone ulcer according to clinic notes. The clinic discontinued the wound vac dressings due to trouble keeping the vac on the ulcer for 3 or 4 days prior to the 4/30/15 clinic visit. It was replaced with wet to dry dressings that seem to have had better healing results due to their consistency. Pressure relieving boots used by the facility also caused pressure ulcer #8 on the R heel as a Stage II. And on 4/16/15 Pressure ulcers #1, 5, 7 were now Staged as IV ( the most severe stage). Pressure ulcer #8 was now staged III. The elevation of the Resident's head of bed beyond 30 degrees was noted as the cause. Also the clinic notes that the AFO boots to relieve pressure on his feet were not padded well and contributed to the development of pressure ulcer #8. The clinic requested different AFO boots that took until May 12th for Resident #1 to receive and they were not put on by May 21, 2015 according to phone conversation with family member. The 4/17/15 Care Plan indicated Resident #1 had a Stage 4 on his tailbone, a Stage 4 on his right hip, a Stage 3 on his left hip, and a Stage 2 on his buttocks, & a healing Stage 2 on his right heel based on Pressure Ulcer Stages ranging from 1 to 4. On 4/30/15, clinic notes identify # 9 as a pressure ulcer on the R lower leg. unstageable and on 5/21/15 there were multiple skin eruptions around the ulcers with multiple excoriations and redness that is probably due to irritant contact [MEDICAL CONDITION] or tinea (yeast). During his stay the interventions for his wound care didn't vary. The facility says that Resident#1 would not allow them to reposition him every 1-2 hours and the resident claims they would not come in and move him because it took two people to do so. The care plan interventions for his pressure sores were not implemented nor evaluated for effectiveness of the interventions nor new approaches to his care and as a result he obtain eight avoidable pressure ulcers and his original pressure ulcer became a Stage 4 (down to the bone). (#9) A pressure ulcer can occur wherever pressure has impaired circulation to the tissue. Resident#1 was on a Clinitron bed used for treatment of [REDACTED]. He was to only be at a 30 degree elevation in order for healing to occur on this type of bed. On 5/11/15 I observed him to be in a 45 degree elevation in the bed which caused him to slide down in the bed pushing his feet against the bottom of the bed and taking his heels off the surface of the bed's therapeutic surface. At 45 degrees he was able to sip liquids through a straw on his over-bed table easily. He also had numerous pillows around his head, shoulders, legs and feet. Pillows contribute to ineffectiveness of the bed's purpose to relieve pressure. It is important to recognize & evaluate each resident's risk factors & to identify & evaluate all areas at risk of constant pressure. Critical steps in pressure ulcer prevention & healing include: identifying the individual resident at risk for developing pressure ulcers, identifying & evaluating the risk factors & changes in the resident's condition, identifying & evaluating factors that can be removed or modified, implementing individualized interventions to attempt to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, & modifying the interventions as appropriate. None of evaluating of the progress or lack of progress, the successful or unsuccessful interventions was done on a regular basis at reassessment times and this resulted in 9 additional avoidable pressure ulcers.

Based on interview, observation and record review, the facility failed to aggressively identify the need for medically related social services and pursue the provision of those services for 1 of 7 residents (#1) reviewed for quality of life when they failed to pursue discharge planning and failed to advocate for the resident's well being. This failure caused harm to the resident who has become increasingly despondent and withdrawn during the facility stay. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 6/13/14, the resident was alert and oriented with some memory problems. The resident was able to communicate his needs, but was totally dependent on staff for all activities of daily living (ADL), including eating. The resident was admitted with pressure ulcers to the coccyx which were being treated at the hospital wound clinic on a weekly basis. On 3/12/14, the discharge plan was for the resident to go home. According to a Social Services note of that date, "Resident admitted to acquire ADL skills and power chair use abilities. Hospital chart notes and (the resident) state he plans to live with son and daughter in law. The home is being renovated for wheelchair use and care requirements. Admission is expected to be less than 90 days." The PHQ-9 score (a tool used to screen for symptoms of depression) reflected the resident a score of 3, indicating minimal depression, with the resident having little interest or pleasure in doing things, trouble falling asleep and feeling tired or having little energy. On 6/24/14, the discharge plan was reviewed. Chart notes reflect the resident was to discharge to the home of his son and would require assistance with overcoming barriers and would need community resources, equipment and home health. Goals were established to "Assist the resident to envision strong capable future" and to "Encourage family training how to care for paralysis/wheelchair." On 7/15/14 a progress note reflected "Had hoped to discharge from facility soon which is not the case. Can not due to more care and rehabilitation." The PHQ -9 score was noted to be 8, indicating increased depression. On 8/5/14, chart notes reflect the resident's Lyrica (a medication which can help with nerve pain) was discontinued as it was no longer paid for by the insurance company On 9/2/14 a care plan meeting was held with the family, resident and interdisciplinary team which reflected "Discharge plan: Long term care." Social Services reported "No concerns, no issues, denies depression, sleeps a lot. Doesn't want counselor and mental health." On 9/4/14 at 9:30 a.m., Licensed Nurse (LN) A stated "I notified the doctor the insurance company was not going to pay for the Lyrica. If the resident won't talk to the doctor, there is nothing else I can do. I can't write prescriptions. The resident felt that (Lyrica) was the only thing that would help his pain, but if he wont talk to the doctor, there's nothing I can do. The resident is refusing care, he says he is in pain, but he won't talk to the doctor." At 10:45 a.m., LN B stated "At times the resident screams when we try to change his dressing or reposition him, then he will tell others he is having no pain. He is very quiet unless spoken to. He is very solemn and withdrawn." At 11:00 a.m., the Social Services Director stated "The resident has no planned discharge at this time. There is a possibility of the resident going home if he chooses to participate. He has had a lot of pain and it's been really hard for him. We did a mental health referral, but he is not being followed by anyone from mental health. He may have refused mental health. We probably need to re-evaluate him. He is very guarded and not really open about his feelings." At 1:20 p.m., the resident stated "I would really like to live in a different place. I am paralyzed and can't do anything for myself. About the only thing I can do is to scratch is to move my hand up toward my face to scratch my nose if my shoulders don't hurt too much. Not being able to move my body would make it hard for me to live at home or anywhere. I am in pain most of the time. My spasms can start by just having the sheets moved on my feet. I don't remember if certain medications have helped. I would like to have my dressings changed only once a day or every other day instead of twice a day because of the pain." At 4:10 p.m., LN A stated "I attended the care conference on 9/2. The resident denied pain, but I told him 'I can see your brow is furrowed - if you are in pain you have to talk to the doctor.' The resident reported he would like to have his dressing changes less than twice a day. I have been trying to call the wound clinic since Tuesday, but they haven't called me back yet." Refer to F 309 .

Based on interview and record review, the facility failed to ensure quality of care and services for the highest level of physical, mental and psychosocial well-being for 3 of 7 residents (#1, 2 & 7) when they failed to address and manage pain and when they failed to monitor and assess resident's bowel function. This caused harm for a resident who had compromised physical functioning and social interaction due to pain, caused harm for a resident who required hospitalization to treat constipation and caused discomfort and physical symptoms for the other resident with on-going bowel problems. Findings include: <Pain> 1) Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 6/13/14, the resident was alert and oriented with some memory problems. The resident was able to communicate his needs, but was totally dependent on staff for all activities of daily living (ADL), including eating. The resident was admitted with pressure ulcers to the coccyx which were being treated at the hospital wound clinic on a weekly basis. According to the Medication Administration Record [REDACTED]. All responses for the month of August regarding the question "Is your pain program effective for you?" are coded as "Yes". On 8/19/14, a nurse practioner note reflected "Complains of increased pain after [MEDICATION NAME] (a pain reliever) stopped. Visited patient who reports no pain and no muscle spasms." On 8/25/14, a nurse practioner note reflected "Patient will not speak to me today about pain management. He is in a mood today. I will not change pain meds until patient discusses his pain with me. He is able to talk." On 9/4/14 at 10:45 a.m., Licensed Nurse B stated "I have worked here for about 6 months. The resident's level of pain has not changed. He has painful spasms. If we try to reposition him or touch him, he screams 'Don't hurt me'. Then at other times he tells people he has no pain." At 1:20 p.m., resident #1 stated "I am in pain most of the time. My spasms can start up just by having the sheets moved on my feet. I can't do anything for myself. My shoulders hurt all of the time. I don't remember if any of the medications have helped." At 2:00 p.m., Nursing Assistant (NA) E stated "I have worked here a little over a month. The resident is in a lot of pain when we try to reposition him. He yells that he is in pain. He tries not to make us feel bad, but I can tell he is in a lot of pain. <Bowel Care> According to the facility bowel protocol, Milk of Magnesia was to be given by the evening shift at bedtime after 8 shifts without a bowel movement. If there were no results, the night shift was to give a [MEDICATION NAME] suppository. If the suppository had no results, a fleets enema was to be administered by the day shift. If there were no results from the fleets enema, the physicain was to be notified. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment instrument, dated 6/28/14, the resident was severely cognitively impaired and was unable to express needs except through moaning or shouting. The resident was unable to eat orally and was fed through a tube feeding. The resident was dependent on staff for all activities of daily living (ADL) care and was incontinent of bladder and bowel. An August 2014 bowel report showed the resident did not have a bowel movement for 16 consecutive shifts between the day shift on 8/9/14 and the day shift on 8/14/14 (greater than 5 days). A review of the Medication Administration Record [REDACTED]. A suppository was not administered at all. A fleets enema was not administered at all. The physician was not notified. The patient had a bowel movement on 8/14/14. A few days later, the resident again did not have a bowel movement for 17 consecutive shifts between 8/16/14 day shift and 8/21/14 evening shift (nearly 6 days). Milk of Magnesia was not administered until the 14th shift following no bowel movement, 6 shifts later than the bowel protocol called for. A suppository was not administered until the 13th shift following no bowel movement, 4 shifts later than the bowel protocol called for. These 2 interventions did not produce results. The physician may have been contacted because an order for [REDACTED]. On 8/17/14, nursing notes reflected the resident was "Up from 11:30 -12:15 when she began shouting in pain. Resident was assisted back to bed and given pain medication." There was no indication the resident had been assessed for the reason of pain. On 8/21/14 following 17 shifts (nearly 6 days) of no bowel movement, the resident's family demanded the resident be sent to the hospital because of unrelenting abdominal pain. A progress note reflected "Pain to right side and on going screaming and moaning." The communication form and progress note indicated the "Bowel sound is active, no abdominal distended. No hard stool noted." On 9/4/14 at 5:15 p.m., when results of an abdominal x-ray ordered by the physician on 8/19/14 could not be located in the record, Licensed Nurse (LN) C stated "We decided the x-ray did not need to be done, because she had a bowel movement." LN B then called the lab and found the x-ray had been done and results reported on 8/20/14 reflected "Moderate constipation." A review of hospital records for the stay of 8/21/14 through 8/25/14 reflected a "CT (CT scan) abdomen with diffuse stool burden and potential signs of possible early SBO (small bowel obstruction). Surgery consulted and agreed with medical management. Pain thought to be secondary to constipation, supported by fact that she improved dramatically with aggressive bowel regimen and multiple BMs (bowel movements)." The resident discharged from the hospital to another facility on 8/25/14 with orders for an aggressive bowel program. 3) Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS dated [DATE], the resident was alert and able to make needs known, but was dependent on staff for ADL care needs. The resident was incontinent of bladder and bowel. An August "Bowel report reflected the resident did not have a bowel movement for 14 shifts between 8/9/14 on the evening shift until 8/14/14 night shift. The resident was incontinent of bowel on 8/14/14 day shift. On 8/14/14, nursing notes reflect "Seems a little sluggish this morning." The resident then did not have a bowel movement for 11 shifts until the day shift on 8/18/14. On 8/18/14, a nursing note reflected "Is more responsive to staff." On 8/20/14, resident "Is more alert and responsive. Improved appetite today." Again, between 8/19/14 day shift and 8/24/14, day shift, or 16 shifts, the resident had no bowel movement. Records reflect the resident was incontinent of bowel on 8/24/14 in the evening. On 8/22/14, a nursing note reflected "Called daughter and reviewed (the resident's) mood decrease and appetite and depression" and discussed possible use of an appetite stimulant to help the resident eat better. Again between 8/25/14, evening shift and 8/31/14, night shift, or 17 shifts, the resident had no bowel movement. Records reflect the resident was incontinent of bowel on 8/31/14 during the day shift. On 8/29/14, the resident experienced an episode of low blood pressure and a decrease in mental alertness A review of the MAR indicated [REDACTED]. No medications were administered as outlined by the facility bowel protocol during the month of August. On 9/4/14 at 4:00 p.m., LN A stated "After 8 shifts of no bowel movement, the night shift nurse is to give the Milk of Magnesia, based from a report they run at bedtime. On the next morning, at the end of the night shift, if there were no results the resident is to receive a suppository. Later in the day, if no results, the evening nurse should give an enema. The bowel protocol should have been started for (resident #7) and it was not. I have reviewed the record and have found that no bowel protocol was administered." .

