Every finding on record at View Ridge Care Center

Based on interview and record review the facility failed to ensure medications were available as ordered for 1 of 4 residents (Resident 1) reviewed for medication administration. This failure placed residents at risk for adverse side effects of not taking prescribed medications and diminished quality of life.Findings included .Review of the facility policy titled Medication Not Available dated 06/24/2026, documented to notify the resident of the delay in giving medication when appropriate, and notify the provider if the medication cannot be obtained before the next scheduled dose. Also, to document the reason the medication was unavailable and record all notifications made, including pharmacy, provider, and resident.Resident 1 was admitted to the facility on [DATE] with diagnoses to include gastroesophageal disease (GERD) with esophagitis (stomach acid backing up to the esophagus that causes inflammation of the tissue lining of the esophagus). According to the admission Minimum Data Set (an assessment tool) dated 07/20/2026, Resident 1 was cognitively intact. In a phone interview on 08/04/2026 at 12:17 PM, Resident 1 stated that the staff were giving them Esomeprazole (medication to treat GERD) in powder form mixed in water. Resident 1 stated initially they refused the medication because they were used to taking Esomeprazole in tablet form but later on took the powder form of Esomeprazole because of increased pain in their throat and stomach. According to the resident, they informed the staff that they wanted the Esomeprazole in tablet and not in powder form.Review of Resident 1's order summary documented Esomeprazole Magnesium oral capsule delayed release 40 milligram (mg) to give one time a day for GERD. Order had a start date of 07/15/2026.Review of Resident 1's Medication Administration Record (MAR) for July 2026 documented on 07/15/2026 through 07/19/2026, the medication Esomeprazole was not given and to see the progress notes. In addition, on 07/22/2026 through 07/25/2026, the same medication was not given and to see the progress notes. On 07/16/2026, it was documented that the resident refused to take the medication because the medication was given in powder mixed with water which was not the prescribed form of the medication.Review of Resident 1's progress notes for 07/15/2026 through 07/19/2026 documented that the Esomeprazole was on order. Further review of the progress note showed that the provider saw the resident on 07/17/2026, but there was no documentation that provider was aware of the resident not receiving the Esomeprazole. On 07/19/2026, a Licensed Nurse (LN) documented that the resident complained of indigestion. On 07/20/2026, there was no mention of the missing Esomeprazole on the provider's progress note. On 07/20/2026, an LN documented that they notified the pharmacy of the missing Esomeprazole. On 07/21/2026, the provider's progress note did not mention the missing Esomeprazole. On 07/22/2026 and 07/23/2026, the progress notes documented that the Esomeprazole was on order and the provider was notified. On 07/24/2026, the progress note from the provider did not document the missing Esomeprazole. On 07/24/2026 and 07/25/2026, the Esomeprazole was documented on order, and the provider was notified. On 07/27/2026, the progress notes from the provider indicated that the resident complained of increased acid reflux, the provider changed the order for the Esomeprazole to 20 mg twice a day. The progress note from the provider did not reveal that the Esomeprazole was not available. On 07/30/2026, an LN documented that the resident refused to take the Esomeprazole because it was not in a tablet form. On 07/31/2026, progress note from the provider documented that the resident reported uncontrolled GERD and the resident had been declining their Esomeprazole or has not been available. The note added that the resident preferred tablet over powder form.In an interview on 08/04/2026 at 11:10 AM, Staff C, Licensed Practical Nurse (LPN) stated if a medication was not available and if it's an over-the-counter medication, they check their medication storage room and if it's not there, they notify their supply person to purchase the medication. If it's a prescription medication, they call the pharmacy to ask the status of the medication order and then notify the doctor and the resident that the medication was not yet available. Staff C stated that they document their reason and follow ups of a missed medication in the progress note. Showed Staff C the MAR for Resident 1 with the missed administration of the Esomeprazole and they stated they should have talked to the doctor and had the medication changed sooner and not wait that long.In an interview on 08/04/2026 at 11:30 AM, Staff B, LPN/Staff Development Coordinator stated that if there was a medication that was not available after one day the staff should talk to the provider and inform them so that the provider can either replace/change the medication. Staff D stated that the pharmacy delivered a powdered form for the Esomeprazole for Resident 1 and that some staff were not aware that it came in a powdered form, so they kept documenting that it was on order. Staff D reviewed the MAR for Resident 1 along with the progress note and stated that the nurses' notes did not reflect that they re-ordered the medication in a tablet form nor did the resident refuse the powdered form. Staff D added that they have documentation and communication issues that they need to work on.In an interview on 08/04/2026 at 3:25 PM, Staff A, Administrator stated that they were not aware that a resident did not receive their medication Esomeprazole for a few days. They added that Esomeprazole was an over-the-counter medication and they could have bought it for the resident. Refer to WAC 388-97-1300(1)(a)

Based on interview and record review, the facility failed explain and ensure residents understood the arbitration agreement for 3 of 3 residents (Residents 74, 75, and 81) when reviewed for arbitration agreement. This failure placed residents at risk of forfeiting their right to a jury trial, inability to seek restitution for errors made by the facility, and a diminished quality of life.Findings included .Review of Resident 74's arbitration agreement, dated 11/18/2025, was electronically signed by them. Review of Resident 74's electronic medical record documented they had a diagnosis of dementia, their Brief Interview for Mental Status (BIMS) assessment score was 7 out of 15 (indicative of severe impairment), and their family member was their power of attorney.Review of Resident 75's arbitration agreement, dated 11/04/2025, was electronically signed by them.Review of Resident 81's arbitration agreement, dated 11/16/2025, was electronically signed by them.In an interview on 11/19/2025 at 2:02 PM Staff C, Admissions Coordinator, stated they assisted and reviewed the arbitration agreement with residents upon their admission and with their admission agreement. When asked how the arbitration agreement was explained to residents, Staff C stated it's the financial agreement for the patient, what fees were owed to the facility and ultimately a financial agreement.In an interview on 11/19/2025 at 2:18 PM Staff A, Administrator, stated the arbitration agreement was not just a financial agreement. Staff A stated arbitration was used if a resident had a dispute they would try to through arbitration. Staff A stated the arbitration was not binding and all residents had the right to sue. In a group interview in Resident Council on 11/20/2025 at 10:35 AM asked if residents were explained what arbitration agreements were and if they were informed of their rights when signing one. Three residents stated they were unaware of what arbitration was and were not provided with explanations of their rights.No WAC reference

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 1 of 1 residents (Resident 81) reviewed for Transmission Based Precaution (TBP-are a set of infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through contact with an infected patient, their bodily fluids, or contaminated surfaces or objects), 1 of 1 residents (Resident 3) observed during wound dressing change, 1 of 1 residents (Resident 78) observed for a Peripherally Inserted Central Catheter (PICC- a long, thin tube inserted into a small arm vein and threaded to a large vein near the heart) dressing changes and the develop a facility water management program to protect against the transmission of Legionella (serious type of pneumonia called Legionnaires' Disease).Findings included .<RESIDENT 81> Resident 81 was admitted to the facility on [DATE] with diagnosis to include Clostridium Difficile infection (C. Diff – a highly contagious bacterium that causes diarrhea and inflammation of the colon). According to the admission Minimum Date Set (MDS-an assessment tool) assessment, dated 10/21/2025, resident was cognitively intact. In an observation on 11/19/2025 at 2:57 PM, Resident 81 was not in their room. There was a sign at the left side of the resident's door that stated Contact Enteric Precaution (CEP). In the sign it showed, prior to entering the room, to wash or gel (hand sanitizer) applied to their hands and to wear a gown and gloves. The CEP sign directed staff to use soap and water upon leaving the room. Record review of Resident 81's electronic medical record (EMR) documented the resident was on CEP due to C. Diff. In an observation and interview on 11/19/2025 at 8:57 AM, Resident 81 was in their wheelchair (w/c) in the hallway being pushed by Staff O, Certified Occupational Therapy Assistant) without any Personal Protective Equipment (PPE – gear worn to minimize exposure to illness or injury). Staff O assisted the resident into their room. When Staff O came out of the room, they were asked what the contact precaution sign was for, they stated they were not sure and would go ask the nurse. Staff O came back and stated the resident had C diff. Staff O stated the resident was at the gym. When asked about the precaution, Staff O stated as long as C. diff was contained, they were directed to work with the resident at the gym and wiped everything down the resident touched. When asked why they did not wear PPE, they stated as long as they did not touch the resident's brief, they were okay not to wear PPE. Staff O was observed to enter Resident 80's room, placed gloves on but did not place a gown on, and heard staff inform the resident that they were putting their call light next to them. Staff O then took the gloves off, washed their hands, and left the room. In an observation and interview on 11/19/2025 at 10:06 AM, Staff M, NAC, went into Resident 81's room and did not wear PPE. When they left the room, Staff M was observed to use gel to clean their hands. When asked if they knew of the precaution for Resident 81, they stated that they were only dropping off a water pitcher for the resident and did not need to wear PPE. A few minutes later, Staff M came back and stated they were supposed to wear PPE in rooms that had contact precaution signs even just to bring water to the resident. In an interview on 11/19/2025 at 10:55 AM, Staff B, Director of Nursing, stated a resident who was on CEP may leave the room for medical necessity if they met the 3 C's – continent, cognizant and contained per the Department of Health. Resident 80 met those criteria, that's why the resident was able to go to the gym to do their exercise, Staff B added staff who transported the resident was not required to wear PPE. Then Staff B stated that the room was contaminated, and the staff should have worn PPE upon entering the room. Staff B then paused and stated they would provide documentation regarding contact enteric precautions. In an interview on 11/21/2025 at 1:01 PM, Staff G, Licensed Practical Nurse (LPN)/Infection Preventionist Nurse, stated staff were notified about residents on precautions during their Interdisciplinary Team meetings in the morning, all the managers were informed, and they then informed their staff. For residents who were on TBP, their expectation was for staff to wear PPE prior to entering the room. When asked about residents who were on CEP being taken to the gym, Staff G stated it was decided on a case-by-case basis and the resident had to be continent, infection had to be contained, and the resident had to have clean clothes. They added they tried not to keep a resident in their room just because they had C. Diff. Requested Staff G provide a copy of the guidelines, they were following regarding residents on CEP. Review of the document provided by Staff G titled, CDC Infection Control, Transmission-Based Precaution, dated 04/03/2024, it was documented, Uses PPE appropriately including gown and gloves. Wear gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry . GRESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include chronic ulcer of the left foot and Type 2 Diabetes Mellitus (chronic condition where the body doesn't use insulin properly, leasing to high blood sugar levels). According to the quarterly MDS assessment, dated 09/05/2025, the resident was cognitively intact. In an interview on 11/19/2025 at 2:26 PM, Resident 3 stated the facility does change their left floor wound dressing daily. Review of the provider order, dated 11/14/2025, documented daily dressing change to Resident 81's left lower extremity wound, cleanse with normal saline, apply Alginate (a type of wound care dressing) to their scabbed wounds, Iodosorb (a type of wound gel) to the wound beds only, then cover with gauze and secure with kerlix and Coban with light stretch. In an observation on 11/21/2025 at 10:27 AM, Staff N, LPN, and Staff G were preparing to do the dressing change on Resident 3's left foot wound. Both staff were gowned and wearing gloves. Staff N performed the dressing change and Staff G assisted them. Staff N removed the old dressing, cleansed the wound, removed their gloves, and donned (put on) a new pair of gloves without performing hand hygiene. Staff N preceded to clean the wounds, removed their dirty gloves, and donned a new pair of gloves without performing hand hygiene. Staff N applied the treatment to the resident's wound with their left gloved hand, then removed their left glove, and donned a new glove without performing hand hygiene. Staff N applied skin prep on the sole of the left foot, then remove their gloves off and donned a new pair of gloves without performing hand hygiene. Once the kerlix and Coban were applied, Staff N removed their gloves and gown off then used gel to clean their hands. In an interview on 11/21/2025 at 11:00 AM, Staff N stated they cleaned their hands every time they enter a resident's room and in between resident care. When asked when they perform hand hygiene during wound care, Staff N stated they use gel when they enter the resident's room, and when they were done with the dressing change. Staff N stated they do not perform hand hygiene in between glove changes because their hands were already clean thus, they do multiple glove changes to keep their hands clean. Staff N stated if they do hand hygiene between glove changes then it will take hours to get finished. In an interview on 11/21/2025 at 1:01 PM, Staff G stated staff should do hand hygiene every time they donned new gloves. Staff G stated they would provide more education to staff regarding hand hygiene. <RESIDENT 78> Resident 78 admitted to the facility on [DATE] with diagnoses to include heart failure and osteomyelitis (an infection in the bone). On 11/19/2025 at 11:10 AM, Resident 78's had a PICC observed in the resident's right arm. The dressing covering the PICC was dated 11/02/2025. On 11/20/2025 at 2:45 PM, observed Resident 78's PICC dressing dated 11/02/2025. On 11/21/2025 at 9:45 AM, observed Resident 78's PICC dressing dated 11/02/2025. Review of Resident 78's Medication Administration Record (MAR) for November 2025, documented a physician's order to change the PICC dressing site 24 hours post, insertion, on admission, every week and as needed with a transparent dressing and change the catheter securement device every week and as needed. Review of the MAR for November 2025 showed no documentation of the dressing had not been changed since Resident 78 admitted on [DATE]. In an interview on 11/21/2025 at 9:46 AM Staff G stated Resident 78's PICC dressing was dated 11/02/2025 and should have been changed upon admission to the facility, and then weekly. When asked why Resident 78's PICC dressing should have been changed at admission and then weekly Staff G stated it was for infection control and integrity of the dressing as it could peel up at the edges and cause the PICC to not be aligned correctly. In an interview on 11/21/2025 at 12:40 PM Staff B stated the PICC dressing was on the MAR for Resident 78, but was transcribed incorrectly and was not visible to the nurses caring for the resident. <WATER MANAGEMENT/LEGIONELLA> On 11/20/2025 at 09:22 AM, the water management book for Legionella was requested from Staff X, Maintenance Director. Staff X stated Staff G had the Legionella water management book and that they would make sure I received the book to review. On 11/20/2025 at 09:26 AM, Staff X stated Staff G did not have the Legionella water management book and Staff B would have it ready in a bit. On 11/21/2025 at 10:58 AM, requested the Legionella water management book from Staff B, who stated they would provide it to the surveyor. On 11/21/2025 at 1:30PM Staff A, Administrator, brought two pieces of paper, dated July 2025, with two testing sites for water. There was no book or binder provided that had the water flow diagram to be able to find where stagnant water may collect and cause Legionella concerns, there was no water management plan provided. A request was made to Resident A for the completed water management binder that included a flow diagram of water pipes, etc. in the facility. On 11/21/2025 at 3:00 PM, Staff A delivered an incomplete water management binder that did not have a facility risk assessment to identify where Legionella or other opportunistic waterborne pathogens could grow or spread, there were no flow diagram sheets to identify opportunistic places. No further information was provided. Reference WAC 388-97-1320(1)(a)(c)

Based on interview and record review the facility failed to ensure 3 of 5 nurse aides (Staff S, T and W) had their required 12 hours of in-service training. The failure to ensure Nursing Assistants Certified (NACs) received 12 hours per year in-service training placed residents at risk of less than competent care and services from staff. Findings included . In a review of the NAC training hours showed Staff S, T and W had not received a minimum of 12 hours of training within the year.In an interview on 11/19/2025 at 10:30 AM Staff B, Director of Nursing Services, stated they had a new electronic system in place which did not record all training completed in an easy-to-read format. Staff B stated the staff development coordinator had not kept records of staff's training accurately. WAC 388-97-1680(2)(a-c)

Based on interview and record review, the facility failed to follow-up on concerns of the resident council related to resident care for 4 of 5 resident council meeting minutes (June-August 2025 and October 2025) when reviewed for resident council. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included .Review of the facility policy titled, Policy and Procedure for addressing resident concerns from Resident Council, undated, documented if there was a concern brought up from resident council, a grievance form would be filled out. Missing clothing, concerns about food, concerns about care and/or call light response time required a grievance form completed and turned into the administrator, director of nurses, and the social services director with the resident council minutes. Review of Resident Council Minutes for the following months showed:06/11/2025 documented noise at shift change and concerns for call light response at shift change.07/09/2025 documented showers requested for more than twice a week and concerns of running out of washcloths and clothing protectors.08/13/2025 documented noise at shift change and want to know when showers were scheduled.10/12/2025 documented concerns related to call light response times and a resident's preference for their medication to be provided.Review of the Grievance Log from June 2025 through August 2025 and October 2025 showed no documented grievances consistent with concerns/grievances voiced at resident council.In a brief interview on 11/19/2025 at 2:40 PM, Resident 29, Resident Council President, stated they attempted to resolve concerns within the resident council meeting without escalating them to the facility administration.During Resident Council Meeting on 11/20/2025 at 10:00 AM Resident 29 stated they were the grievance official for the facility.In an interview on 11/21/2025 at 3:20 PM, Staff D, Activities Director, stated they completed grievance forms for concerns expressed at resident council. Staff D stated they encouraged residents who voiced concerns to fill out grievance forms, and they filled one out if the resident does not. When asked if they follow up with resident council about grievances discussed there, Staff D stated they do not, they follow up with the resident who voiced the grievance. Reference WAC 388-97-0920

Based on interview and record review the facility failed to ensure residents were provided notices of their resident rights, both orally and written, annually for interviewed in the resident council for 4 of 10 who attended (Residents 6, 8, 29, 30). This had the potential to affect all residents in the facility.Findings included .During a Resident Council meeting on 11/20/2025 at 10:00 AM, four of 10 residents who attended stated they were not aware of their resident rights. When asked if staff talk about and review the rights of residents in the facility Residents 6. 8, 29 and 30 indicated they had not.During an interview on 11/20/2025 at 10:00 AM, Staff D, Activities Director, stated they had not been reviewing the resident rights in the resident council meeting and would be doing so moving forward. Staff D stated they were unaware they should be reviewing resident rights during the resident council meetings.Reference WAC 388-97-0300 (1) (a)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-an assessment tool) assessment accurately reflected the status for 3 of 14 sampled residents (Resident 8, 58, and 80) reviewed for accuracy of assessments. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . <RESIDENT 8> Resident 8 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (ESRD - final stage of kidney disease where kidneys can no longer function adequately requiring dialysis), malnutrition (body does not receive enough protein and calories to maintain proper health), and epilepsy (neurologic disorder characterized by recurrent seizures). Review of Resident 8's Quarterly MDS assessment, dated 10/09/2025, showed the resident required supervision or touching assist to eat meals. Review of the Centers for Medicare &Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual showed supervision or touching assist with meals was defined as a helper provided verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity. Assistance may be provided throughout the activity or intermittently. Review of Resident 8's Kardex, dated 10/09/2025, showed they ate independently after set up assistance. Review of Resident 8's care plan showed they ate independently after set up. In an observation on 11/19/2025 at 9:30 AM, Resident 8 was observed in their room eating breakfast independently, no staff visualized to supervise or assist the resident. In an observation on 11/20/2025 at 9:24 AM, Resident 8 was observed in their room eating breakfast independently, no staff visualized to supervise or assist the resident. In an interview on 11/20/2025 at 12:08 PM, Staff U, Licensed Practical Nurse (LPN/Admissions Nurse Manager/Resident Care Manager (RCM), stated Resident 8 was independent with eating. In an interview on 11/24/2025 at 11:35 AM, Staff J, LPN/MDS Nurse/Restorative Nurse, stated they were responsible for filling out the section of the MDS for eating. Staff J stated they obtain their information from reviewing progress notes in the resident's medical records. Staff J confirmed Resident 8 was coded in the MDS assessment to have supervision or touching assist to eat. Staff J stated Staff B, Registered Nurse/Director of Nursing Services, had to review their MDS documentation to sign it off. In an interview on 11/24/2025 at 11:53 AM, Staff B stated their expectation was Staff J follows the RAI user manual and completed the MDS assessments. Staff B stated resident's status were reviewed in their interdisciplinary team meetings. Staff B stated they review Staff J's documentation for accuracy to make sure the correct interventions and care plan were in place. Staff B stated eating supervision or touching assistance meant the resident required set up assist for meals. Staff B did not answer when asked about what touching assist would mean. Staff B stated Resident 8 was independent with eating. <LIMITED RANGE OF MOTION> <RESIDNET 58> Resident 58 was admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack (TIA- A short-term block in blood flow to the brain that causes symptoms similar to a stroke.), dementia, muscle weakness, and lack of coordination. Review of a hospice progress note, dated 01/27/2025, documented Resident 58 developed a contracture (a condition characterized by the tightening and stiffening of soft tissue, which can lead to reduced flexibility and range of motion) to their left elbow and hand. Review of the Quarterly MDS assessment, dated 5/2/2025, and Significant Change MDS assessment, dated 06/27/2025, documented no functional impairment to Resident 58's upper or lower extremities. In an interview on 11/24/2025 at 11:34 AM Staff J stated a contracture should be coded on the MDS under functional impairment. Staff J stated they completed all sections of the MDS except for social service sections pertaining to mood/behavior, cognition and discharge planning. Staff J stated once the MDS was completed it was sent to Staff B for their signature. When asked if hospice notes were reviewed as part of data collection for the MDS, Staff J stated they do glance at the hospice notes. <RESIDENT 80> Resident 80 was admitted to the facility on [DATE] with diagnoses to include Stroke with hemiplegia (paralysis or severe weakness of muscle on one side of the body, affecting arm, leg and sometimes the face). According to the 5-Day Minimum Data Set assessment, dated 11/03/2025, the resident had moderately impaired cognition, adequate vision, and no impairment of both upper extremities. In an interview on 11/20/2025 at 8:44 AM, Resident 80 stated they could not read regular size font letters and their left side vision was limited due to stroke. The resident stated they could not move their left arm and left leg due to a stroke. In an interview on 11/24/2025 at 9:00 AM, Staff L, Nursing Assistant Certified (NAC), stated Resident 80 had impaired vision and staff assisted them in reading their menu. Staff L added the resident required extensive assistance with dressing. In an interview on 11/24/2025 at 9:45 AM, Staff G, LPN/RCM, stated Resident 80 had impaired vision on their left side from a stroke and was paralyzed on their left side. In an interview on 11/24/2025 at 10:15 AM, Staff N, LPN, stated Resident 80 had impaired vision, and staff helped the resident read regular sized fonts upon request such as the menu selections. In an interview on 11/24/2025 at 11:35 AM, Staff J stated they assessed residents' vision by asking the residents to read the menu or activity papers on the residents overbed table. When asked how they filled out section GG – Functional Assessment in the MDS, they stated during the Interdisciplinary Team, held twice a week, they discussed residents' mobility status, and reviewed documentation in the EMR. When asked about Resident 80's vision, Staff J stated Resident 80 was able to read during their assessment and they did not see any diagnoses regarding the resident's vision in their chart. Regarding Section GG, Staff J stated that it was an oversight and would correct the resident's MDS assessment dated [DATE]. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 3 of 6 sampled staff (Staff R, S, and T) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or underqualified care staff, and diminished quality of life. Findings included .<Staff R>Review of Staff Rs', Nursing Assistant Certified (NAC), personnel file showed they were originally hired on 06/20/2023. No documentation of a performance evaluation was found. <Staff R>Review of Staff R's, NAC, personnel file showed they were originally hired on 09/27/2023. No documentation of a performance evaluation was found. <Staff T>Review of Staff T's, NAC, personnel file showed they were originally hired on 04/30/2024. No documentation of a performance evaluation was found.In an interview on 11/24/2024 at 12:30 PM Staff B, Director of Nurses, stated there was a new system in which annual reviews were being electronically coordinated. Staff B stated they attempted to complete all annual reviews, but there were some that were not completed due to delay by the staff member needing to complete their portion electronically.Reference WAC 388-97-1680 (1)(2)(a-c)