Based on interview and record review, it was determined the facility failed to provide care in accordance with each resident's written plan of care for 1 of 6 residents (#4) when they failed to have 2 (two) caregivers (deemed necessary according to the assessment and care plan) provide bedside care. This failure caused harm when the resident sustained [REDACTED]. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was noted to be in a persistent vegetative state and lacked the ability to move, to communicate or to protect self. The resident was in bed most of the time and was on an air mattress. According to the Minimum Data Set, MDS, an assessment instrument, dated 7/14/14, the resident was completely dependent on staff for activities of daily living and required 2 staff members for all care. The resident required machines to help with breathing and feeding. According to the plan of care and the care directives (directions for the care providers) the resident was to have 2 staff members provide all care because of the resident's size and inability to move. According to facility records, on 7/19/14 at 05:50 a.m., Licensed Nurse (LN) D observed Nursing Assistant (NA) E to be at the bedside of Resident #4. Knowing the resident required the assistance of 2 persons, LN D inquired if NA E needed assistance. NA E stated "No, we got this." LN D made the assumption that NA E had someone else assisting with Resident #4's care. At 06:00 a.m., LN D was notified that Resident #4 was lying on the floor at the foot of the bed and had bruising to the cheek and bruising on the chest. The physician was consulted, the resident was sent to the emergency department for evaluation, where no additional injuries were found. Resident #4 returned to the facility later in the day. On 7/24/14 at 12:50 p.m., NA F stated "We should always have 2 staff members for repositioning a resident if they are using an air bed. It's too dangerous to do care by yourself when a resident in on an air bed. I learned this in basic nurse aide training." At 1:25 p.m., NA G stated "We always have to have 2 staff when we are providing care for a resident on an airbed. It is too easy to flip a resident off the bed." At 4:25 p.m., the Director of Nursing stated "It is not acceptable for our staff to provide care to a resident outside of the care plan. When I interviewed {NA E}, she stated she could not find anyone to help her, but I know the Licensed Nurse had just checked in with her and I know the day shift would have been arriving any minute." On 7/24/14 at 08:00 a.m., during telephone interview, NA E stated "I knew the resident was a 2 person assist. I knew the care directive called for 2 people. I was in a hurry and was trying to get done with my work assignment before the next shift came on at 06:00 a.m., I thought I could provide care and reposition the resident by myself. I made a mistake."

Based on interview and record review it was determined the facility failed to provide the necessary timely care and services when there was an obvious change of condition for 1 of 8 residents (former Resident #1) reviewed. The Resident had an episode of decreased level of consciousness, shallow and rapid respirations, elevated temperature, decreased oxygen saturation and diminished lung sounds which indicated acute respiratory distress. The facility's failure to obtain emergent evaluation deprived this resident of life sustaining treatment options. Findings include: Resident #1 was a long term resident of the facility. He had [DIAGNOSES REDACTED]. He was legally blind, required two staff to transfer him using a mechanical lift and had some cognitive impairment. In a review of the medical record it was noted Resident #1was generally alert and oriented to self and able to make his needs known. According to the Medication Administration Record [REDACTED]. During the month of March his oxygen levels were routinely recorded to be above 90% and the majority of the time he was recorded as being on room air. He did have physician orders [REDACTED]. His routine vital signs taken during his stay indicated his normal respiration rate to be around 18 per minute and his heart rate usually mid 70's to low 80's. There were no documented routine vital signs for Resident #1 found after [DATE]. He was recently treated for [REDACTED]. According to his POLST (Physician order [REDACTED]. In a review of the medical record the Situation Background Assessment Recommendation (SBAR) Communication Form and Progress Note written on [DATE] indicated the resident had decreased LOC (level of consciousness) and decreased response. His vital signs were blood pressure ,[DATE], Pulse 112, Respirations 32, Temperature 101.8. He had an oximetry of 88% and he was on 4 liters of oxygen. The Licensed Nurse (LN -J) documented on the SBAR the resident had shallow breathing, diminished lung sounds with bilateral wheezes, and absent bowel tones. LN - J also documented resident was on nectar thick liquids as of [DATE] and felt it could be aspiration. According to the documentation, LN - J placed a call to the physician (Dr - R) at 3:25a.m. and as of 4:00a.m. there had been no response. LN - J wrote he would continue to monitor. There was no further assessment or notes made by LN - J. In a telephone interview with LN - J on [DATE] at 7:45a.m. when asked why he had not sent the resident to the hospital when he could not contact the physician he stated, "because of the return to hospital rates, we are supposed to call the DNS (Director of Nurses) or Residential Care Manager (RCM) on call first." LN - J stated RCM - S said not to send him to the hospital but to monitor and give APAP (tylenol) suppository. When LN - J was asked what information did he provide RCM - S he said he provided all the information off of the SBAR. LN - J stated he was surprised RCM - S did not want to send the resident to the emergency room . When asked if he had respiratory therapy come and assess the residents' lung sounds he said "No, he had not asked respiratory to come and assess the resident." He did put the resident on the 24 hour alert charting board so everyone would know to assess him. He stated he never did hear from the physician during his shift. The next documentation in the medical record was found in a Progress Note written [DATE] at 11a.m. by LN - S. The note indicated the resident was alert and oriented to self and remained afebrile. The documentation indicated the resident oxygen saturation was going down into the 70's on room air and up to 89% on 5 liters of oxygen. Documentation indicated respiratory therapy assessed the resident and that Residential Care Manager (RCM) - S was notified and changed orders. RCM - S added a nebulizer treatment as needed every 4 hours and to titrate oxygen ,[DATE] liters. Dr - R was notified. RCM - S assessed the resident and no new orders were given. There was no documentation made by the respiratory therapist of his assessment of the resident. There were no vital signs obtained or documented. RCM - S did not document his assessment of the resident. In a telephone interview [DATE] at 10:55a.m. with LN - S when asked if he contacted MD - R regarding the resident's condition at anytime on [DATE], he replied, "It was a Saturday and he never answered the phone, I left him a message and he never called me back." He said he was given the order from RCM - S to titrate the oxygen and to do the nebulizer treatments. He agreed RCM - S was not a physician and could not give orders, but he took them anyway. LN - S stated he understood MD - R called sometime later and spoke with RCM - S and approved the orders. In a written statement dated [DATE] provided to the investigator by the facility on [DATE] Respiratory Therapist (RT)-R stated he saw the resident in the dining room around noon. The resident had no signs of respiratory distress. His oxygen saturation was in the mid 90's on 3 liters of oxygen. His breath sounds were clear without wheezes or rhonchi. Documentation made in the progress note at 5p.m. by RCM - S indicated he contacted the guardian about the diminished lung sounds of the resident. He reported to the guardian the oxygen saturation was 90% but it had been dipping into the 60s. He wrote the resident was comfortable. In the written statement RCM - S wrote he came to the building at 5p.m. and visited with Resident #1, listened to his lungs and his oxygen saturation was ,[DATE]% on 5 liters of oxygen. He wrote Resident #1 was in no distress and appeared stable. In his written statement RCM - S wrote he contacted the Residents' Guardian to inform him of all that had occured during the day. He wrote the Guardian felt the Resident had not been the same since his last surgery and asked how long he had to live. He did not request the resident be sent to the hospital. The progress note written [DATE] (noc) indicated LN - J was called into the room at 9:57p.m. by the aide and found the resident with no signs of life. As he was a full code, CPR (cardio [MEDICAL CONDITION] resitation), was initiated and 911 was called. Resident was pronounced dead by the emergency response team at 10:27p.m. In review of the MAR for [DATE] the recorded oxygen saturation levels were recorded as: AM 90% on room air; MIDDAY 80% on 4 liters and HS (evening) 88% on 5 liters. There was no documentation of breath sounds, vital signs or notification of the physician. In a written statement provided by the facility to the investigator [DATE], Dr - R wrote, "On [DATE] at around 4:30a.m. I became aware of condition of (Resident). I spoke with respiratory therapist and was told that (Resident) O2 (oxygen) sats (saturation) had dropped down to 88% and that nursing and respiratory therapy had assessed him. Resident was alert at this time and stated that he did not feel short of breath. His O2 sats had returned to greater than 90%." Dr - R's written statement went on to state, "...no further reports of decreased O2 saturation received, chest pain or any cardio/respiratroy symptoms identified by the patient or staff." In an interview with the DNS and Administrator on [DATE] they said they had completed an investigation and ruled out abuse and neglect after the resident had passed away. They had obtained statements from the staff to indicate the resident had been at baseline all day, up for meals and in no distress. The DNS stated LN - J assessed the Resident and based on his second assessment the resident did not need emergent medical attention. They admitted the documentation was lacking but based on statements given them by the staff involved, did not feel there was any harm to the resident as he was in a state of decline and had been fine all day.