Based on interview and record review, the facility failed to ensure that power of attorney (POA) legal documents were in the resident's medical record for 1 of 4 (Resident 5) residents reviewed for advance directives. This failure placed the resident at risk of having someone make medical decisions for the resident without proper legal authority, possible unmet care needs, or unwanted medical treatments.Findings included .Resident 5 was last admitted to the facility on [DATE] with diagnoses to include heart failure, depressive disorder, anxiety disorder and chronic obstructive pulmonary disease (COPD) (lung disease characterized by obstructed air flow, which causes shortness of breath, and chronic cough)Review of Resident 5's electronic heath record (EHR) showed they had a POA listed on their profile page, which indicated the POA was for financial, care and medical decisions.Review of Resident 5's EHR showed there were no legal POA documents found or provided.In an interview on 11/20/2025 at 12:08 PM, Staff U, Licensed Practical Nurse / Admissions Nurse Manager/ Resident Care Manager, stated they would not add a POA to a residents EHR without having been provided legal documents. Staff U verified that Resident 5's profile page showed they had a POA documented and were unable to locate POA documents in the EHR.In an interview on 11/24/2025 at 9:38 AM, Staff F, Social Services Director, stated they would not document a POA in the resident's EHR without having the POA documents and would instead document the resident had a point of contact person, which is someone who could be notified or contacted by the facility if needed. Staff D stated they had asked Resident 5's family for the POA documents and had never received them. Staff D verified that Resident 5's profile page had listed a POA and did not have a copy of the legal document.Reference WAC: 388-97-0280 (3)(c)(i-ii)

Based on observation, interview and record review, the facility failed to develop comprehensive care plans to reflect the resident's current medical status and/or to include all provided nursing services for 1 of 1 resident (Resident 19) reviewed for edema management, 1 of 1 residents (Resident 80) reviewed for stroke and impaired vision. These failures placed residents at risk of not receiving needed care, decline in condition, and diminished quality of life. Findings included .<EDEMA MANAGEMENT> <RESIDENT 19> Resident 19 admitted to the facility on [DATE] with diagnoses to include developmental disability and localized edema (swelling). In a review of Resident 19's admission and Quarterly Nursing assessment dated [DATE] documented they had swelling to both their lower legs. Review of Resident 19's care plan dated 10/29/2025 documented they had pain related to edema and had potential for skin issues related to edema. Resident 19's care plan provided no description of their edema, how it manifested, or how to manage it. In an interview on 11/24/2025 at 12:00 PM, Staff B, Director of Nursing Services (DNS) stated that care plans were based on interview with residents on admission, then MDS nurse does their interview and personalized the care plan then they also put in the resident's preferences. Staff B stated that they expect the care plans to be documented to what care the residents were receiving. <STROKE AND IMPAIRED VISION> <RESIDENT 80> Resident 80 was admitted to the facility on [DATE] with diagnoses to include Stroke that caused paralysis. According to the 5-Day Minimum Data Set (MDS-an assessment tool) dated 11/03/2025 the resident had moderately impaired cognition. In an interview on 11/19/2025 at 10:20 AM, Resident 80 stated that they were paralyzed on their left side. Resident 80 stated they wanted to place a note on the wall informing staff not to put things on their left side. In an interview on 11/20/2025 at 8:44 AM, Resident 80 stated that they could not read regular size letters and their left sided vision was limited. Resident viewed a document with regular print that was at the bedside and stated they could not read it. Resident 80 stated they were unable to read their menu and need assistance from staff. Review of Resident 80's care plan showed there was no documentation regarding the resident's impaired vision. The interventions regarding resident's stroke did not specify on the resident's needs of having things placed on their right side, there was no mention about the resident requiring assistance with their menu. Review of Resident 80's Kardex (a quick-reference tool of resident's care needs) showed no documentation regarding the resident's impaired vision, required assistance with their menu selection or setting things on the resident's right side due to paralysis on the left side. In an interview on 11/24/2025 at 9:00 AM, Staff L, Nursing Assistant Certified (NAC) stated that Resident 80 had impaired vision and staff assisted the resident to read their menu. When asked how they find out information on how to care for a resident, Staff L stated that they do bedside reporting with the previous shift, review the Kardex, or the nurse will give them information. In an interview and record review on 11/24/2025 at 11:30 AM, Staff G, Resident Care Manager (RCM), stated all nurses had access and can update the care plan. Staff G stated a resident's care plan was initiated during the admission process and the MDS nurse updated it after they completed the admission MDS assessment, and the care plan was updated quarterly. Staff G stated that impaired vision and placing things on the residents right side due to left sided paralysis would be documented on the care plan. Staff G reviewed the care plan with the surveyor and reported that there was no documentation regarding the resident's impaired vision and there were no interventions related to Resident 80's left sided paralysis. In an interview on 11/24/2025 at 12:00 PM, Staff B, was informed that Resident 80's care plan did not include impaired vision and lacked interventions for their left sided paralysis. Staff B stated they would review the care plan to ensure they were geared to the residents specifically. Reference WAC 388-97-1020(1)(2)(a)

Based on interview and record review, the facility failed to ensure that dialysis communication documents were filled out before and after the resident had their dialysis appointments for 1 of 1 resident (Resident 8) reviewed for dialysis. This failure placed Resident 8 at risk of inadequate information given to the dialysis staff, a lack of assessment and documentation upon arrival back to the facility, undetected dialysis complications, and a decreased quality of life.Findings included .Resident 8 was admitted to the facility on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) (final stage of kidney disease where kidneys can no longer function adequately requiring dialysis), malnutrition (body does not receive enough protein and calories to maintain proper health) and epilepsy (neurologic disorder characterized by recurrent seizures).In an interview on 11/18/2025 at 1:54 PM, Resident 8 stated they thought the facility and dialysis clinic should have better communication.Review of Resident 8's dialysis communication documents dated August, September and October of 2025 showed the following missing documentation:- 08/05/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill (sound heard over an artery and sensation felt over an artery) was detected, no nurse signature, upon returning to facility from dialysis- 08/29/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 08/30/2025 showed no resident status, recent pain or anxiety medication or nurse signature were documented in the portion of the document that is sent with the resident to dialysis- 09/11/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 09/13/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 09/16/2025 showed no resident status, recent pain or anxiety medication or nurse signature were documented in the portion of the document that is sent with the resident to dialysis- 09/20/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 09/23/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 09/27/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 10/09/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 10/14/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 10/18/2025 showed no resident status, recent pain or anxiety medication or nurse signature were documented in the portion of the document that is sent with the resident to dialysis and showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis- 10/23/2025 showed no documentation related to vital signs, assessment of Resident 8's dialysis site, or if a bruit or thrill was detected, no nurse signature, upon returning to facility from dialysis In an interview on 11/20/2025 at 12:08 PM, Staff U, Licensed Practical Nurse/ admission nurse manager/ Resident Care Manager, stated nurses were to fill out the dialysis communication sheet and give it to the resident to take to the dialysis appointment. Staff U stated any change in status or medication changes should be documented and signed by the nurse. Staff U stated the nurse was to document on the communication sheet upon return, assess the resident's dialysis site, obtain vital signs and document on the return portion of the dialysis communication sheet.In an interview on 11/24/2025 at 11:53 AM, Staff B, Registered Nurse (RN), Director of Nursing Services (DNS) stated it was their expectation that the nurse complete and document recent vital signs, any change in resident status, and recent medications. Staff B stated there was documentation after the resident returns from dialysis that should also be completed by the nurse, after everything was documented, the document was uploaded into the resident's electronic Health Record. Staff B stated their expectation was all portions of the dialysis communication document were filled out.Reference WAC: 388-97-1900(1) (6)(a-c)