Based on interview and record review the facility failed to ensure 1 of 4 sampled residents (#1) at risk for developing pressure ulcers, or having a pressure ulcer received timely treatment to promote wound healing. The facility failed to identify resident #1's pressure ulcer, notify the physican and provide appropriate necessary treatment. This failure resulted in actual harm to the resident as the pressure ulcer worsened requiring hospitalization and specialty services of a wound clinic. Findings include: Resident #1 was admitted to the facility 9/10/13. She had [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS - tool used for assessment by the facility) resident #1 was alert and oriented and totally dependent on staff to meet her daily needs to include bed mobility and transfers. Document review indicated on 9/10/13 when she was admitted the skin of her buttocks was red with a rash. Progress note written 9/13/13 on night shift stated, "Slight redness noted on coccyx area, patient to be turned every 1-2 hours and barrier cream to be applied." On 9/13/13 resident #1 was sent to the hospital for respiratory problem and returned to the facility on [DATE]. According to the SNF Discharge Orders/Nursing Report sent from the hospital to the facility with Resident #1 on 9/15/13 Resident #1 had a Stage III (full thickness of skin, serosanguineous -blood colored - drainage) pressure ulcer on her buttocks. The pressure ulcer, according to the transfer paperwork was 1cm x 1.5cm and was to be covered with allyven (dressing used to cover wounds). A skin assessment was completed when resident #1 was readmitted to the facility on [DATE], according to the assessment there was slight redness to residents' buttocks. There was no evidence the facility recognized the pressure ulcer and there were no orders written for treatment. Review of the progress notes and treatment sheets did not indicate there was any identified skin issue for the resident except some excoriation in the groin which was treated with dimethacone (cream for minor skin irritations and [MEDICATION NAME] powder (used for skin irritations and yeast). Weekly skin assessments between 9/10/13 and 10/15/13 indicated there were no skin issues. Progress note written night shift 10/11/13 stated, "Patient had skin wounds on/near coccyx area. Treated with cream and 4x4 allevyn. Diarrhea appears to be causing skin damage." There was no doctors' order found or any indication in the documentation to indicate the physician was made aware of the "wounds". There was no documentation to support there was any assessment of the wounds completed. Progress note written 10/11/13 dayshift stated, "...buttocks and coccyx area red and excoriated; cleaned and protective cream applied." Again there was no mention of wounds or assessment being done or physician notified of any change in condition. According to the treatment sheet the weekly skin assessment was not completed on 10/22/13. On 10/29/13 the skin assessment box on the treatment sheet indicated there was a skin issue. There was however, no documentation of what the skin issue was, what was done about it and/or if the physician was notified. 10/30/13 day shift progress note, "....residents' sacrum with black eschar noted with excoriation around the black eschar." Progress note written 10/30/13 written at 12:45p.m. .. "TO (telephone order) to discontinue current treatment to coccyx (there was no evidence of any prior order); new order cleanse area with normal saline, pat dry, apply skin prep to eschar (slough), cover with pad, change every day, turn resident every hour and refer to wound healing center. Progress note written 10/30/13 at 2:50pm indicated the residents' buttocks were assessed. The wound measured 4cm x 4cm on sacrum, with black eschar covering the area. To right and below the sacrum there was an excoriated area 6.5cm x 4.5cm and to the left and below was 8.5xm x 6.5cm blanchable red area. There was no odors or drainage noted. When the facility assessed the resident prior to sending her to the emergency room they documented on the skin grid - pressure ulcer/[MEDICAL CONDITION] ulcer/other form, the pressure ulcer on her coccyx was unstageable and was 9cm x 8cm and pressure ulcer to the right anterior coccyx was unstageable and 11cm x 7cm. On 10/30/13 the family, according to the progress notes, insisted the resident be sent to the emergency room for treatment of [REDACTED]. Resident was taken to the emergency room and returned to the facility on [DATE]. Facility stated in their investigation, the pressure sore was present on admission to the facility. There was no evidence found in the documentation to indicate they were aware of the pressure ulcer prior to 10/30/13. There was no treatment or assessment completed of a pressure ulcer prior to 10/30/13. Resident did have care plan in place with interventions such as air flow mattress and turning every 1 or 2 hours but no other treatment or interventions were noted. In an interview with resident #1 on 11/19/13 she stated she did not have a pressure ulcer when admitted to the facility. She stated she did not always get turned and when the pressure ulcer developed staff did not do anything about it. Resident #1 stated she was now getting turned on a regular basis and going to the wound clinic for treatment. In an interview with the director of nurses on 11/19/13 she had no explanation as to why staff had not identified the presence of the pressure ulcer but believed it had developed in the hospital and was present according to hospital documentation when resident returned to the facility on [DATE]. She agreed the assessment of "slight redness" was not the same as a stage III pressure ulcer. She agreed the lack of assessment and appropriate treatment led to the worsening of the residents' pressure ulcer. She stated she had/was implementing interventions to prevent future episodes.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 2 of 4 residents (#5 and 8) when they continued to administer laxatives to residents already experiencing loose or liquid bowel movements during treatment for [REDACTED]. Findings include: According to the Centers for Disease Control and Prevention, "[MEDICAL CONDITION] is a bacterium that causes an inflammation of the colon; this condition is called [MEDICAL CONDITION]. Diarrhea and fever are the most common symptoms of [MEDICAL CONDITION] infection." <Resident #5> Resident #5 was admitted to the facility on [DATE], was a hospitalized for [REDACTED]. [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 11/17/12, the Resident was completely dependent on staff for activity of daily living (ADL) care and was not interviewable. The Resident had a [MEDICAL CONDITION] (a bag used to collect stool when the bowel was diverted from it's usual route). The Resident also had a [DEVICE] (a tube going into the stomach) through which all nutrition and medications were delivered. The plan of care stated "[MEDICAL CONDITION] output {stool} will be formed." Bowel records show the Resident had frequent loose or liquid stools. Diarrhea was recorded on 53 of the 63 days during the Resident's stay. Laxatives were administered during 62 of those days. No information was available to explain this finding. Medication administration records showed the Resident received Senna-Gen (a laxative) by [DEVICE] daily between 11/13/12 and 12/11/12 with directions to "Hold for loose stool or diarrhea." The medication was held once on 12/07 for loose stool but was administered all other days, despite diarrhea being recorded on the bowel flow sheets. When the Resident returned from the hospital on 12/18, physician orders [REDACTED]. The medication was administered daily during December and January. On 01/22/13, a physician order [REDACTED]. On 01/23/13 at 12:15 p.m., Licensed Nurse (LN) H stated "The DSS was discontinued for {Resident #5} yesterday because of watery stools. The Resident always had diarrhea because of the [MEDICAL CONDITION], but it was worse with the stool softener." The LN could not explain why the medication was given over an extended period of time. At 12:25 p.m., Nursing Assistant (NAC) Q stated {Resident #5} "Has an ostomy bag. The stools are always liquid." At 12:40 p.m., Resident Care Manager (RCM) E stated "I got the order discontinued yesterday for the laxative. The Resident should not have been receiving the laxative. I guess we did not make the connection that the Resident didn't need the medication." <Resident #8> Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the plan of care, the Resident had "recurrent C- difficile" and had been treated with several courses of medications to help control diarrhea. The Resident's care delivery guide stated "Contact precautions for [MEDICAL CONDITION]." According to the MDS dated [DATE] the Resident was dependent on staff for ADL care and was unable to speak for self. Bowel records reflected the Resident had frequent loose or liquid stools. During the month prior to 01/22/13, bowel records reflected diarrhea or watery stools on 21 of the 30 days. Medication records for November, December and January reflected the Resident with orders to administer [MEDICATION NAME] powder (a laxative) 17 grams in 8 ounces of water every day for constipation. The Resident received 20 doses of [MEDICATION NAME] in the first 21 days of January. In addition to the [MEDICATION NAME], medication records reflected the Resident had orders for Senna Plus (a laxative) 1 tablet to be given twice a day for constipation. During the first 21 days of January, the Resident received 37 of the scheduled 41 doses. On 01/21/13 a physician's orders [REDACTED]. On 01/22/13 at 12:47, the Resident Care Manager (RCM) D was asked about the laxatives being administered to a Resident with [MEDICAL CONDITION] and he replied "I don't have an answer for that." Refer also to F 329 Refer to Centers for Medicare and Medicaid statement of deficiencies form 2567 dated 12/11/12 for currently open citations at F 309. .

Based on observation, interview and record review, the facility failed to to monitor and provide adequate indications for use or discontinue unnecessary medications when residents (# 5 and 8) continued to receive laxatives while being actively treated for [REDACTED]. This failure placed the residents at risk for weight loss, skin break down, dehydration or other severe complications. Findings include: <Resident #5> Resident #5 was admitted to the facility on [DATE], was hospitalized for [REDACTED]. [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 11/17/12, the Resident was completely dependent on staff for activity of daily living (ADL) care and was not interviewable. The Resident had a [MEDICAL CONDITION] (a bag used to collect stool when the bowel was diverted from it's usual route). The Resident also had a [DEVICE] (a tube going into the stomach) through which all nutrition and medications were delivered. The plan of care stated "[MEDICAL CONDITION] output {stool} will be formed." Senna-Gen (a laxative) and DSS (a laxative) were administered to the resident through the [DEVICE] without regard for the frequent loose or liquid stools the Reisdent was experiencing. The laxatives were administered nearly every day for most of a 3 month period until 01/22/13 when a physician order [REDACTED]. The Charge Nurse and the Resident Care Manager did not have an explanation for the continuing use of laxatives as part of the Resident's medication regime. <Resident #8> Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the plan of care, the Resident had "recurrent C- difficile" and had been treated with several courses of medications to help control diarrhea. The Resident's care delivery guide stated "Contact precautions for [MEDICAL CONDITION]." According to the MDS dated [DATE] the Resident was dependent on staff for ADL care and was unable to speak for self. Senna Plus ( a laxative) and [MEDICATION NAME] (a laxative) were administered to the resident without regard for the frequent liquid, watery diarrhea the Resident was experiencing as a result of having and being treated for [REDACTED]. The laxatives were discontinued on 01/21/13. During interview on 01/23/13 at 02:35 p.m., Resident Care Manager (RCM) F stated "I had heard something about the Resident {#8} having loose stools. I checked the records and felt the laxative should be discontinued because of many loose/liquid stools. I was asked to call the physician because the RCM for that Resident had a day off. I am not sure why this was not discovered before." Refer to F 309 Refer also to Centers for Medicare and Medic aid statement of deficiencies form 2567 dated 12/11/12 for open citations at F 329.

Based on observation, interview and record review it was determined that the facility failed to provide adequate supervision including lack of thorough assessment and inadequate care planning for accident prevention for 34 sampled residents who were included in the stage 2 review. As a result, Resident #115 experienced harm after he was left unattended and fell and Resident #117 had the potential to experience serious re-injury. Findings include: RESIDENT #115 Resident #115 was admitted to the facility in June 2012 with multiple medically disabling conditions including stroke with left sided weakness and brain damage. The resident required extensive to total assistance for all of his activities of daily living (ADLs). Resident #115 was discharged from the facility on 11/30/12. A Minimum Data Set (MDS), an assessment tool dated, 11/05/12 documented Resident #115 could not complete a Brief Interview of Mental Status (BIMS) due to his cognitive deficits of inattention and altered level of consciousness. A care plan dated 11/06/12, documented Resident #115 was resistive to care, combative and "violent." The resident was listed as being at risk for falls and had actual falls with approaches to check him frequently and to keep near nurses' station for visibility. The care plan noted the resident walked but did not inform staff when he got up to walk and "will not stay in wheelchair." The Accident/Incident Log documented Resident #115 had falls on 10/21/12, 10/26/12, 10/28/12, 10/29/12, 10/31/12, 11/08/12, 11/13/12, 11/15/12 and 11/16/12. Resident #115 sustained injuries with the falls that occurred on 11/15/12 and 11/16/12 requiring two separate emergency room medical treatments within hours of the two incidents. An Incident Report dated10/21/12, documented Resident #115 was witnessed by staff to lose his balance and fall forward into his dresser striking his left cheek. The report noted the resident was agitated prior to the incident. An Incident Report dated10/26/12, documented Resident #115 was found on the floor next to his bed. On 10/28/12 he was found sitting on the floor next to his wheelchair in the main dining room. On 10/29/12 he was found on the floor next to his bed. On 10/31/12 he was on the floor on his back. The resident told staff he lost his balance and fell to the floor. A Fall/Injury Prevention and Management care plan dated 7/31/12 had no specific updates for accident prevention between 10/21/12 and 11/06/12 during which time Resident #115 had 5 falls. Staff completed investigation reports with the same repeated notations recording the resident fell due to his refusal to use his call light and his poor balance. There was no evidence of specific care plan approaches or analysis after each fall incident to attempt to prevent further accidents. An Interdisciplinary Team (IDT) Report dated 10/31/12, documented Resident #115 was to have frequent checks by staff and to position resident in a visible area. The note documented, "All efforts are being made to ensure when a fall does occur there will be no serious injury." The note further documented Resident #115's care plan was updated to reflect these approaches. A Social Service note dated 10/11/12, by Staff J documented, "analysis" of the behavior tracking chart notes indicated continued behaviors of verbal outbursts, physical abuse, wandering and care rejections. Staff J noted, "One most effective intervention is 1:1 (one to one) interaction." An Incident Report dated11/15/12 at 11:45 p.m., documented Resident #115 was found on his back on the floor with his head beneath the sink, the bathroom floor was wet with urine, resident was yelling to go to the hospital, his head bleeding from left earlobe and behind left ear due to lacerations, complains of head hurting everywhere stating his pain was at "10 plus another 10" on a scale of one to 10. Resident #115 was transported to the hospital where he received sutures and a pressure bandage to his injured head areas. A progress note dated 11/16/12 at 2:45 a.m., written by a registered nurse (Staff L) documented Resident #115 returned from the local emergency room with sutures to his left ear and scalp and a pressure dressing over the area. Staff L documented she remained one on one with the resident and directed Staff M to provide one to one supervision for the resident because "he is continuing to attempt (independent) mobility and being a fall risk he will injure himself again." Staff L documented at 3:30 a.m. that she requested Staff N who was supervising Resident #115's roommate, to also supervise Resident #115 in the room together. Staff L documented Resident #115 was hungry so Staff N instructed Staff W to assist Resident #115 to get something to eat. According to the progress note, Staff W took Resident #115 to the dining room to get something to eat. Staff W left Resident #115 "unattended" in the dining room to attend to other duties. At 5:45 a.m. Staff L was called to the main dining room because Resident #115 was on the floor with a new laceration to his left eyebrow. Staff L sent Resident #115 back to the hospital for emergency medical treatment. Resident #115 required additional sutures to his new head injury before returning to the facility. On 11/30/12, observation of the main dining room found it to be in another part of the facility from Resident #115's room which was directly across from the Nurses' station. There was no ability to provide any visual or auditory supervision of the resident left alone in the dining room. On 12/08/12 at 4:30 p.m., Staff A said he had determined Staff W had not neglected Resident #115 when he left him unattended in the main dining room because Staff L had not instructed Staff W to directly supervise Resident #115. Staff A said Resident #115's care plan had not been "officially" updated to require 1:1 supervision until after the second injury fall on 11/16/12. However, a report written by Staff A dated 10/19/12, documented Resident #115 was placed on one to one supervision on 10/19/12 due to an altercation he had with Resident #93. When asked what his investigation revealed on how Staff L ensured all staff on duty was instructed to provide adequate supervision to reduce the risk of Resident #115 having another accident he stated he had not made that determination. The facility failed to ensure Resident #115 was provided interventions consistent with his needs to prevent further accidents such as ensuring all staff provided appropriate supervision to the resident after the resident sustained [REDACTED]. RESIDENT #117 On 12/3/12 at 11:43 a.m. and 2:32 a.m. and 3:28 a.m. Resident #117 sat on the edge of the bed in her room with a non-skid matt on the floor beneath both feet. On 12/7/12 at 9:33 a.m. the resident sat on the edge of the bed and leaned on an over bed table. Staff in the room stated "you are falling asleep" and assisted the resident to lie down. An admission Minimum Data Set (MDS, a comprehensive assessment) dated 8/16/12 identified Resident #117 admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. MDS assessments identified the resident went to the hospital and returned to the facility multiple times since admission. An MDS assessment dated [DATE] identified the resident returned from the hospital on [DATE] with a fractured hip. An Activity of Daily Living care plan dated 10/24/12 identified Resident #117 was non-weight bearing (do not stand on legs) due to previous surgery for [REDACTED]. A "Fall/Injury" plan of care updated on 11/8/12 identified the resident continued to be non-weight bearing and had a history of [REDACTED]. A therapy note dated 11/26/12 documented due to weight bearing restrictions standing and pivot transfers were not recommended. A facility investigation documented on 11/5/12, two staff attempted to transfer Resident #117 to a bedside commode. Two staff statements indicated, during the attempted transfer, the resident slid off the bed and slid down to the floor. Licensed staff assessed the resident and determined no injury occurred. The investigation summary identified staff did not follow the care delivery guide. A caregiver statement in the investigation documented both staff who attempted the transfer did not know the Resident #117 was non-weight bearing. On 12/7/12 at 6:24 p.m. Staff B reported the nursing aid care directive in place at the time of the incident identified Resident #117 should be non-weight bearing. Staff B also reported all nursing aide staff were informed in oral report of updates to care plans. Staff B did not know why staff attempted to transfer Resident #117 when they should not have. Licensed staff failed to provide adequate supervision to ensure staff followed the care delivery guide to ensure non-licensed staff did not attempt to transfer a non-weight bearing resident. This placed Resident #117, who had recent surgery for [REDACTED]. .