Based on observation, interview, and record review, the facility failed to provide 1 of 4 residents (Resident 58) consistent equipment and assistance to maintain their mobility. This failure placed residents at risk for decline in functional ability, frustration, and a diminished quality of life.Findings included. Review of the facility's undated policy titled, Restorative Nursing, showed the facility would ensure residents received the highest practicable level of care and the restorative program was to assist residents to get to their highest practicable level through physical exercise and rehabilitation. Procedures included making progress in the resident's electronic chart and updating the resident's care plan with measurable goals and timelines, weekly reviews/meetings of the charting by the restorative manager, restorative programs reviewed and noted in the resident's chart summarizing the program, goals, and progress. Resident 58 was admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack (TIA- A short-term block in blood flow to the brain that causes symptoms like a stroke), dementia (memory loss), muscle weakness and lack of coordination. Review of Resident 58's medical provider note, dated 10/15/2024, documented they had good upper extremity and lower extremity motor strength, and they were able to move all extremities freely with their Passive Range of Motion (PROM - when someone physically moves or stretches a part of your body) intact. Review of the current Restorative Program care plan, with a start date of 11/14/2025 and last edited on 08/27/2025, showed (or is it documented) Resident 58 had a restorative nursing program (RNP) to maintain their current range of motion (ROM - the extent or limit to which a part of the body can be moved around a joint or a fixed point) and prevent contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to shorten and become very stiff which prevented normal movement of a joint or other body part) and discomfort related to their muscles tightening. The goal was Resident 58 would maintain their current ROM to both their upper and lower extremities and reduce the risk of contractures. Interventions included a completed PROM exercise program to Resident 58's shoulders, elbows, wrist, fingers, hips, knees, ankle flexion and shoulder/hip abduction (moving your arms or legs out to the side, away from your body)/adduction (moving a body part toward the middle of your body) six times a week as tolerated. Resident 58's care plan showed no documentation of Resident 58's contractures.Review of hospice records showed Resident 58: -admitted to hospice services on 10/23/2024 for end stage dementia and failure to thrive.-On 11/14/2024, Resident 58 was evaluated by hospice occupational therapist (OT) related to stiffening joint on their left side and a restorative program was started.-On 12/31/2024, a hospice progress note showed the facility staff reported Resident 58's left hand was getting stiffer, causing discomfort when trying to straighten.-On 01/15/2025, a hospice progress note showed they spoke with Staff I, Restorative Aide/Nursing Assistant Certified, who reported Resident 58's left arm/hand was becoming contracted.-On 01/27/2025, a hospice progress note showed Resident 58 developed a contracture to their left elbow and hand. The hospice Occupational Therapist (OT) consulted with Staff I the restorative nurse (unnamed) and recommended a left palm protector (a soft cover that protects the palm of your hand), a pillow to their left side after ROM to maintain the stretched position, and premedication prior to the RNP. The hospice OT noted they provided the recommendations to the facility Administrator.-On 01/27/2025, a hospice progress note documented Resident 58's Representative (CC1) reported they were not getting the therapy services.-On 01/30/2025, a hospice progress note showed Resident 58 had a contracture to their left hand.-Resident 58 discontinued hospice services on 06/18/2025. Review of Resident 58's progress notes showed no documentation regarding the development of their contractures to their left hand and elbow. A progress note, dated 07/21/2025, documented Resident 58's RNP was placed on hold while they worked with the facility's OT for contracture prevention/management. Review of Resident 58's facility OT notes documented:-On 09/24/2024, Resident 58 had no contracture with grip strength better in their right hand than their left. No restorative program was developed as it was not indicated at that time. Prognosis to maintain Resident 58's current level of function was good with consistent staff follow-up.-On 06/20/2025 Resident 58's goal was to wear a resting hand splint on their left arm fingers for up to an hour and to progress wearing the hand splint for four hours on and four hours off for contracture management.-On 09/29/2025 Resident 58 was documented to tolerate wearing the hand splint for eight hours during the nighttime.-On 11/07/2025 Resident 58 was documented to be wearing a soft hand splint on their left hand to prevent further contracture. Review of Resident 58's Treatment Administration Record (TAR) for January 2025 through September 2025 showed no orders related to a splint, a therapy carrot (specialized orthotic device-to prevent contracture), or palm protector (orthotic device) as described in OT notes. Review of Resident 58's TAR for 11/18/2025 through 11/24/2025 documented an order dated 10/29/2025 for a left soft hand splint on for contracture, monitor for skin breakdown when in use, and to notify the provider and therapy if skin issues were present. Review of Resident 58's TAR for January 2025 through September 2025 showed no orders related to a splint, a therapy carrot, or palm protector. During an observation on 11/19/2025 at 10:55 AM, Resident 58 was lying in their bed with no splint on their left hand. Resident 58's left hand was balled into a fist with their thumb pressed firmly against their pointer finger. On 11/20/2025 at 12:01 PM, observed Resident 58 sitting in their wheelchair, with their lunch meal in front of them on an overbed table. Resident 58 was observed with no hand splint to their left hand. In an interview on 11/20/2025 at 12:54 PM. CC1 stated Resident 58's placement of the splint on their left hand/arm was not consistent. CC1 stated the inconsistency of the splint placement was an ongoing issue. On 11/21/2025 at 9:27 AM, observed resident lying in bed with no splint on their left hand. In an interview on 11/24/2025 at 10:05 AM with Staff I, stated they were familiar with Resident 58 and had provided restorative services to them. Staff I stated Resident 58 had been on hospice services and their left hand became hard to open and the facility now had a splint for them. Staff I stated Resident 58 had to keep the splint on for 24 hours. Staff I stated they had to check to make sure Resident 58 was wearing the splint every four hours. Staff I stated when they were not working the aides checked on Resident 58 to ensure they were wearing the splint. Staff I stated Resident 58 had always held their left hand in a fist and different splints were tried and stated the contracture was probably painful for them. When asked if Resident 58 was supposed to be wearing the splint last week Staff I stated Resident 58 was to wear it all the time or their contracture would worsen. In an interview on 11/24/2025 at 10:35 AM Staff G, Licensed Practical Nurse/Resident Care Manager, stated Resident 58 had developed a contracture a while ago, they were on hospice at the time and were documented on the care plan. Staff G stated that prior to Resident 58 development of contractures they received ROM and frequent repositioning. When asked what interventions were put in place after the contractures were identified, Staff G stated hospice OT assessed Resident 58 and a restorative program was implemented along with a splint. In a follow up interview on 11/24/2025 at 1:14 PM with Staff I, stated the OT from hospice had spoken to them about Resident 58's left side contractures and had brought them a therapy carrot for them to use. Staff I stated sometimes they were unable to locate the carrot and Staff B, Director of Nurses Services, had to purchase another one at one point. In an interview on 11/24/2025 at 1:14 PM with Staff B, when asked for details about the therapy carrot, its use, and how they ensured proper use of it, Staff B did not provide a response. Reference: (WAC) 388-97-1060(3)(d)

Based on observation, interview, and record review the facility failed to provide the assistance with activities of daily living (ADL's) for 1 of 2 sampled dependent residents (Resident 58) reviewed for ADL's. The facility failed to provide one-to-one feeding assistance to Resident 58. This failure placed residents at risk for inadequate nutrition and unmet care needs and a diminished quality of life. Findings Included.Resident 58 was admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack (TIA- A short-term block in blood flow to the brain that causes symptoms similar to a stroke), dementia, muscle weakness and lack of coordination.Review of Resident 58's care plan, dated 09/23/2024 and revised on 08/27/2025, documented they required one-to-one assistance to eat their meals.In a continuous observation starting at 11/20/2025 at 12:01 PM, Resident 58 was observed in common area, across from the nurse's station, with their lunch on an overbed table in front of them. Resident 58 was not wearing a clothing protector and was covered in a blanket. Resident 58 was eating their lunch with their right hand/fingers spilling on their blanket. At 12:16 PM Staff P, Nursing Assistant Certified (NAC), ask Resident 58 if they needed assistance. Resident 58 stated yes and Staff P then assisted them.In an observation and interview on 11/21/2025 at 9:27 AM, Resident 58 was observed in their bed with their breakfast tray on their overbed table in front of them. Resident 58's head of bed was position at a 45-degree angle, their head was hanging down, chin to their chest. Resident 58's meal tray contained a full glass of juice and milk, full bowl of oatmeal, a full plate of eggs and French toast and an unopened health shake. Observed Staff Q, NAC, enter Resident 58's room, remove their meal tray from the over bed table and remove the clothing protector from their chest. Resident 58 was not offered anything else to eat or drink. When asked how much Resident 58 consumed, Staff Q stated they had two bites of eggs. Staff Q stated they were familiar with Resident 58's care and use the Kardex (guide for caregivers to provide care to a particular resident) to know how to provide care to them. Staff Q stated they help feed him most of the time.On 11/21/2025 at 12:29 PM, Resident 58 was observed in their bed, eyes closed. Resident 58 had their lunch meal tray still covered on their overbed table, out of reach, by their window. On 11/21/2025 at 12:46 PM, Resident 58's lunch meal tray was on their overbed table, observed in the same place as 12:29 PM.On 11/21/2025 at 2:20 PM, Resident 58's lunch meal tray was observed on their overbed table, located in the middle of their room, with the lid off and their food was partially eaten.In an interview on 11/21/2025 at 2:20PM, Staff Q stated Resident 58 ate all their lunch. When asked what time Resident 58 ate their lunch, Staff Q stated at the normal time around 12:00 PM.In an interview on 11/24/2025 at 12:30 PM Staff B, Director of Nursing Services, stated Resident 58 had been in the common area at the time lunch was served, was offered lunch, and then taken back to bed after they declined to eat.Refer to WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to provide services that ensured a resident's abilities in activities of daily living (ADLs) did not diminish for 1 of 2 sampled residents (Resident 19) reviewed for activities of daily living. This failure put residents at risk for physical decline and decreased quality of life.Findings Included .Resident 19 admitted to the facility on [DATE] with diagnoses to include developmental disability and need for assistance with personal care. Review of Resident 19's Brief Interview for Mental Status (BIMS - an assessment tool used to screen for cognitive impairment) dated 10/23/2025 documented a score of 8 out of 15, indicating the resident had moderate impairment. Review of Resident 19's care plan, dated 10/29/2025, documented they required limited assistance by one staff with personal hygiene and oral care. In an observation and interview on 11/19/2025 at 10:03 AM, Resident 19 stated they did not know where their toothbrush was located and thought their toothbrush was in their bedside table. Resident 19 provided consent to look in their bedside table drawer and bathroom, there was no toothbrush observed in either location. Resident 19 was observed to have gray and white matter in between their teeth and at their gumline. When a toothbrush was not located, Resident 19 stated their toothbrush was at home and they would brush their teeth when they returned home. On 11/20/2025 at 9:26 AM observed Resident 19's teeth with debris in in between their teeth and at their gumline. In an observation and interview on 11/20/2025 at 9:54 AM, Staff M, Nursing Assistant Certified (NAC), stated when they start their shift, they check all the residents, assist with getting them changed and dressed, provide breakfast room trays, and afterward assist residents with oral care and changing clothing if needed. When asked about Resident 19's toothbrush, Staff M stated they were not assigned to care for Resident 19, but would look for their toothbrush. Observed Staff M look through Resident 19's bedside table, bathroom, and closet. Staff M stated they were unable to locate Resident 19's toothbrush. Staff M stated Resident 19 required assistance with their oral care. In an interview on 11/20/2025 at 9:58 AM Staff P, NAC, stated they were assigned to care for Resident 19. Staff P stated every morning they provide Resident 19 and other residents with warm washcloths to wipe their face. Staff P stated they then take the vitals of Resident 19 and other residents. Staff P stated they provided Resident 19 with their toothbrush and toothpaste to brush their teeth. In an interview on 11/24/2025 at 10:19 AM Staff G, Resident Care Manager/Licensed Practical Nurse, stated they expected staff to provide oral care to residents two to three times daily. Staff G stated all residents were to have a toothbrush, if a resident did not have a toothbrush at admission, one would be provided to them. Staff G stated they were unaware Resident 19 did not have a toothbrush. Refer to WAC 388-97-1060(1)(2)(a)(i)

Based on interview and record review, the facility failed to ensure timely reporting of an allegation of neglect to the State Agency for 1 of 1 resident (Resident 78) reviewed for abuse/neglect reporting. This failure placed residents at risk for potential unidentified and ongoing abuse and lack of protection from abuse.Findings included .Review of the facility policy titled, Abuse and Neglect Policy, undated, documented the reported allegations of abuse or neglect by following nursing home guidelines outlined in the Purple Book.Review of the Purple Book, dated October 2015, documented a report must be made when there was a reasonable cause to believe violations had occurred involving abuse, neglect, abandonment, mistreatment, injuries of unknown source, personal and/or financial exploitation, or misappropriation of resident property. Neglect was defined as 1) pattern of conduct or inaction by an individual or entity with a duty of care for nursing home residents. Or 2) a one-time act or omission by an individual or entity with a duty of care for nursing home residents.In an interview on 11/19/2025 at 11:10 AM, Resident 78 stated the night before they had to wait over an hour to have their brief changed. Resident 78 stated they were soiled with feces and urine and when left unchanged they developed a rash. On 11/19/2025 at 1:30 PM, Staff B, Director of Nursing Services (DNS), was informed of Resident 78's allegation of neglect and they stated they would follow the facility process.In an interview on 11/21/2025 at 9:46 AM, Resident 78 stated they were fully soaked in urine, had used their call light during the night several times, and did not obtain assistance for a brief change.In an interview on 11/21/2025 12:40 PM, Staff B stated they had reported Resident 78's allegation of neglect to the state reporting agency.On 11/24/2025 at 11:46 AM requested from Staff B Resident 78's incident report from 11/19/2025 by electronic communication.On 11/24/2025 at 2:58 PM, the incident from 11/19/2025 was requested again from Staff B. Staff B stated the incident had not been logged, had been placed on a grievance, and not called in until Resident 78 had made an additional allegation of neglect on 11/21/2025.Review of an electronic communication dated 11/24/2025 at 10:00 AM, from Staff F, Social Services Director, documented they met with Resident 78 on 11/19/2025 and discussed the allegation of neglect and Staff F found this was not a pattern, thus not neglect.On 11/25/2025 at 12:45 PM, Staff B provided the incident report, dated 11/21/2025, for Resident 78 and the grievance dated 11/19/2025 by electronic communication. When asked about how they ruled out neglect within two hours, Staff B documented they had followed the guidance from the Purple Book and it did not meet the criteria of neglect at the time as there was no pattern.Reference: (WAC) 388-97-0640 (5)(a)

Based on interview, and record review, the facility failed to ensure the medical records reflected the accurate weight for 1 of 4 residents (Resident 81) reviewed for weights and 1 of 2 residents (Resident 58) and for complete records to include hospice communication/documentation. These failures placed residents at risk for inaccurate medication dosage calculation, unmet care needs and possible medical complications.Findings included.<RESIDENT 81> Resident 81 was admitted to the facility on [DATE]. According to the admission Minimum Date Set (MDS-an assessment tool) assessment, dated 10/21/2025, the resident was cognitively intact, and the weight entered in Section K was 179 pounds (lbs.). In an interview on 11/20/2025 at 8:19 AM, Resident 81 stated they were just weighed and it was 248 lbs. The resident added they had gained three lbs. Resident 81 stated they used to weigh more than 300 lbs. and was working on losing more weight. The resident stated they have not weighed less than 200 lbs. Record review of Resident 81's weight showed the weights entered into the electronic medical record (EMR) for the month of October 2025 were all struck out with a note Incorrect Documentation, dated 11/14/2025. November weights entered were: 11/07/2025 250 lbs., 11/10/2025 251.8 lbs., 11/13/2025 248.2 lbs., 11/14/2025 248.6 lbs., 11/15/2025 246.6 lbs., and on 11/17/2025 250 lbs. Record review of Resident 81 progress notes since admission did not show any notes regarding why October 2025 weights were struck out. Record review of Resident 81's assessment under Nutrition at Risk Assessment, dated 11/06/2024, documented the resident's weights were: 10/15/2025 170.4 lbs., 10/18/2025 179.2 lbs., and 10/23/2025 179.4 lbs. Record review of Resident 81's provider progress note, dated 10/20/2025, 11/05/2025, and 11/10/2025, showed the resident's weight was 179.4 lbs. Then on 11/13/2025 and 11/18/2025 the weight documented on the provider's progress note was 250 lbs. There was no mention about the weight difference. Record review of Resident 81's hospital Discharge summary, dated [DATE], showed the resident's weighed 279.4 lbs. There was a 109 lbs. difference from the weight taken by the facility on admit which was 170.4 lbs., and 100.4 lbs. difference from the weight documented in the MDS. In an interview on 11/24/2025 at 8:45 AM, Staff L, Nursing Assistant Certified (NAC), stated when a resident was admitted they were weighed daily for the first three days, and then whenever the nurse requested them. The resident weights were documented in the residents' EMR. In an interview on 11/24/2025 at 9:35 AM, Staff G, Licensed Practical Nurse/Resident Care Manager (RCM), stated newly admitted residents were weighed daily for the first three days, then weekly for a month, then monthly after to establish the resident's baseline weight. They reviewed residents' weights in their weekly Nutrition at Risk (NAR) meeting with the dietitian. Staff G reviewed Resident 81's weight, stated they were not sure why the weights were struck out and could not find any notes in the resident's EMR why there were huge differences in the weights that were documented. Staff G was unable to provide documents explaining the weight differences. In an interview on 11/24/2025 at 12:05 PM, Staff B, Director of Nursing Services, stated they saw the weight discrepancy during their NAR meeting and documented the corrected weight. Staff B stated they had placed a note in the progress note this morning regarding the weight discrepancy. Staff B was unable to explain the weight discrepancy. <RESIDENT 58> Resident 58 was admitted to the facility on [DATE] with diagnoses to include transient cerebral ischemic attack (TIA- A short-term block in blood flow to the brain that causes symptoms similar to a stroke.), dementia, muscle weakness and lack of coordination. Resident 58 admitted to hospice services on 10/23/2024. Review of Resident 58's EMR on 11/19/2025 showed inconsistent documentation from hospice services and was not all inclusive of dates when the resident was seen by hospice. In an interview on 11/24/2025 at 2:27 PM, Staff B stated hospice documentation was kept in an EMR not linked with the facility's EMR. Staff B stated all of Resident 58's hospice documentation was being uploaded into their EMR at the facility. Staff B stated the hospice records should have been in Resident 58's EMR at the facility. On 11/24/2025 at 2:30 PM, Resident 58's EMR showed an additional six hospice records were added with dates ranging from October 2024 through March 2025. WAC 388-97-1720(1)(a)(i-iv)(b)

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in 1 of 1 facility kitchens, 1 of 2 dining rooms (1st floor) and 2 of 2 nourishment refrigerators (1st and 2nd floors). The facility failed to ensure the dishwashing machine maintained adequate hot water temperature, to ensure the kitchen and dining room ceilings were free of dust and lint, to ensure the nourishment refrigerators were clean and sanitary, to ensure food preparation equipment surfaces were sanitary, and to ensure overhead light fixtures were sanitary and in good repair. These failed practices placed residents at risk for foodborne illnesses. Findings included . In an observation on 08/27/2024 at 9:50 AM, the 2nd floor nourishment room refrigerator and freezer were observed to have sticky residue and scattered food/debris, and the freezer had approximately 1/2 inch of ice on the walls and upper and lower surfaces. In an observation on 08/27/2024 at 10:02 AM, the 1st floor nourishment room refrigerator and freezer units were soiled with food residue and the refrigerator had a layer of frozen water on the bottom surface of the refrigerator. The overhead light fixture in the nourishment room was broken and was observed to have many dead insects. In an interview on 08/27/2024 at 10:02 AM, Staff D, Housekeeper, stated housekeeping was supposed to clean the nourishment room counters, cupboards and refrigerator every morning and maintenance was responsible for defrosting the freezer. Review of the Low Temperature Dish Machine Log showed the minimum acceptable wash cycle temperature was 120 degrees Fahrenheit (F). Unacceptable low temperatures were logged at lunch on 08/17/2024 (115F), 08/23/2024 (119F), 08/24/2024 (116F), 08/25/2024 (119F), 08/26/2024 (119F), and Breakfast on 08/21/2024 (115F) and 08/22/2024 (118F). In an observation and interview on 08/27/2024 at 10:43 AM, the dishwashing machine wash cycle temperature was observed to be 115F, Staff C, dietary manager, stated the machine needed to be warmed up, and they restarted another load, and the temperature was observed to be 124F for the wash cycle. In observations on 08/27/2024 from 11:02 AM to 11:06 AM, the dishwashing machine wash cycle temperatures ranged from 103 - 118 degrees F. In an observation/interview on 08/27/2024 at 11:13 AM, the kitchen ceiling in the food preparation area had lint blowing back and forth from the air coming out of the ceiling air conditioner. The flooring in front of the dishwashing area was missing approximately 6 feet by 8 feet of linoleum, Staff C stated they had plans to replace the kitchen flooring, but they were uncertain of the replacement dates. The food preparation shelving under the kitchen overhead air conditioning vents had a layer of dust and debris. The coffee maker in the kitchen had a layer of dust and coffee grounds. Several overhead light fixtures in the kitchen food preparation area had dead insects. In observations on 08/28/2024 from 12:47 PM to 1:39 PM, the dishwashing machine wash cycle temperatures varied from 111F - 127F. In an observation on 08/28/2024 at 1:46 PM, Staff C was observed assisting dishwashing staff to set up the sinks for manual washing of dishes. In an interview on 08/29/2024 at 10:30 AM, Staff F, Corporate Operations, stated they had scheduled the kitchen flooring to be replaced after they had completed repairs of other parts of the building. In an observation on 08/29/2024 at 10:35 AM, the first-floor dining room ceiling had four overhead vents that were surrounded by ceiling tiles that had a build-up of lint and dust in approximately two to three feet in all directions around the vents. In an observation on 08/29/2024 at 10:40 AM, Staff G, Environmental Services Manager, stated they were not sure who was responsible for cleaning the ceiling around the overhead vents, but they would take the hit and make sure it got cleaned. In an interview on 08/29/2024 at 12:45 PM, Staff E, Corporate Operations, stated they had the dishwashing machine repair company come out and they changed the settings on the dishwashing machine, and they think the dishwashing machine temperature issue had been fixed. Staff E stated they were looking at getting a different dishwashing machine to replace their current machine. Refer to WAC 388-97-1100 (3) and -2980 51312