Based on observation, interview and record review it was determined that the facility failed to ensure staff operationalized policies and procedures to identify, immediately report and protect residents, log incidents within 5 days and thoroughly investigate allegations of actual and/or potential abuse and missing property for 3 of 5 Sampled Residents (18, 52 & 93) of the 34 residents who were included in the stage 2 review. This resulted in psychological harm for Resident #93 and placed Residents (#s 18 & 52) and all other residents at risk for physical and/or psychological harm and/or loss of property. Findings include: Review of the facility's abuse and neglect policy found the facility policy defined mental/emotional and sexual abuse to include humiliation, harassment, coercion or assault. The policy identified all staff were to be trained to identify, correct and intervene regarding situations of possible abuse, neglect or mistreatment. The facility policy stipulated staff were to provide for the immediate safety of residents upon identification of "potential" abuse. RESIDENT #93 Resident #93 was admitted to the facility in June 2012 with multiple medically disabling conditions. The resident required extensive to total assistance for all of her activities of daily living (ADLs). A care plan dated October 2012 for Mood and Behavior, documented the resident was at risk for depression and had symptoms of anxiety for which she received medications. Approaches documented in the care plan noted, " Encourage resident to take a deep breath and relax for emotional swings." On 12/07/12 at 4:50 p.m., Resident #93 was observed sitting in her wheelchair near her bed. The resident had a mesh stop sign guard that was hanging from one side of the doorway (a mesh strip with a stop sign symbol in the middle, approximately 12 inches wide that connected to either side of the doorway by Velcro strips to attempt to prevent wandering residents from entering the room). Resident #93 had continuous oxygen flowing via a nasal cannula. In interview, Resident #93 stated she had an altercation with Resident #115 sometime in October 2012. Resident #93 stated in October, Resident #115 entered her room. He was clothed but was fondling his groin area while he was in Resident #93's room. Resident #93 stated, "It was drastic because he came in my room and did that." Resident #93 reported it took staff over 15 minutes to get to the room after she put her light on and tried to use her phone to get help. "I was screaming, hollering and yelling for help." Resident #93 said Resident #115 came to her doorway or into her room on multiple occasions over a 2 month period. Resident #93 said Resident #115 fondled himself more than one time. On one occasion, Resident #93 observed the resident naked from the waist down after he had removed what appeared to Resident #93 to be a wet incontinent brief. Resident #93 said she viewed "his private parts" before he left the room. She stated she called staff again to report Resident #115 was naked in her room. Resident #93 said she reported the incidents to the staff on duty and they would take Resident #115 from her room or doorway. The resident said Staff J assured her it would not happen again but it continued to occur. The staff gave her a bicycle bell to keep at her bedside in case Resident #115 entered her room. Resident #93 said she was told by Staff J Resident #115 was not really fondling himself and he was harmless. However, Resident #93 said the incident in October, "Really creeped me out." Record review of a facility Incident Report dated 10/20/12, documented on 10/19/12 at 8:25 p.m., staff was called to Resident #93's room to escort Resident #115 out of the room. The report documented "resident felt threatened as (Resident #115) grabbed the door guard/stop sign ...threw it on the floor, he placed his hand on his groin area without exposing himself and was rubbing himself. The look in his eyes was 'aggressive' and she (Resident #93) feared being harmed." The report documented the final outcome was, "resident wandered into another resident's room, staff redirected and helped out of the room." The report documented there was no abuse or neglect regarding the resident to resident altercation. On 12/08/12 at 1:15 p.m., Staff B said the incident was a one-time incident and the resident had not done this before or after that time. A progress note dated 10/13/12 written by a registered nurse documented, Resident #93 complained of other residents coming into her room and was "requesting a baseball bat to hit the other residents, threatening to call the police to have them keep guard at her door." Staff B said she was not aware of the progress note documentation completed by her staff. A progress note dated 10/19/12 documented Resident #115 was disruptive to his peers privacy and feeling of safety. A progress note dated 10/20/12 with the notation "NOC" (night- no time indicated), written by a registered nurse (RN), documented Resident #93 complained Resident #115 "put his hand on his private area and is rubbing it." The RN documented Resident #93 "got anxious about what happened." A progress note dated 10/21/12 documented the night nurse reported Resident #115 was combative, "telling this RN to b--- me." A social service note written by Staff J dated 10/26/12, one week after the incident, documented Staff J told Resident #93, "The two male residents (including #115) who wander into many rooms throughout the day are very confused and harmless." Staff J told Resident #93, "the tremor hand (of Resident #115) looks like the resident is fondling the groin but he is not." On 12/08/12 at 5:00 p.m., Staff A stated Resident #115 never entered Resident #115's room on 10/19/12 according to his own investigation. Staff A did not have the written investigation at the time of the survey. Staff A stated he would attempt to locate the report and fax the report to the Department. Staff A stated Resident #93 mistook Resident #115's hand tremor for fondling his groin area. On 12/11/12 the Department received a fax report from Staff A. The report consisted of a typed document dated 10/19/12. There was no time documenting the event. The report referred to a neurology report (dated 11/20/12) that documented Resident #115 had symptoms of spastic tone in the left upper and lower extremity with flexor posturing of the left upper extremity. Staff A documented the "flexor posturing" was "a tremor like movement" in Resident #115's hand that Resident #93 misunderstood for fondling of his groin area. Resident #115 did not have the neurology consultation until 11/20/12 that Staff A referred to in his investigation report dated 10/20/12. Review of the neurology report found no description of tremor on exam for Resident #115. According to Mosby's Dictionary of Medicine and Nursing 7th Edition, 2006, page 518, [MEDICAL CONDITION] posturing conditions such as flexor posturing are described as rigid flexion (such as a clenched fist, not as a tremulous movement). Record review of Resident #115's chart and a neurology exam report dated 11/20/12 found no [DIAGNOSES REDACTED]. The neurology report dated 11/20/12, documented an abnormal neurological tone (caused by brain damage) of the left upper extremity with a fixed flexing posture. The neurologist documented the resident's behavioral and cognitive changes were related to bi-hemispheric dysfunction (areas of the brain with damage which contributed to disinhibited behavior and cognition). On 12/08/12 review of a physician's medical exam dated 8/05/12, documented Resident #115 held his left arm in elbow flexion, wrist flexion and finger flexion close to his body (arm, wrist and hand in a fist held to the upper body with little to no ability to move his left upper arm). The physician made no documentation of any type of hand tremor diagnosis. On 12/08/12 review of a physician note dated 11/05/12 found the physician had assessed the resident and the resident's anti-psychotic medications. The chart note documented, "No sedation or tremor." Observations of Resident #115 on 11/29/12 and 11/30/12 found the resident sitting in his wheelchair with no observable hand tremors. On 11/30/12 at 12:00 p.m., there were no observed signs of any type of tremor at rest or when the resident was cued to move both of his hands by Staff Z. His left hand was in a clenched fist position with his elbow flexed in a fixed position. Upon cue he could only make slight finger movements with the left hand. There was no observed tremor. Resident #115 could fully extend his right hand and fingers. There was no observed tremor at rest or with movement of his right hand. The facility failed to recognize and protect Resident #93 and other residents from Resident #115's disruptive behaviors on multiple occasions including observations of inappropriate behaviors that were perceived as a sexual nature which resulted in repeated incidents of mental anguish for Resident #93. There was no adequate preventive measures to monitor Resident #93 or address how often incidents occurred, why they occurred or what the facility would do to reduce recurrences of male residents entering her room and causing her distress. Staff minimized Resident #93's reports by telling her she did not see what she reported she observed when Resident #115 repeatedly entered her room or was in her doorway exhibiting inappropriate behaviors in her presence. Refer to F 223 . RESIDENT #18 An Interdisciplinary progress note dated 10/8/12 identified Resident #18 had multiple medical conditions that included [MEDICAL CONDITION], bilateral amputation of legs, urinary catheter placement, [MEDICAL CONDITION] and generalized anxiety. A quarterly assessment dated [DATE] identified the resident required extensive assistance from two staff to move in bed, total dependence on two staff to transfer out of the bed, functional loss of use of one upper extremity and used a wheelchair for mobility. On 12/3/12 at 12:13 a.m. Resident #18 lay in bed on his/her right side with right arm bended at the elbow and placed under his/her head. A partially uncovered lower body revealed loss of both lower legs. The resident lay with eyes closed and appeared to be sleeping. A facility investigation dated 10/16/12 documented on 10/6/12 (Saturday night) at 9:00 p.m., a resident to resident altercation occurred during the weekend. Resident #18 reported Resident #115, the resident's roommate, walked over to his/her side of the room and told Resident #115 to go back to his/her own side. The report documented Resident #115 responded and told Resident #18 to "shut up - if you don't I'll smother you and if that doesn't work I'll slit your throat." The investigation documented the facility determined the incident as verbal abuse. On 12/8/12 at 10:10 a.m. Resident #18 briefly discussed the incident with the surveyor and reported he recalled the incident with a former roommate and thought he was "probably" afraid and informed staff on duty right away when it occurred. The facility investigation did not contain a thorough account or identify the following information: - The time Resident #18 reported the alleged incident to staff on 10/7/12. - Interviews or statements of all staff assigned who worked with Resident #18 and Resident #115 to determine what they knew and when. The investigation only contained one written statement from one staff member Resident #18 reported the allegation to. - Interviews with other residents in the area to determine if Resident #115 exhibited threatening behaviors to others. The facility investigation identified staff did not implement policies and procedures in a timely manner: - The investigation documented Resident #18 informed licensed staff on 10/7/12 and staff did not notify administration until 10/8/12 at 6:37 a.m. The date the facility investigation documented the resident informed staff the incident occurred did not match Resident #18's statement he/she informed staff immediately of the alleged incident that occurred on 10/6/12. -Resident #18 did not receive immediate protection. The investigation identified the facility delayed removing Resident #115 from the room and provide one to one observation for "safety" until 10/8/12. -Staff did not immediately assess Resident #18 for abuse or begin monitoring for psychological harm until 10/8/12, the following day. Failure to immediately remove Resident #115 from the room and initiate monitoring placed Resident #18 at risk for further abuse and harm. Failure to immediately assess and monitor Resident #18 and report the incident to administration delayed response to treat the resident for physical and/or psychological harm if needed. RESIDENT #52 Refer to F 166 for Resident #52's medical history. On 11/30/12 at 11:26 a.m. Resident #52's family member reported a $120 iPod was missing from the resident's nightstand drawer. A facility investigation dated 4/23/12 documented Resident #52's family member "was at the building on 4/5/12 at 10:00 p.m. and he returned on 4/6/12 at 5:30 p.m. When he returned that evening, the family member reported a lock was "drilled out" from the resident's drawer and an iPod was missing. The family member also reported informing staff of the loss immediately following discovery. The following policies and procedures for abuse protocol were not timely implemented: - The facility failed to conduct a thorough and timely investigation and report results of the investigation to the administrator within five working days. - Night shift assignments identified seven staff were on duty the night of 4/5/12 (6:00 p.m. to 6:00 a.m.) during the time when the alleged incident may have occurred. The facility investigation only contained statements from one staff member assigned to work during that timeframe. The investigation also did not contain interviews or statements from additional staff present during the day shift on 4/6/12 before the family member returned to the facility and discovered the item missing to determine if they had additional information to provide. - The investigation contained evidence Resident #52's roommate was interviewed and did not contain evidence additional facility residents or family members were interviewed to inquire if similar incidents had occurred. - The investigation documented maintenance staff provided replacement lockable storage but it did not indicate if the facility conducted physical checks to determine if other locks in nightstand drawers were damaged, description of the damaged lock or determination if the facility felt the lock had been tampered with. - The incident occurred on 4/5/12 or 4/6/12. Staff did not report to the State until 4/23/12, 17 days later. - Facility staff did not report the allegation of alleged theft immediately to administration until 4/19/12, 13 days later. On 12/3/12 at 1:00 p.m. Staff A reported the facility followed the "Purple Book" regarding procedures for potential theft. The "Purple Book" includes mandated requirements for state reporting and investigating allegations of misappropriation of resident property. Misappropriation of resident property may include facility staff or others taking resident property without permission. Corporate procedures for misappropriation of resident property directed staff to report alleged violations to administration immediately, meaning as soon as possible but not to exceed 24 hours. - A "Personal Item Loss Report" identified the facility did not notify the State agency or police until 4/23/12 or identify if the facility assured staff background checks were current and checked. - Failure to immediately report the allegation to administration, immediately protect all residents and thoroughly conduct an investigation placed all residents at risk for further potential loss of personal property. .

Based on observation, interview and record review it was determined that the facility failed to recognize and ensure 1 of 5 Sampled Residents (#93) was free from perceived sexual abuse or harassment by another resident of 34 sampled residents reviewed. This failure caused actual psychological harm to Resident #93. Findings include: Resident #93 was admitted to the facility in June 2012 with multiple medically disabling conditions. The resident required extensive to total assistance for all of her activities of daily living (ADLs). A Minimum Data Set (MDS, an assessment tool) dated 10/12/12 documented Resident #93 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15 indicating she did not have any significant cognitive deficits for recall. A care plan dated October 2012 for Mood and Behavior, documented the resident was at risk for depression and had symptoms of anxiety for which she received medications. Approaches documented in the care plan noted, " Encourage resident to take a deep breath and relax for emotional swings." Record review of Resident #93's care plan found no update to address possible psychological harm regarding multiple incidents of male residents entering her room or an actual incident (10/19/12) that caused harm. On 12/07/12 at 4:50 p.m., Resident #93 was observed sitting in her wheelchair near her bed. In interview, Resident #93 stated she had an altercation with Resident #115 sometime in October 2012. Resident #93 stated Resident #115 came into her room multiple times which was "an invasion of privacy." Resident #93 said she had a shared bathroom with male residents including Resident #115 so he had direct access to her room. Resident #93 stated in October, Resident #115 entered her room. He was clothed but was fondling his groin area while he was in Resident #93's room. Resident #93 stated, "It was drastic because he came in my room and did that." Resident #93 said Resident #115 fondled himself more than one time. On one occasion, Resident #93 observed the resident naked from the waist down after he had removed what appeared to Resident #93 to be a wet incontinent brief. Resident #93 said she viewed "his private parts" before he left the room. Resident #93 stated she called staff again to report Resident #115 was naked in her room. Resident #93 said she reported the incidents to the staff on duty and they would take Resident #115 from her room or doorway. The resident said Staff J assured her it would not happen again but it continued to occur. The staff gave her a bicycle bell to keep at her bedside in case Resident #115 entered her room. Resident #93 said she was told by Staff J Resident #115 was not really fondling himself and he was harmless. However, Resident #93 said the incident in October, "Really creeped me out." Record review of a facility Incident Report dated 10/20/12, documented on 10/19/12 at 8:25 p.m., staff was called to Resident #93's room to escort Resident #115 out of the room. The report documented "resident felt threatened as (Resident #115) grabbed the door guard/stop sign ...threw it on the floor, he placed his hand on his groin area without exposing himself and was rubbing himself. The look in his eyes was 'aggressive' and she (Resident #93) feared being harmed." The report documented the final outcome was, "resident wandered into another resident's room, staff redirected and helped out of the room." The report documented there was no abuse or neglect regarding the resident to resident altercation. On 12/08/12 at 1:15 p.m., Staff B said the incident was a one-time incident and the resident had not done this before or after that time. A progress note dated 10/13/12 written by a registered nurse documented, Resident #93 complained of other residents coming into her room and was "requesting a baseball bat to hit the other residents, threatening to call the police to have them keep guard at her door." Staff B said she was not aware of the progress note documentation completed by her staff. A social service note written by Staff J dated 10/26/12, one week after the incident, documented Staff J told Resident #93, "The two male residents who wander into many rooms throughout the day are very confused and harmless." Staff J told Resident #93, "the tremor hand (of Resident #115) looks like the resident is fondling the groin but he is not." On 12/08/12 at 5:00 p.m., Staff A stated Resident #115 never entered Resident #115's room on 10/19/12 according to his own investigation. Staff A did not have the written investigation at the time of the survey. Staff A stated he would attempt to locate the report and fax the report to the Department. Staff A stated Resident #93 mistook Resident #115's hand tremor for fondling his groin area. The facility failed to adequately prevent Resident #115 from causing Resident #93 distresses on multiple occasions including observations of inappropriate behaviors that were perceived as a sexual nature which resulted in repeated incidents of mental anguish for Resident #93. There was no follow-up to monitor Resident #93 or address how often incidents occurred, why they occurred or what the facility would do to reduce recurrences of male residents entering her room and causing her distress and placed all residents at risk for harm. Refer to F 226 .

Based on interview, observation, and record review, the facility failed to implement written policies and procedures to prohibit mistreatment, abuse and neglect for 3 of 42 current sampled residents, who resided in various locations throughout the facility, (#14, 73, & 57) reviewed for abuse which resulted in harm. The facility repeatedly failed to identify, protect, investigate, prevent, and/or report allegations of abuse. Failures by multiple facility staff to operationalize facility policy/procedures relating to recognizing, protecting, preventing, investigating and reporting potential abuse as required placed residents at risk for serious harm that constituted immediate jeopardy on 10/06/2011 at 3:00 p.m. Findings include: The facility's abuse policy and procedures, "prohibits the mistreatment, neglect, and abuse of residents and misappropriate of resident property by anyone including staff, family, friends, etc." The facility had "designed and implemented processes, which strive to ensure the prevention and reporting of resident abuse, neglect, mistreatment, and/or misappropriation of property." The facility procedure directs staff to report allegations to state agencies and facility will take all necessary corrective actions depending on the results of the investigation. The facility requires staff to report to the Administrator and Director of Nursing immediately all incidents. "The Administrator is responsible for the assurance of this policy." The facility procedure directs the charge or unit nurse to complete the accident/incident report, an investigation is initiated, incidents will be logged, results of the investigation will be logged, identify trends from the completed accident/incident report summary, and report results of all investigations to administrator and to other officials in accordance with State law. 1) Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 07/27/11, indicated the resident was cognitively intact and participated in her health care decisions. On 10/04/11, at 1:42 p.m., the resident stated Nursing Assistant (NA) A had threatened "to cut off her feet" and would throw her evening snacks at her from the doorway. The resident stated NA B was "sarcastic and rude", calling her "[***] and whore." "They deliberately antagonize me and I get so upset I shake." At 1:50 p.m., the resident said NA A and NA B "threatened to physically hurt" her but she was afraid to hit them to protect herself because she would be thrown out on the street. Resident stated she was afraid because of how NA C was "swinging a[***]y diaper and nearly hit me in the face." At 2:00 p.m., NA B came to the resident's room to check the resident's oxygen saturation level and left the room. Immediately following NA B's exit, the resident pointed toward NA B and said, "that's the one I was talking about, she is the one (referring to NA B)." The resident was observed to be shaking and gasping for air. The resident stated, "See what she does to me." Entry in the Nurses Note for 07/22/11 indicated the resident reported to a licensed nurse that three staff members threatened to cut off her toes and kill her birds. On 10/4/11, at 5:10 pm., Resident Care Manager (RCM) A stated she was aware the resident made the above mentioned allegations against two nursing assistants (NA A and NA B) and a Medical Records Staff. RCM A stated NA A and NA B were told not to care for the resident "for awhile." No other intervention was put into place to protect the resident from future incidents. RCM A said, she "never thought to tell anyone or call the hotline." At 6:58 p.m., RCM A stated on 07/25/11 (three days later) she reported the incident to the administrator. RCM A stated the administrator told her the incident should have been reported to the state at the time the allegation was reported. RCM A stated the administrator indicated to her, it was too late now to report the incident to the state. The incident was not reported to the state certification agency. The administrator did not investigate the incident. The resident was continuously cared for by the same staff members she had reported as being responsible for harming her. Although the facility was aware of the allegations reported on 07/22/11, no investigation was conducted upon the allegations, no one acted to protect the resident, and no interventions were implemented to protect the resident. The facility failed to follow their abuse policies and procedures. 2) Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact and participated in her health care decisions. On 10/05/11, at 11:50 a.m., Resident #73 stated, a few days ago, the Restorative Nurse (RN) "got up in her face," and yelled in a harsh tone "go back to your bed, sit down and be quiet" after the resident had asked the RN not to take her trash can. The resident stated she felt "degraded" and reported the incident to the Social Service Director (SSD). The SSD told the resident the comment from the RN was not meant in a demeaning way. Later that day, the resident saw the RN. The resident reported, the RN "snapped" at her saying, "I'm not going to talk to you without an appointment." The resident stated, "This is not an isolated incident; this is not a good place to live." The resident explained, she has been "threatened" by the Administrator that her space is needed; and if she does not find a place to live, she will be put out. The resident stated the inflection of the voice was "condescending, demeaning, rude and threatening". The facility Administrator was not available for interview during the survey. The resident stated the facility staff "try to come across as [MEDICATION NAME], but if you buck their system, everything changes." The resident stated, she had voiced her complaints to social services, and was told she was "just paranoid." The resident said she was afraid of retaliation and she would be thrown out of the facility before she could find a place to live. The resident stated, "The repeated degrading comments are making me fearful." "I need someone to protect me; I need someone on my side." On 10/06/11, at 1:57 p.m., the resident stated the SSD asked told her, "What do you want from me?" in a condescending tone, after the resident had requested assistance in obtaining housing outside of the facility. The resident stated about two months ago, she had an incident at night where she awoke to a male resident at her bedside. She felt afraid and concerned he would put a pillow over her head or sexually assault her. The resident reported the incident to nursing staff who told her, "he would never do that." The resident stated she felt her concerns were dismissed by staff. On 10/15/11, at 2:00 p.m., SSD stated she was aware of the resident's allegation. There was no facility documentation to support the incident was reported or investigated. No documentation was found to indicate the facility had identified the resident's allegations. There was no documentation found indicating the facility interviewed the resident about the incidents or an investigation was completed. The facility failed to protect the resident. The facility failed to follow their abuse policies and procedures. 3) Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact, able to participate in health care decisions, and required extensive assistance with activities of daily living from staff. Resident #57 stated the staff are "snotty." The resident reported an incident that occurred a month ago when she was receiving assistance with a transfer from NA D. The resident was shoved and grabbed by staff who insisted she move to the right and she told NA D she needed to move to the left. The resident stated NA D physically hurt her and the staff's nails dug into her skin. The resident was bruised on both forearms and hands. The resident struck NA D in an attempt to stop the rough treatment. The resident reported being treated roughly by the staff to RCM A. On 10/10/11 at 3:40 p.m., RCM A stated NA D was "only tapping the resident like joke hitting." RCM A instructed NA D "tapping a resident" was not ever appropriate. On 10/14/11, at 5:47 p.m., NA D stated he provided care for the resident one time. They did have a disagreement about care. NA D stated he wanted the resident to move one way and the resident wanted to move another way. Record review revealed RCM A did not report the abuse allegation to the state certification agency nor anyone in her chain of command. RCM A was not able to provide documentation regarding the incident. RCM A failed to protect the resident. RCM A failed to follow the facility's abuse policies and procedures. Staff Member A stated, "it's like a store front, when you (the survey team) are here, we do things one way, and when you leave we go back to the way things have always been done." On 10/17/11 the immediate jeopardy was abated.

Based on interview, observation, and record review, it was determined the facility's governing body failed to ensure the facility was operated in a manner to follow established policy to ensure not only the health and safety needs of the residents were met, but also the compliance with state and federal regulations when the governing body failed to appoint a licensed administrator. This failure placed residents at continuous risk for unmet care needs and decrease in quality of life. Findings include: 1) Refer to: 42 CFR 483.75, F490-Effective Administration/Resident well-being, related to the administration's failure to administer the facility in a manner to use its resources effectively and efficiently to attain or maintain residents' highest level of function and optimal well-being. On 11/22/11, at 11:00 a.m., the Administrator presented a certificate showing a "Nursing Home Administrator" license from the state of Washington with a "pending" status. At 11:15 a.m., the Washington State Department of Health (DOH), the Licensing Board for nursing home administrators was called. A Licensing Board employee (A), from the DOH, indicated the Administrator's license was in "pending status" because the application to practice as a nursing home administrator was not completed. The initial application was initiated in 2009 with no followthrough since that time. At 1:30 p.m., the Administrator presented a copy of a current Arizona state license to practice as a Nursing Home Administrator. At 2:10 p.m., the Administrator and surveyor placed a telephone conference call to the DOH. A Licensing Board employee (B) indicated the Administrator was not allowed to practice as a Nursing Home Administrator without a license or supervision. She stated the license had been sitting in pending status for over 2 years with no action. She stated the Administrator had no license to pratice as a Nursing Home Administrator in the state of Washington. At 2:30 p.m., the Administrator stated, "We have had an administrator from another building coming every day to hold the stand up meeting during the first week after survey, but he has not come for several weeks."

Based on observation, interview and record review it was determined the facility Administration failed to monitor and effectively administer services to attain and/or maintain residents' highest level of function and optimal well-being. Failure to assess for sufficient qualified staffing and address staff knowledge to meet resident needs resulted in harm for residents and placed residents with individualized and specific needs at risk for failure to reach the highest level of function and a decrease in quality of life. Findings include: 1) Refer to: 42 CFR 483.13(b)&(c), F223-Free from Abuse, The facility failed to ensure 3 of 40 residents (#14, 57 & 73) was free from abuse. The facility failed to take immediate action to identify the residents' report of abuse, failed to take immediate steps to protect the residents. This failure resulted in harm when the residents related to residents were not protected and/or residents harm was not recognized after allegations of abuse were reported resulting in resident harm. 2) Refer to: 42 CFR 483.13(c)(1)(3)(4), F225-Investigate/Report Allegations - The facility failed to thoroughly investigate and immediately report alleged incidences of abuse and/or neglect and prevent further similar incidents in accordance with 42 CFR 483.13(c)(3) for 3 of 9 Sample Residents (#s14, 57 & 73) reviewed for accidents and incidents. Failure to identify, report, and investigate allegations of abuse and neglect in a timely manner placed all residents at risk for harm due to unrecognized abuse or neglect and further incidents and accidents.related to allegations of abuse/neglect were not reported or investigated after staff had observations and/or knowledge of allegations resulting in resident harm. 3) Refer to: 42 CFR 483.13(c)(2), F226-Abuse Policies and Procedures - The facility failed to implement written policies and procedures to prohibit mistreatment, abuse and neglect for 3 of 42 current sampled residents, who resided in various locations throughout the facility, (#14, 73, & 57) reviewed for abuse which resulted in harm. The facility failed to identify, protect, investigate, prevent and/ or immediately report allegations of abuse. This failure placed residents at risk for abuse. An immediate jeopardy was called on 10/06/2011 at 3:00 p.m.related to investigations were not initiated and allegations of abuse/neglect and mistreatment were not reported as facility policy and procedures directs resulting in an Immediate Jeopardy. 4) Refer to CFR 483.35(b), F 362-Sufficient dietary support personnel-observation of a meal service conducted on 10/10/11 between 11:50 a.m. and 12:27 p.m., it was determined the facility failed to employ sufficient support personnel to carry out the functions of the dietary service in the Therapy Dining Room for 7 of 83 current residents (#s 5, 17, 37, 59, 98 & 137). Failure to provide sufficient staff to assist dependent and judgement impaired residents with meals placed the residents at risk for potential harm when residents were left unsupervised for 25 minutes and waited over 30 minutes for staff assistance to eat their meals. 5) Refer to: 42 CFR 483.25, F309-Provide Care/Services for Highest Well-Being - related to wound care and bowel management resulting in resident harm. The facility failed to provide the necessary care and services for bowel management, skin and respiratory care to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 6 of 40 current sampled residents (#50, 57, 5, 114, 39, & 97) reviewed for quality of care. 6) Refer to CFR 483.25(a)(3), F 312-ADL Care Provided For Dependent Residents- it was determined the facility failed to provide grooming and personal hygiene for 2 of 4 current sampled residents (#44 & 50) reviewed activities of daily living. 7) Refer to CFR 483.25(c),F 314-Treatment/Services to Prevent/Heal Pressure Sores- The facility failed to implement planned interventions to monitor and document findings of changes in skin for 1 of 1 resident (#85) who develeoped 3 pressure ulcers. Once the pressure sores developed, facility documentation failed to accurately describe the resident's clinical condition. This failure placed the resident at risk for delayed treatment. 8) Refer to CFR 483.25(e)(2),F 318-Increased/Prevent Decrease in Range of Motion-The facility failed to consistently provide restorative services for 2 of 3 current sampled residents (#5,57) reviewed for range of motion services. This failure placed the resident at risk of a decline in mobility. 9) Refer to: 42 CFR 483.30(a)(1)&(2), F353-Sufficient Nursing Staff - related to accommodation of needs, quality of care, range of motion treatment and services, and sufficient dietary staff.