Based on observation, interview and record review, the facility failed to ensure 2 of 3 medication carts (Carts 3 and 4) and 1 of 1 medication rooms (first floor medication room) had unexpired medications and/or biologicals and medications were stored at the proper temperature. These failures placed residents at risk of receiving compromised medications and biologicals. Findings included . Review of a facility policy titled, Medication Storage in the Facility, dated 03/30/2023, showed: Outdated medications were to be removed from inventory; Facility should maintain a temperature log in storage area and record temperatures at least once a day; If vaccines are stored in the refrigerator the temperature should be checked at least two times a day.; When the original seal of a multidose vial is broken, the container will be dated; Expiration date of a vial will be 30 days once opened. <CART 4> During an observation on 08/28/2024 at 9:42 AM, Medication cart 4 was reviewed with Staff M, Licensed Practical Nurse (LPN). An opened bottle of acidophilus probiotic was in the top drawer of the cart. The label showed refrigerate after opening. In addition, there was a box of glucometer (meter to check sugar level in the blood) control solution which contained level 1 solution with an expiration date of 06-13-2024 and level 2 solution that expired 05-27-2024. During an interview on 08/28/2024 at 10:03 AM, Staff M stated the bottle of acidophilus probiotic was in the cart when they arrived, and it had not been stored in the refrigerator as the label showed. Staff M stated that the glucometer control solution was no longer good as the bottles were expired. <CART 3> During an observation and interview on 08/28/2024 at 10:12 AM, Medication cart 3 was reviewed with Staff K, Registered Nurse (RN). A bottle of calcium polycarbophil was found in the cart. The label showed an expiration date of 05/2024. Staff K stated the medication was no longer good as it had expired and would remove it from the cart. <FIRST FLOOR MEDICATION ROOM> During an observation on 08/29/2024 at 10:02 AM, the contents of the refrigerator in the first-floor medication room were reviewed. Inside the refrigerator were several vaccines. There were two individual dose vials of Flucelvax quad (influenza) vaccine, a vial of Prevnar 20 (pneumonia vaccine) and a multidose vial of Flucelvax quad. The multidose vial of Flucelvax quad vaccine was dispensed on 11/17/2023. The vial was open, but it was not dated when it was opened, and the label showed an expiration date of 06/16/2024. There was also an open vial of tubersol (solution to test for tuberculosis) that was not dated to show when it had been opened. Affixed to the front of the refrigerator were the temperature logs for August 2024 and July 2024. The temperature log showed that temperatures should be done twice a day but had several missing entries: August 2024 log (from August 1st- [DATE]th) showed missing 14 of 56 entries (2nd- PM, 3rd-PM, 12th- AM and PM, 13th- AM and PM, 14th- AM, 17th-PM, 18th-PM, 19th-PM, 20th-PM, 25th-PM, 26th-PM, and 27th-PM). July 2024 log showed missing 23 of 62 entries (2nd- AM and PM, 5th - AM, 7th - PM, 8th - PM, 9th- PM, 12th- AM and PM, 13th-PM, 14th- AM, 15th- AM and PM, 16th- AM and PM, 17th- AM, 21st- PM, 22nd- PM, 23rd- PM, 25th- AM, 27th-AM, 28th- PM, 30th- PM, and 31st- PM). During an interview on 08/29/2024 at 10:12 AM, Staff J, Patient Care Coordinator/RN, stated they could not find an open date on either the multidose vial of Flucelvax quad or the vial of tubersol. Staff J stated the Flucelvax quad vaccine also was expired so they would discard those vials. Staff J stated the nursing staff were supposed to check the refrigerator temperature in the morning and evening, but it did not look like they had been checking it twice a day. Refer to WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for 1 of 4 residents (Resident 14) reviewed for Activities of daily living and 1 of 1 resident (Resident 6) reviewed for dental care. This failure placed residents at risk for inaccurate care planning and decreased quality of care. Findings included . <Resident 14> Resident 14 admitted [DATE] with diagnoses that included Schizophrenia and Bipolar disorder. Review of Resident 14's Medication Administration Records for the prior six months showed the resident frequently refused ordered medications and treatments. Review of Resident 14's progress notes from April 1, 2024, through August 26, 2024, showed Resident 14 exhibited behaviors such as yelling, cursing and refusing cares. Review of the Annual Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed Resident14 exhibited no behaviors or refusals of care in the reference period. Review of the Quarterly MDS dated [DATE] showed the resident exhibited no behaviors or refusals of care. In an interview on 08/29/2024 at 12:05 PM, Staff O, Licensed Practical Nurse (LPN)/MDS Coordinator, stated the MDS' for Resident 14 were incorrect. Staff O stated they had signed those sections (behaviors/refusals of care); however, the facility social worker usually completed those sections. Staff O stated they had reviewed nursing assistant documentation which did not show refusals but had not reviewed progress notes or licensed staff documentation for the resident. 50725 <Resident 6> Resident 6 admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that block airflow and make it difficult to breath), Diabetes Mellitus Type 2(a disease that occurs when your blood sugar is too high). According to the admission MDS dated [DATE], showed Resident 6 was cognitively intact. In an interview on 08/26/2024 at 1:25 PM, Resident 6 stated that they were interested in getting dentures. In an interview and observation on 08/27/2024 at 1:38 PM, Resident 6 stated that they have missing teeth and cavities on the right side of their mouth and that they have a difficult time chewing hard food. Resident 6's mouth was observed and cavities were observed on their teeth, and they were missing teeth on the top and bottom of the right side of their mouth. Resident 6 was unable to recall the last time they saw a dentist. Review of the Admission MDS dated [DATE] showed that Resident 6 did not have dental issues. Review of the current care plan on 08/27/2024 showed the care plan did not address Resident 6's dental issues, goals or interventions. Review of a dietician progress note dated 07/30/2024 showed Resident 6 had complained of chewing difficulties due to broken teeth and recommendations were made for Resident 6 to have easy to chew food. Resident 6's current diet order was general diet with downgraded texture due to broken teeth. In an interview on 08/27/2024 at 2:54 PM, Staff J, Registered Nurse/Patient Care Coordinator stated they were going to put Resident 6 on the list to be seen by the dentist. Staff J stated they were going to assess the resident's diet and texture. Staff J stated that any licensed staff can update the care plan as needed. In an interview on 08/28/2024 at 12:48 PM, Staff O, LPN/MDS Coordinator, stated they were not able to explain why Resident 6's MDS assessment showed no dental issues. Staff O stated that they don't look at the resident's mouth, and the admission nurse was the one that completes that assessment. Refer to WAC 388-97-1000 (1)(b)

Based on interview and record review the facility failed to identify a significant change and complete a timely Significant Change in Status Assessment (SCSA) within the required 14-day timeframe for 1 of 4 residents (Resident 7) reviewed for Hospice Services. Failure to complete the SCSA timely placed the resident at risk for unmet care needs, decreased quality of care and diminished quality of life. Findings included . Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.18.11, dated October 2023, stated a Significant Change in Status Assessment must be completed no later than 14 days from the Assessment Reference Date and no later than 14 days from the determination date of the significant change in status. (For purpose of this section, a significant change means a major decline in status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of a resident's health status). SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains in the nursing home. Resident 29 admitted to the facility on [DATE] with diagnoses including pressure ulcer (bed sore) to right buttock, long term use of anticoagulants (blood thinners), and osteomyelitis (bone infection). The admission Minimum Data Set (MDS - an assessment tool) assessment, dated 07/05/2024 showed the resident had intact cognition. Review of Resident 29's clinical record on 08/26/2024 showed that the resident had been placed on hospice services on 08/06/2024. Review of the MDS assessments showed no significant change assessment was completed. In an interview on 08/28/2024 at 2:00 PM, Staff O, Licensed Practical Nurse/MDS Coordinator stated whenever there was a change in condition, they are required to complete a significant change MDS assessment. Staff O stated that they usually receive communication from the nurse manager in the morning clinical meeting if there are any residents that have had a change in condition. Staff O stated that Resident 29 did not receive a significant change assessment when they were placed on hospice services. In an interview on 08/29/2024 at 11:15 AM, Staff J, Registered Nurse/Patient Care Coordinator stated all residents that are experiencing a change in condition are discussed in the morning clinical meeting every Monday - Friday. Staff J stated they were out of facility on vacation during the first two weeks that Resident 29 was on hospice services and was not sure who had been responsible in their absence, nor why that information was not communicated to the MDS coordinator. In an interview on 08/29/2024 at 12:33 PM, Staff B, Director of Nursing Services stated they discuss any residents with a change in condition at the morning clinical meetings. Staff B stated they were aware of who was covering for Staff J while they were out on vacation but ultimately the responsibility fell with them, and they did not get that communication regarding Resident 29 to the MDS coordinator to complete a significant change assessment for the resident. Refer to WAC 388-97-1000(3)(b)

Based on interview and record review, the facility failed to ensure accurate pharmaceutical services/procedures when dispensing and administering medications for one of three residents (#1) reviewed for pharmaceutical services. Failure to: 1) accurately process a physician's orders [REDACTED].#1 was harmed when she fell and sustained a [MEDICAL CONDITION] after receiving a 400% increase of the physician ordered dose 29 times before the facility discovered the medication error. Upon discovering the medication error, the facility failed to document the error in the resident's clinical record and staff failed to consider whether the multiple overdoses were contributory to the resident sustaining a [MEDICAL CONDITION]. Findings included . Definitions: Ombudsman (Ombud): An ombud was a representative from the Washington State Long-Term Care Ombudsman Program, which was an organization that advocated for residents of nursing homes, adult family homes, and assisted living facilities. The purpose of the program was to protect and promote the Resident Rights guaranteed these residents under Federal and State law and regulations. Ombuds were trained to receive complaints and to resolve problems in situations involving quality of care, use of restraints, transfer and discharge, abuse and other aspects of resident dignity and rights. [MEDICATION NAME] - an anticonvulsant medication that was used to prevent [MEDICAL CONDITION], it was also used to relieve nerve pain. Side effects of [MEDICATION NAME] (from WebMD.com) included drowsiness, dizziness, loss of coordination, tiredness, blurred/double vision, unusual eye movements, or shaking (tremors). RESIDENT #1 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her admission Minimum Data Set assessment, dated 04/03/2020, she had no cognitive impairment, and she required 1-person physical assist with walking. Review of the Skilled Nursing Facility Transfer Orders, dated 03/27/2020, revealed under the Unchanged medications section of the orders, was an order for [REDACTED]. Review of an electronically transmitted prescription, from the pharmacy to the nursing home, dated 03/27/2020, revealed the pharmacy had faxed the nursing home about the dosage discrepancy between the ordered [MEDICATION NAME] dose of 300 mg three times daily, and the nursing home's directions to give 1200 mg three times daily. Review of an investigation summary, dated 04/06/2020, revealed Resident #1 had two falls on 04/06/2020. The second fall that the resident had on this day, she sustained a left [MEDICAL CONDITION]. The investigative report findings did not find abuse or neglect because the resident was independently up and walking and getting ready for bed when her legs gave out and she fell . There was no mention at all in the investigation that there had been a medication error related to excessive [MEDICATION NAME] being administered to the resident three times a day from 03/27/2020 - 04/06/2020, for a total of 29 incorrect doses. Review of a Medication Error Report, dated 04/07/2020, discovered on 04/06/2020 Resident #1 had received [MEDICATION NAME] 1200 mg (milligrams) three times daily from 03/27/2020 - 04/06/2020, when the physician's orders [REDACTED]. The form had a block to Describe impact of error on resident, including assessment, to which staff wrote in None. The resident remained alert and oriented, participated with therapies, was not sedated, no complaints of weakness, her vital signs were stable and there was no orthostatic (where the blood pressure was taken in a lying position, then sitting, then standing positron) blood pressure was done. There was no mention at all of the falls or the fall with fracture, even though these falls occurred on the same day the medication error was discovered by staff. In the spot on the form for family notification, staff wrote in the patient was notified, but not family or the resident's power of attorney. Review of other medication error documentation revealed during the investigation, the facility identified that the medication card documentation did not match from the card to the physician order [REDACTED]. Review of a nurse practitioner's progress note, dated 04/06/2020, revealed the resident was evaluated that day for a chief complaint/nature of presenting problem of a fall, and for follow-up of multiple comorbidities including a fall. The note indicated the resident was also evaluated that day for increased somnolence (somnolence per Wikipedia was alternatively called sleepiness or drowsiness, and was a state of strong desire for sleep, can be accompanied by lethargy, weakness, or lack of mental agility), that she recently had some medication adjustments, tapering down of [MEDICATION NAME] as well as [MEDICATION NAME] (opiate pain medication). Note: this note did not mention anything at all about the resident's medication errors of receiving excessive doses of [MEDICATION NAME]. Review of a nursing progress note, dated 04/06/2020 at 11:15 PM, revealed the resident fell twice that shift, and the nurse had notified the resident's daughter of the fall and the plan of care. Note: this note did not mention anything at all about the resident's medication errors of receiving excessive doses of [MEDICATION NAME]. Review of a hospital history and physical examination [REDACTED]. It sounds like the fall was mechanical, though she is very sleepy and not able to provide details before falling back asleep. In a phone interview on 06/01/2020 at 3:05 PM, the resident's daughter/Power of Attorney, stated she had not been able to visit her mother during the stay at the nursing home due to the COVID-19 pandemic, but she talked to her on the phone. The daughter stated her mom had been telling her on the phone that the nursing home was giving her more medications than her usual. The daughter stated her mother had been telling her she could not stay awake and she was always very sleepy. The daughter stated ever since her mother went into the nursing home, her mother had told her she was always feeling overly sleepy, which is why she started investigating what was going on because she wasn't allowed to go visit due to COVID. The daughter stated prior to hospitalization , she had been the one to manage her mother's medications and she knew exactly what her mother was taking because she set up her medication cassettes for her at home. The daughter stated her mother had been taking [MEDICATION NAME] 300 mg, 1 tablet, three times daily. The daughter stated after she brought her mother home from the nursing home after the surgery, her mother fell again and re-broke her left hip and her left wrist. In an interview on 06/02/2020 at 3:19 PM, the Administrator was asked why the medication errors had not been documented in the resident's clinical record, she stated she didn't know that was required. The Administrator was asked why the medication errors had not been included in the fall incident investigation, she stated they didn't feel the medication error was related to the fall because the medication error occurred 12 days prior to the fall. In a phone interview on 06/04/2020 at 9:47 AM, Resident #1 stated with her first fall (on 04/06/2020) she just lost her balance and fell and was wobbly. She said with the second fall (same day, on 04/06/2020) she didn't remember much about that. She said she knows she felt dopey, that she just didn't feel right, she felt wore out, that she felt she could just go to sleep at any time. She stated she hadn't always felt like that, and she just didn't know what was going on. She stated she just didn't care because she was just so tired. She stated she did not know about her medications because her daughter was in charge of her medications. She said she was tired all the time, and all she wanted to do was lay down and sleep all the time. She stated she told her daughter she was tired all the time, and that she hurt. She stated since her daughter couldn't come and visit her, she just had to trust that they all knew what they were doing for her. She stated it was all pretty foggy for me. The resident denied any knowledge at all of the medication errors. In a phone interview on 06/04/2020 at 10:20 AM, Staff A, Pharmacist, stated the pharmacy processed the initial [MEDICATION NAME] order on 03/27/2020 for 300 mg, three times a day. Staff A stated they had also gotten a copy of the Medication Administration Records (MARs) for that same order, and the pharmacy realized the physician's orders [REDACTED]. Staff A stated they put a note on the prescription on 03/27/2020 and faxed it back to the nursing home. Staff A stated they weren't confident in the note being seen. Staff A stated the pharmacy's fax was all electronic, and nothing really happened with it. Staff A did state that on 03/30/2020 and 03/31/2020 the nursing home requested multiple times for a refill on the [MEDICATION NAME], but it was too early for refills based on the original correct order of 300 mg three times daily. In a phone interview on 06/05/2020 at 3:10 PM, Staff A stated initially on 03/27/2020 the pharmacy had filled the initial [MEDICATION NAME] order with 42 tablets of 300 mg each. Staff A stated the initial supply of [MEDICATION NAME] provided should have lasted for two weeks, but the nursing home was requesting a refill after only three days. Review of Ombuds notes, dated 05/13/2020, revealed the resident's daughter had reported the nursing home had called her about two falls on 04/06/2020 and that the resident had sustained a possible fracture and was sent to the hospital. There was no report at all of any medication errors. The Ombud notes also revealed the residents' daughter had reported to the Ombud that during the daughters' phone calls with her mother, her mother had reported several times that she was unusually tired and that she did not feel right. In a phone interview on 06/05/2020 at 3:10 PM, the resident's daughter/Power of Attorney, reported the nursing home never reported the medication errors to her, but that they should have because her mother was confused and wasn't capable of managing her own medications. The residents' daughter stated her mother was now in a different nursing home, and was still quite confused at times. Reference: (WAC) 388-97- 1300 (1)(a)(b)(i)(ii)(c)(i)(ii)(4)(d)