Based on interviews, observations and record review, the facility failed to ensure 3 of 40 residents (#14, 57 & 73) was free from abuse. The facility failed to take immediate action to identify the residents' report of abuse, and failed to take immediate steps to protect the residents. This failure resulted in harm when Resident #14 exhibited signs and symptoms of mental anguish, Resident #57 voiced fear and Resident #73 sustained bruise on her arms and hands from rough treatment. Findings include: 1) Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 07/27/11, indicated the resident was cognitively intact and participated in her health care decisions. On 10/04/11, at 1:42 p.m., Resident #14 stated one Nursing Assistant (NA) A threatened her with physical harm "...to cut off her feet" and he would throw snacks to her from the doorway. Another NA (NA B) would be "sarcastic and rude". She said she was called "[***] " and "whore." She stated a third staff member, NA C, had been in her room to provide care and had been, "...swinging a[***]y diaper and nearly hit me in the face." The resident stated, "They (staff) deliberately antagonize me and I get so upset I shake." The resident stated she had reported the incidents to the facility. The resident was observed during an interaction with NA B. When NA B checked the resident's blood oxygen saturation at 2:03 p.m. and left the room, the resident was shaking in her upper extremities and became short of breath. The resident stated, "That's the one (NA B) I was talking about, she is the one." The resident's hands began to shake. She raised her hands to show the surveyor her hands were shaking. The resident said to the surveyor, "...did you hear what she said to me?" The surveyor was aware the NA mumbled to the resident, but was unable to discern the comments. The resident said, she told me "You are not suppose to have any visitors." On 10/04/11, at 5:10 p.m., Resident Care Manager (RCM) A confirmed the resident reported allegations on 07/22/11 against NA A, NA B (both were currently working in the facility) and MRS. RCM A read an entry in the nurses' notes for 07/ 22/11. The incident documented in the resident's record involved NA A allegedly threatening to cut the residents toes off and kill her birds. NA B and MRS were allegedly making "comments and talking about her." RCM A stated, "She (the resident) hasn't made anymore comments about that (the allegation)." On 10/04/11, at 5:21 p.m., RCM A stated NA A and NA B were told not to work with the resident and the scheduler was aware of this. This surveyor brought up the fact that NA B went into resident's room on 10/04/11 at 2:00 p.m. and took the resident's blood oxygen saturation level with an oxygen meter. RCM A was unaware NA B was assigned to the resident to provide care. On 10/04/11 at 5:35 p.m., the scheduler confirmed NA B was assigned to Resident #14 to provide care. The scheduler was unaware NA B should not work with the resident. On 10/04/11, at 6:58 p.m., RCM A stated she talked with the Social Services Director (SSD) on 07/25/11 and informed the SSD of the allegations made by the resident on 07/22/11. On 10/04/11, at 6:56 p.m., RCM A stated the Director of Nursing Services was not informed of the incident but that it was reported to the facility Administrator on 7/25/11. RCM A was unsure if information was communicated to all staff regarding who would not be assigned to provide care to the resident. RCM A said, "I did tell NA A and NA B not to work with her (the resident) for a while, not take care of her, not go in her room." But the length of time was not quantified. RCM A said, "...it (direction to staff) probably should have been clearer." The facility had knowledge of the resident's reported allegations of being physically and verbally threatened. The facility did not identify the resident's report as potential abuse. No interventions were implemented to protect the resident and the staff who were identified to have threatened the resident were allowed to continue to provide care and assistance to the resident which caused mental anguish. 2) Resident #73 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact and participated in her health care decisions. On 10/05/11, at 11:50 a.m., Resident #73 stated, a few days ago, the Restorative Nurse (RN) "got up in her face," and yelled in a harsh tone "go back to your bed, sit down and be quiet" after the resident had asked the RN not to take her trash can. The resident stated she felt "degraded" and reported the incident to the Social Service Director (SSD). The SSD told the resident the comment from the RN was not meant in a demeaning way. Later that day, the resident saw the RN. The resident reported, the RN "snapped" at her saying, "I'm not going to talk to you without an appointment." The resident stated, "This is not an isolated incident; this is not a good place to live." The resident explained, she has been "threatened" by the Administrator that her space is needed; and if she does not find a place to live, she will be put out. The resident stated the inflection of the voice was "condescending, demeaning, rude and threatening". The facility Administrator was not available for interview during the survey. The resident stated the facility staff "try to come across as [MEDICATION NAME], but if you buck their system, everything changes." The resident stated, she had voiced her complaints to social services, and was told she was "just paranoid." The resident said she was afraid of retaliation and she would be thrown out of the facility before she could find a place to live. The resident stated, "The repeated degrading comments are making me fearful." "I need someone to protect me; I need someone on my side." On 10/06/11, at 1:57 p.m., the resident stated the SSD asked told her, "What do you want from me?" in a condescending tone, after the resident had requested assistance in obtaining housing outside of the facility. The resident stated about two months ago, she had an incident at night where she awoke to a male resident at her bedside. She felt afraid and concerned he would put a pillow over her head or sexually assault her. The resident reported the incident to nursing staff who told her, "he would never do that." The resident stated she felt her concerns were dismissed by staff. On 10/15/11, at 2:00 p.m., SSD stated she was aware of the resident's allegation. There was no facility documentation to support the incident was reported or investigated. No documentation was found to indicate the facility had identified the resident's allegations of abuse. There was no documentation found indicating the facility placed interventions to protect the resident. 3) Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact, able to participate in health care decisions, and required extensive assistance with activities of daily living from staff. Resident #57 stated the staff are "snotty." The resident reported an incident that occurred a month ago when she was receiving assistance with a transfer from NA D. The resident was shoved and grabbed by staff who insisted she move to the right and she told NA D she needed to move to the left. The resident stated NA D physically hurt her and the staff's nails dug into her skin. The resident was bruised on both forearms and hands. The resident struck NA D in an attempt to stop the rough treatment. The resident reported being treated roughly by the staff to RCM A. On 10/10/11 at 3:40 p.m., RCM A stated NA D was "only tapping the resident like joke hitting." RCM A instructed NA D "tapping a resident" was not ever appropriate. On 10/14/11, at 5:47 p.m., NA D stated he provided care for the resident one time. They did have a disagreement about care. NA D stated he wanted the resident to move one way and the resident wanted to move another way. Record review revealed RCM A was not able to provide documentation regarding the incident. RCM A failed to identify the resident's allegations of abuse and did not put interventions in place to protect the resident. Staff Member A stated, "it's like a store front, when you (the survey team) are here, we do things one way, and when you leave we go back to the way things have always been done."