Based on observation, interview and record review the facility failed to ensure three of four (#1, #11 & #13) residents reviewed received thorough initial and periodic assessments consistent with professional standards of practice and/or had appropriate and timely interventions in place based on individual risks, to promote healing of existing pressure injuries and prevent new pressure injuries from developing. Additionally, there were failures and delays in initiating interventions and lack of or inaccurate wound documentation. These failures resulted in harm to Resident #13 who developed a Deep Tissue Injury. The failures also resulted in a Stage II Pressure Injury to Resident #11. Additionally, the failure to complete thorough assessments of pressure injuries on Resident #1 prevented nursing staff from being able to evaluate for changes. These failures resulted in actual harm and placed residents at risk of deterioration of the pressure injuries and associated complications. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage I Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration, these may indicate deep pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable). Review of the undated facility Skin at Risk Program, included: 1. The pressure ulcer prevention and management program is based on the nursing process and includes: a. identification of residents at risk for skin breakdown b. care plan development to prevent skin breakdown c. implementation of care plan interventions consistent with current standards of nrsinng practice d. monitoring interventions to determine effectiveness . RESIDENT #13 Resident #13 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was admitted on palliative care with hospice services. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. He was always incontinent of bowel and bladder. He was at risk of pressure injury development with no current pressure injuries. He had no turning or repositioning devices for bed or wheelchair and was not on a turning or repositioning program. Review of Resident #13's admission assessment dated [DATE] revealed he had red area to his sacrum on admission. There was no measurement of the area of concern. Review of the Treatment Administration Records (TAR) for January and February 2020 showed that an order for [REDACTED]. Review of the resident's TAR for February 2020 showed the resident had skin checks on 02/06, 02/23, and 02/20/2020; all are marked with a - which indicated no skin impairment. Review of the resident's clinical record revealed no documentation of deep tissue injury appearance to coccyx as reported by licensed staff interviews to be present on 02/04/2020. There was no documentation of the resident's skin appearance until the area became open. Review of facility investigation dated 02/06/2020 showed on this date the resident was noted to have excoriation measuring 6 centimeters (cm) by 5 cm, 2 non stageable open areas to the right and left buttocks measuring around 3.5 cm by 2.2 cm by 0.1 cm in depth on the right buttocks and 2.3 cm by 1.3 cm by o.2 cm to the left buttocks area. Review of hospice documentation dated 02/08/2020 revealed the hospice nurse assessed the resident's Deep Tissue injury which had opened. The documentation showed on this date a low air loss mattress was delivered for the resident. The placement of the mattress was 15 days post-admit, in spite of numerous risk factors and presence of sacral redness on admission. Review of Provider note dated 02/10/2020 showed the resident was previously noted with unstageable pressure ulcer to sacrococcygeal area. Review of Skin Check Body Diagrams assessment forms, showed the first one was completed on 02/12/2020, six days after the resident's coccyx area was noted to be open. Review of all progress notes revealed the resident began resisting care and expressing increased pain 0n 02/07/2020, after pressure injuries developed, which conflicts with interviews (02/04/2020) that indicated refusals pre-dated identification of pressure injuries. Review of the resident's current care plan and kardex dated 02/13/2020 did not include interventions for his refusals/resistance of incontinent care and turning/repositioning, consequently this information was not on the Nursing Assistant Kardex (plan of care). In a telephone interview on 02/18/2020 at 7:00 PM, the resident's son stated when his father admitted to the facility he had a little bit of redness on his coccyx, not associated with any pain. He stated it quickly developed into a serious pressure ulcer which he observed with the nurse on 02/05/2020 or 02/06/2020. He stated due to pain from the pressure ulcer his father had increased refusals of care. He stated he does not believe staff repositioned and provided incontinent care per orders or standards of care. He gave examples of a day his mother spent seven hours at the facility and the resident was never repositioned. Additionally, he stated he had arrived at the facility a number of times to find his father either severely incontinent including brief and bedding or observations of urine stained sheets and the resident with disheveled appearance. In an interview on 02/25/2020 at approximately 12:00 PM, the interim Director of Nursing Services stated they did not initiate a special mattress for the resident on admission. She stated they probably should have done so before he had significant skin breakdown, due to redness to his sacrum on admission and multiple [DIAGNOSES REDACTED]. She stated he also had refusals of care and stated staff did not document this issue until the resident's son had complaints. In an interview on 02/26/2020 at 11:00 AM, Staff M, Resident Care Manager/Licensed Practical Nurse stated the resident should have had an air mattress on his bed since admission as he had multiple risk factors and had redness to his sacrum on admission. He stated the reason they did not start a special mattress on admission was because Hospice would not provide one until the resident had a Stage III or greater pressure injury. He stated the facility had special mattresses which they use for residents who are at significant risk or have skin breakdown. Staff M stated when he saw the resident's skin on 02/04/2020, the resident's skin had the appearance of deep tissue injury. He stated the resident's skin was still intact at that time. He stated on approximately 02/06/2020 the residents sacrum and coccyx area had started to open on each buttock approximately 2 centimeters (cm) by 3 cm each, with fragile skin in between and surrounding skin very macerated. He stated the open areas were not stageable. When asked if he had informed the resident's son of the deep tissue injury (DTI) on 02/04/20, he stated he recalled telling him at a care conference he was concerned about the resident's skin and told him they were going to use more barrier cream, however did not recall stating it was a DTI. On 02/26/2020 at approximately 11:15 AM, the administrator stated the facility had special mattresses for residents who had skin breakdown or were at high risk. She stated even if they had not had a special mattress available at the time, they could have rented or purchased one for him. In an interview on 02/26/2020 at 12:30 PM Staff AA, an employee who requested to remain anonymous stated he/she has observed this resident on several occasions with bedding and/or brief saturated with urine. This employee also stated with a little extra effort and encouragment the resident would accept incontinent care and repositioning and observed numerous caregivers to not bother to put in the extra effort, and instead just walked away at the first voice of refusal. In observations on 02/26/2020 at 9:55 AM, 11:00 AM, 11:40 AM, 12:20 PM, 1:00 PM, 1:30 PM, 2:00 PM, 2:30 PM, and 2:45 PM, the resident was in bed, lying partially on his right side. There were no observations of any change in position during almost five hours. On 02/26/2020, at 2:20 PM Staff Q, Registered Nurse stated he observed the resident's skin the day prior (approximately 02/05/2020) to it opening and stated it was dark purple and looked like a deep tissue injury. He was informed Resident #13 had not been observed to be turned/repositioned in almost five hours on 02/26/2020. On 02/26/2020 at 2:30 PM, Staff P, NAC was informed the resident had been observed in the same position for almost five hours. She stated she had not received report from day shift or from the nurse that Resident #13 had refused care during the day and would reposition him as soon as possible. RESIDENT #11 Resident #11 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was on hospice services. According to the quarterly MDS assessment dated [DATE], Resident #11 had cognitive impairment and she required extensive assist with Activities of Daily Living to include transfers, bed mobility, toileting, bathing, and transfers. She was at risk for pressure ulcer development and coded to have no pressure reducing device for her bed or chair. Review of the resident's current care plan revealed the resident sat and slept in her recliner, was incontinent, had a history of [REDACTED]. Nursing was to check her Roho (special cushion for chair to reduce pressure) for inflation and placement each shift. Review of Resident#11's Treatment Administration Record showed an entry dated 02/04/2020 for treatment of [REDACTED]. Review of progress notes revealed no documentation of skin issues other than a response from the residents provider dated 02/04/2020 regarding a note from staff of a new skin tear to the residents left buttock likely caused by friction and that the resident sat in her recliner or wheelchair all day. The provider indicated the resident would be seen on 02/04/2020. Review of the clinical record revealed the first assessment of the wound was dated 02/13/2020, nine days after treatment had started. The Skin Check Body Diagram revealed shearing and moisture associated skin damage to the right gluteal fold. Documentation revealed the resident was very incontinent. There was no description of tissue type, drainage, or presence/absence of related pain. The injury measured 3 cm by 0.5 cm by 0.1 cm. Review of provider note dated 02/04/2020 revealed no documentation about the skin issue. Review of hospice note dated 02/25/2020 revealed the resident had a Stage II pressure injury between gluteal folds. Review of skin assessment documentation signed by an RN and dated 02/27/2020 revealed the resident had a Stage II pressure ulcer which measured 4 cm by 2 cm by 0.02 cm with well defined edges, moderate bloody drainage, beefy pink wound bed with no eschar or slough. In an interview on 02/25/2020 at approximately 11:00 AM, Staff L, RN had what they thought was a skin tear on her buttocks. She stated the resident refused to lie in bed and slept in her recliner. In an interview and observation on 02/25/2020 at 1:50 PM, Resident #11 was sitting in her wheelchair. There was a bed pillow on the wheelchair. There was no roho cushion in either the wheelchair or the leather recliner, nor visible in the room. She complained and cried of pain all over, especially her bottom. Upon her request, staff transferred her to her recliner. A brief observations of her right buttock, as she did not tolerate being on her side more than momentarily, revealed what appeared to be a Stage II pressure injury on her right buttock. On 02/26/2020 at 10:45 AM, Resident #11 was observed sitting in her recliner. There was nothing but an incontinent pad between her and the recliner. She stated she slept in the recliner and did not use the bed because she could not stand it. In an interview on 02/06/2020 at 11:10 AM Staff M, RCM/LPN stated he had assessed the residents buttock wound but he was not permitted to stage the wound. He stated per his wound experience and observations it would be a Stage II pressure ulcer. He stated to his knowledge, Resident #11 had not used her bed and spent the majority of her time in her recliner. He was informed the resident had not had any type of pressure relieving device in her wheelchair or recliner in spite of care plan for Roho and air mattress. He stated the facilty had quit using Roho cushions because they had not been able to ensure they were being kept properly inflated. He stated they had changed to gel cushions. He stated the resident had a history of [REDACTED]. In an observation and interview on 02/26/2020 at 12:10 PM, Staff M was observed to bring a Roho to the resident's room and placed it in her wheelchair. The resident was sitting in her recliner, again without a pressure relieving cushion. In an interview on 02/26/2020 at 3:20 PM, Staff N, NAC stated they had not been using a Roho or any other pressure relieving cushion in Resident #11's wheelchair or recliner. She stated they may put the memory foam pillow in her wheelchair, but nothing other than an incontinent pad in her recliner. She stated the resident had a bad sore on her bottom. In an interview on 02/26/2020 at 3:45 PM, the Regional Nurse stated the skin issue on Resident #11 was a chronic problem. She stated nursing staff should have assessed, documented, informed the provider and responsible party, obtained treatment orders, and made any needed intervention changes. She stated they made weekly wound rounds on residents such as Resident #11 who were not followed by wound consultant. She stated Resident #11 was not on the wound round list and she would add her. RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission note dated 11/30/19 revealed the resident had blisters on both heels on admission. Review of the resident's care plan dated 12/16/19 showed the resident admitted to the facility with pressure sores to bilateral heels. review of the resident's medical record revealed [REDACTED]. There were no measurements, temperature, color, surrounding tissue appearance, presence/absence of pain, or other description of the pressure injuries. Review of the resident's discharge summary dated 12/30/19 showed upon discharge to assisted living facility, the resident had bilateral heel blisters. There was no description of the appearance or size of the blisters or whether there were any changes from the date of admission. Review of hospital records dated 01/01/2020 showed the resident admitted to the hospital 12/31/19 with bilateral full thickness heel ulcers with eschar. In an interview on 02/03/2020 at 10:45 AM, Staff B, Registered Nurse (RN) stated all wound documentation was completed in the electronic medical record, Point Click Care. She stated wounds to include pressure injuries were assessed weekly and documented in the progress notes. On 02/03/2020 at approximately 12:00 PM, Staff E, Nurse Practitioner stated she recalled Resident #1 and followed his care while he was at the facility. She stated she recalled his heels were boggy, pressure-related injuries, and likely full thickness. On 02/03/2020 at 1:00 PM, Staff F, RN/Regional Nurse, stated she reviewed the resident's clinical record and found no wound assessments. She stated she found documentation the wounds were present on admission and discharge, but without assessment documentation there was no means of determining any change during the residents stay at the facility. She stated they had been doing weekly wound rounds and then hired a wound consultant company. She stated not all residents with wounds were seen by the consultant company, including Resident #5, and his assessments were completely missed. In a telephone interview on 02/04/2020 at 6:15 PM, Staff G, RN stated she recalled Resident #1. She stated the resident's heel blisters would be staged (per The National Pressure Ulcer Advisory Panel) as unstageable due to not knowing what was underneath the blisters. She stated some residents with wounds were assessed by a wound consultant weekly and stated the others were supposed to be seen by the facility management team in weekly rounds and assessment documentation was in the electronic chart. She was unable to state if Resident #1's wounds had improved, stayed the same or declined during the resident's stay. Reference: (WAC) 388-97-1060 (3) (b)