Based on interview, observation, and record review, it was determined the facility failed to provide the necessary care and services for bowel management, skin and respiratory care to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 4 of 40 current sampled residents (#5, 114, 39, & 97) reviewed for quality of care. Findings include: <BOWEL MANAGEMENT> According to the facility Constipation Policy, revised January 2009, the standard bowel care to relieve constipation included: "Milk of Magnesia 30 cc PO (by mouth) every third day without BM (bowel movement); [MEDICATION NAME] Suppository rectally if no results from the Milk of Magnesia; Fleets enema rectally if no results from the [MEDICATION NAME] Suppository" 1) Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired, required extensive or total assistance for all activities of daily living. Review of the bowel elimination care plan, updated 07/27/11, noted the resident had problems with bowel elimination due to a medication (Trazadone) with adverse reactions of constipation, bowel dysfunction related to [MEDICAL CONDITION] and immobility. The interventions included monitor bowel elimination during care tracker and provide medication as ordered to aid in elimination. Review of the physician's orders [REDACTED]. These medications were not part of the Bowel Protocol: *Ordered 09/29/00 - [MEDICATION NAME] 10mg suppository given rectally every other day for Spastic Quad. *Ordered 03/31/09 - [MEDICATION NAME] 10mg/15ml solution given by mouth every morning for Bowel Management. *Ordered 04/06/09 - Senna S tablet given by mouth twice daily for Bowel Management. *Ordered 09/29/00 - [MEDICATION NAME] 10mg suppository given rectally every day as needed (PRN) for Constipation. physician's orders [REDACTED]. Ordered 10/16/08 - Monitor BM (bowel movement) and Blood Pressure (BP) once a day (am shift monitor BP; all shifts monitor BM +/-). If No BM every 24 hours & BP is elevated begin Bowel Protocol. (NOTE: No parameters were specified for elevated blood pressure.) Ordered 04/01/09 - If No BM in 24 hours start Bowel Protocol. The following Bowel Protocol was ordered on [DATE] in the physician's orders [REDACTED]. MOM 30ml by mouth/per tube if no BM on 9th shift. LN to initiate Bowel Protocol for Constipation. [MEDICATION NAME] Suppository rectally if no results by 10th shift for Constipation. Fleets Enema rectally if no results by 11th shift for Constipation If no results from the Fleets Enema, LN will notify Physician for further orders. Review of the resident's Bowel and Bladder Detail Report (BBDR) indicated the resident had the following incidents of no BM (3 shifts equal a 24 hour period): 2nd shift on 08/07/11 through 2nd shift on 08/08/11 (4 shifts)-Per August MAR, the Bowel Protocol was not initiated. 1st shift on 08/21/11 through 2nd shift on 08/23/11 (8 shifts)-Per August MAR, the Bowel Protocol was not initiated. 1st shift on 08/28/11 through 3rd shift on 08/30/11 (9 shifts)-Per August MAR, the Bowel Protocol was not initiated and the resident's blood pressure was 152/80 on 08/30/11. 2nd shift on 08/31/11 through 1st shift on 09/03/11 (9 shifts)-Per August and September MAR, the Bowel Protocol was not initiated and the resident's blood pressure was 147/97 on 09/02/11 and 155/100 on 09/03/11. 2nd shift on 09/07/11 through 3rd shift on 09/08/11 (5 shifts)-Per September MAR, the Bowel Protocol was not initiated. 2nd shift on 09/09/11 through 3rd shift on 09/10/11 (5 shifts)-Per September MAR, the Bowel Protocol was not initiated and the resident's blood pressure was 142/97 on 09/10/11. 2nd shift on 09/15/11 through 3rd shift on 09/16/11 (5 shifts)-Per September MAR, the Bowel Protocol was not initiated and the resident's blood pressure was 150/97 on 09/15/11. On 10/11/11, at 4:58 p.m., the resident stated he does not recall how often he moves his bowels or if the staff give him anything to help him. On 10/14/11, at 3:12 p.m., RCM A stated after 24 hours, three shifts, the bowel protocol should have been implemented for this resident. The RCM stated the order does not provide any parameters regarding the blood pressure. When asked what would be considered elevated blood pressure, the RCM stated anything above 140/90. RCM A stated the Bowel Protocol would be the facility's bowel protocol, and it would be added on top of all his other Bowel Management medications he receives on a regular basis. The facility provided additional information on 10/18/11 on Resident #5's Bowel and Bladder Detail Report. The information did not provide supporting documentation to verify information. The MAR for the months of August and September, and the October MAR indicated [REDACTED]. 2) Resident #97 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, an assessment tool, dated 08/21/11, indicated the resident is moderately cognitively impaired; required extensive assistance with bed mobility, transfers and toileting; and was occasionally bowel incontinent. Review of the resident's BBDR noted the resident had a BM on 10/05/11. The next documented BM was 10/09/11, 11 shifts later. No documentation was present on the MAR indicated [REDACTED]. On 10/07/11, at 2:40 p.m., RCM A stated MOM should be given to the resident after the ninth shift of no BM. On 10/11/11, at 3:15 p.m., the Director of Nursing Services (DNS) stated she printed out a facility report, "No BM or Small BM in the last 9 Shifts," daily. The report was given to the RCMs every morning for their review. The floor nurses also printed out the same report and identified what need to be done on their shift. On 10/16/11, at 4:20 p.m., the resident stated she sometimes had problems with constipation. <Skin> 1)Resident #114 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. This medication was started on 06/23/11. On 10/04/11, at 10:30 a.m., the resident was observed to have bruises on both arms. The resident's skin integrity care plan, updated 08/29/11, did not document the resident received [MEDICATION NAME] daily and was at risk for bruising. The resident's Braden Risk Assessment, tool to determine skin impairment, indicated the resident had a minimal risk for skin impairment. On 10/06/11, at 1:50 p.m., Resident Care Manager (RCM) A stated when a resident was at risk for skin concerns related to medications, she usually added it to the care plan. The care plan did not indicate the resident was at risk for bruises. RCM A stated, "I will add it right now." When asked how the nursing assistants would know to look for bruising for a resident, RCM A stated it would be documented on the care delivery guide. The RCM said she would add the resident being at risk for bruising to Resident #114's care directive guide now. RCM A said, "I try to add it to the care delivery guide when they are at risk for bruising." RCM A stated resident skin checks are completed weekly by the licensed nurses. If there was excessive bruising, it was documented. Review of the skin checks revealed Resident #114 was assessed on 10/03/11 and no concerns were identified. At 2:00 p.m., the resident was observed to have small bruises on both arms and to the top of his left hand. The resident stated he bruised easily. At 2:15 p.m., Nursing Assistant (NA) E said he was not aware the resident bruised easily. NA E stated he was updated today on this. "It must be new." 2) Resident #97 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residen'ts Minimum Data Set (MDS), an assessment tool, dated 08/21/11, indicated the resident was moderately cognitively impaired and requires extensive assistance with activities of daily living including bed mobility and transfers. According to the Care Area Assessment, dated 08/22/11, the "...resident has had episodes of confusion and would remove her surgical dressings." The resident's skin integrity care plan, updated 09/09/11, included surgical wound to the right thigh/calf and the right fourth toe amputation. On 10/04/11, at 4:30 p.m., the resident was interviewed. She stated she was very afraid she was going to lose her one remaining leg. She indicated she was not getting the assistance she needed for cares. When questioned directly if she was frightened because of not receiving needing assistance she said "no, I am frightened I will lose this leg, that is my biggest fear. That is what I am frightened most about." At 4:52 p.m., the resident's right lower extremity was observed with redness and orange peel appearing skin above the knee and at the ankle. The leg wrap appeared soiled. On 10/16/11, at 3:05 p.m., Resident Care Manager (RCM) A stated the resident's bandage is on the right lower leg and the dressing was changed every other day and as needed. The RCM said the resident removed her bandage herself yesterday. The weekly skin assessment, dated 10/15/11, indicated the resident's surgical incision on the right toe had 6 centimeters (cm) of tunneling. The skin assessments, dated 08/17/11, 09/08/11, 09/12/11, 09/25/11, 10/04/11 and 10/07/11, did not document any tunneling to the wound site. RCM A stated the tunneling was not new and had been reported by the wound nurse. Documentation dated 10/13/11 from the consulting wound nurse indicated the dressing was not applied as directed to be tuck into the "tract." No documentation was present indicating the presence of tunneling to the wound site prior to 10/13/11. On 10/16/11, at 3:45 p.m., Licensed Nurse (LN) E stated she spoke to the wound nurse yesterday and she was told she had not applied the dressing correctly into the wound. The LN said the dressing needed to be packed into the wound. LN E stated the wound nurse told her the wound was not worse and there was tunneling; therefore she documented tunneling on her assessment. Review of the wound nurse staff message, dated 10/13/11, documented, "Tuck [MEDICATION NAME] strips ..." The treatment sheet also documented to "Tuck [MEDICATION NAME] strips ..." LN E stated she had not packed the dressing because the treatment sheet indicated to "tuck" the dressing. No documentation was present indicating the order had been clarified. At 3:50 p.m., RCM A stated the wound sheets are looked at weekly. The RCM's expectation was that she was notified when there was a significant change in a wound. She stated LN E notified the DNS today regarding this issue. 3) Resident #39 was admitted to the facility in 2009 and readmitted [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Physician orders [REDACTED]. Skin assessment documentation indicated there were no recent changes in skin condition. On 10/11/11, at 4:45 p.m., a family member stated he had sores that were not healing. On 10/15/11, at 11:30 a.m., observation of the area with RCM C revealed severe excoriation of the skin on both buttocks worse near the gluteal fold. The area was covered with ointment and there was a dressing applied over an area on the right buttock mid way and near gluteal fold which was bleeding when the dressing was removed. Review of the resident's record failed to provide documentation since 05/30/11 regarding the progression of the resident's excoridated and denuded areas on his buttocks. Nurses' Notes only mention the area in May 2011 but did not include a description of site, size or appearance. No note follows in June or July 2011 in the record. Additional documentation to show the progression of the areas was requested on 10/15/11 at 12:15 p.m. RCM C presented additional Nurses' Notes on 10/15/11 at about 2:30 p.m. but no detailed information to include site, size, appearance and treatment to determine whether there was improvement was included in the documents. On 10/16/11 at 10:50 a.m. the DNS discussed the issue regarding documentation in the record regarding the resident's skin issues. There was no documentation to describe the area of his buttocks to include what the area looked like from the time he was admitted to current assessment. The DNS stated treatments are in place and implemented and the resident had been evaluated. The DNS was in agreement that the documentation was lacking in information and progression of the skin changes. Failure to consistently monitor, assess and accurately document the findings of the resident's excoriated skin. They failed to provide evidence the desired outcomes of the treatment were evaluted for effectiveness. Surveyor: Conway, Sonya M.

Based on observations, interviews and record reviews, the facility failed to thoroughly investigate and immediately report alleged incidences of abuse and/or neglect and prevent further similar incidents in accordance with 42 CFR 483.13(c)(3) for 3 of 9 Sample Residents (#s14, 57 & 73) reviewed for accidents and incidents. Failure to identify, report, and investigate allegations of abuse and neglect in a timely manner placed all residents at risk for harm due to unrecognized abuse or neglect and further incidents and accidents. Findings include: 1) Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 07/27/11, indicated the resident was cognitively intact and participated in her health care decisions. At 1:52 p.m., the resident stated she was afraid because of the way she had been treated. She had reported to the facility three staff members Nursing Assistant (NA) A, NA B and Medical Record Staff threatened her. Refer to F-tag 223. On 10/04/11, at 6:58 p.m., RCM stated the resident had reported to her on 07/22/11 that staff threatened to kill her birds and cut off her toes. She said she interviewed the caregivers that day, 07/22/11, but "...did not document it." RCM A read an entry in the nurses' notes for 07/ 22/11. The incident documented in the resident's record involved allegations about NA A and NA B and MRS. RCM A stated, "She (Resident #14) hasn't made anymore comments about that (the allegation)." RCM A said she talked with the Social Services Director on 07/25/11 and informed her of the allegations made by the resident on 07/22/11. On 10/4/11, at 6:56 p.m., RCM A stated she was unsure who was told about the allegation and if information. When questioned if anyone else had been notified of the resident's reported allegation, RCM A stated she notified the facility administrator on Monday 07/25/11. RCM A asked the administrator if the incident should be called in to the state hotline. RCM A stated the administrator said the incident should have been called in on 07/22/11 (when the report of the allegation was made), but that it was no longer appropriate to report it on 07/25/11 (3 days later). The facility did not recognize the resident's allegation as potential abuse or initiate an investigation to rule out abuse, neglect or mistreatment. The facility did not report the allegation to the state certification agency. Although the facility was aware of the incident and the resident was fearful of staff members, the facility did not implement interventions to prevent future incidents. 2) #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was cognitively intact, able to participate in health care decisions, and required extensive assistance with activities of daily living from staff. On 10/03/11, at 4:43 p.m., Resident #57 stated the staff are "snotty." The resident reported an incident that occurred a month ago when she was receiving assistance with a transfer from staff (NA D). The resident was shoved and grabbed by NA D who insisted she move to the right and she told staff she needed to move to the left. The resident stated NA D physically hurt the resident and the staff's nails dug into her skin. The resident stated she had bruises on both forearms and hands. The resident stated she struck NA D in an attempt to stop the rough treatment. The resident reported being treated roughly by the staff to RCM A. On 10/10/11, at 3:40 p.m., RCM A stated NA D was "only tapping the resident like joke hitting." RCM A instructed NA D "tapping a resident" was not ever appropriate. On 10/14/11, at 5:47 p.m., NA D stated he provided care for the resident one time. They did have a disagreement about care when NA D stated he wanted the resident to move one way and the resident wanted to move another way. Record review revealed RCM A did not report the abuse allegation to the state certification agency nor anyone in her chain of command. RCM A was not able to provide documentation regarding the incident. RCM A failed to follow the facility's abuse policies and procedures. The facility failed to initiate an investigation to rule out abuse, neglect, or mistreatment. The facility did not report the allegation to the state certification agency. 3) Resident #73 was admitted to the facility 02/16/11 with [DIAGNOSES REDACTED]. The resident was alert and made decisions regarding her health care. The resident's MDS, dated [DATE], indicated the resident had behavioral problems. On 10/06/11, at 1:57 p.m., the resident recalled an incident which occurred about two months ago. The resident reported Resident #98 wandered into her room and woke her up. He was at her bedside. She stated she was afraid he would put a pillow over her face or sexually assault her. When she reported the incident to nursing staff, she was told "...he would never do that." On 10/10/11, at 12:44 p.m., Resident #73 stated that Resident #98 never returned to her bedside to her knowledge, but the week following the bedside incident, Resident #98 would park in front of her door and roll back and forth in his wheelchair. The resident stated she called out to the nurses station, "I feel like I'm being stalked." Resident #98 heard the comment and stated, "You think I'm stalking you?" and then laughed. Resident #73 reported this incident to Licensed Nurse (LN) B. At 1:50 p.m., RCM B stated she is was not aware of the allegations regarding Resident #98. At 3:47 p.m., RCM A, who is assigned to Resident #98, stated she currently investigating an allegation from another resident regarding Resident #98, but cannot recall an allegation or incident reported by Resident #73 regarding Resident #98. No documentation was found in the resident's record indicating the incident was addressed. No documentation or investigation was found to indicate the facility identified the incident as possible abuse, neglect or mistreatment. Interventions were not found in the resident's record to prevent future incidents. The facility did not report the allegation to the state certification agency. Resident #98 was observed self-propelling his wheelchair about the facility without supervison. .