Based on interview and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for one of three residents (#12) reviewed. Failure to respond to the resident's call light and provide toileting assistance in a timely manner resulted in psychosocial harm, embarrassment, humiliation, and diminished self-worth. Findings included . Review of Resident Rights provided to residents by the facility included the Federal and State regulations for resident rights. Resident rights related to dignity included the following: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Additionally, The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. Resident #12 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set assessment dated [DATE] showed the resident was cognitively intact. Resident #12 required extensive assistance of 2 persons for bed mobility, transfers, dressing, toileting, and hygiene. The resident was assessed to have frequent bowel incontinence and occasional urinary incontinence. Review of the resident's current care plan showed she required hoyer transfer to the toilet or use of bedpan. Review of facility investigation dated 02/04/20 showed Resident #12 reported to Social Services she had her call light on for approximately an hour and had an incontinent bowel movement while waiting. Review of Director of Nursing Assistant interview of Staff I, Nursing Assistant Registered (NAR), showed Staff I was helping other Nursing Assistants at the time and did not notice Resident #12's light had been on. In an interview on 02/26/20 at 12:35 PM, Staff I NAR stated she recalled the day she was assigned to Resident #12 and found out her call light had not been responded to in approximately an hour and resulted in the resident being incontinent of BM. She stated on that date it was very busy and she was frequently requested to help other Nursing Assistants with their residents. She acknowledged she failed to check her own call lights. She stated apparently other staff had not responded to Resident #12's call light while she was busy with other residents. SHe stated the resident was incontinent of BM related to the delayed call light response. She stated the resident wore a brief and was incontinent at times but also continent at times and requested toileting assist. In an interview on 02/19/20 at 3:20 PM, Resident #12 stated she could not recall the date, but there was a day when she had her call light on an hour or more and could not wait any longer and was incontinent of bowel. She stated it was embarrassing/humiliating to her when it happened. She said after that episode she just made herself realize That's just the way it is and it's not my fault if I have an accident. She then said its kind of embarrassing to tell you this, but now I just don't worry about pooping in my brief, I often don't even bother putting on my light on for the bedpan and wait until I need cleaned up. In an interview on 02/25/20 at approximately 12:00 PM, the Administrator stated the facility did not have a specific policy for dignity; they use the Resident's Rights. Reference: (WAC) 387-97-0180 (1) & (2)

Based on interview and record review the facility failed follow their house bowel protocol and performed a digital rectal examination without a physician order [REDACTED]. Findings included . Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Diabetes, heart failure, arrythmia, and anxiety disorder. Review of the facility House Bowel Program showed after 3 days without a bowel movement, the nurse was to administer Milk of Magnesia (MOM) on the day shift. If no results, a [MEDICATION NAME] suppository (a laxative) was to be given on the evening shift. If no results from the suppository the resident was to be given a fleets enema. Review of the facility investigation dated 11/25/19, showed the facility became aware of an allegation that Staff A, Resident Care Manager/Licensed Practical Nurse (LPN), had attempted to disimpact (digitally remove stool from the rectum) Resident #1 on 11/22/19. Upon facility interview of Staff A, he stated he performed a digital assessment for impaction. Upon receipt of his written statement, however he stated he palpated and inspected the rectal area for visible hard stool. Due to inconsistency in his statements, Staff A was terminated. Review of the resident's bowel record showed Resident #1 had a bowel movement on 11/20/19, 11/21/19 and 11/22/19. Review of the resident's November Medication Administration Record, [REDACTED]. Review of the emergency room report dated 11/22/19, revealed the resident reported facility staff attempted to disimpact her which was very uncomfortable. Review of the current hospital history and physical, revealed abdominal computerized tomography (CT) scan showed no evidence of constipation or obstruction. Review of hospital case manager assessment dated [DATE], showed the resident described her experience at the facility of an unsuccessful disimpaction as traumatizing. Notes revealed the resident expressed a strong desire to not discharge back to the facility or to any other skilled nursing facility. In an interview on 12/04/19 at 1:30 PM, Staff E, Registered Nurse was asked what she would do if a resident complained of constipation. She stated she would follow the house bowel program orders. If no results, she stated she would call the resident's physician for further orders. She stated she would never do a rectal examination or attempt a disimpaction without a physician's orders [REDACTED].>In an interview on 12/04/19 at 1:40 PM, the Director of Nursing Services and Administrator stated the facility did not have a policy for digital rectal examination or removal of fecal impaction. They stated these procedures were not to be completed by Licensed Nurses without a physician order. In an interview on 12/04/19 at 2:45 PM, Staff F, LPN, stated she followed the house bowel program for residents with constipation. She stated if no results, she would complete a thorough assessment and contact the physician for further orders. In a telephone interview on 12/04/19 at 3:00 PM, Staff A stated on 11/22/19 he responded to Resident #1s call light and assisted the resident to the bathroom. He said the resident told him it was her third unsuccessful try to have a bowel movement in the past hour. Staff A stated the resident's bowel tones were hypoactive (abnormally inactive), her abdomen was distended, and she complained of stomach pain. He stated he asked if while she was sitting, he could palpate her rectum for any hard stool and she consented. He stated he palpated and felt no stool. Contrary to his initial interview with the Administrator and DNS, and contrary to the resident's statement, he denied having done a digital rectal examination or attempted to disimpact. In a telephone interview on 12/04/19 at 3:20 PM, Staff AA, Anonymous Hospital employee, stated he spoke with the resident after she was admitted to the hospital and she described a disimpaction attempt by a male staff member at the facility. Staff AA stated the resident told him that the nurse (at the nursing home) inserted his finger into her rectum which caused pain and caused her to bleed. He stated she was very upset. On 12/04/19 at 3:50 PM, Staff B stated he was Resident #1's nurse on the date she was sent to the hospital. He stated Staff A was the Resident Care Manager from upstairs and came to help out. He stated Staff A said he was going to disimpact the resident but upon digital examination he found no stool. Staff B stated had it been up to him, he would have waited 3-4 hours to see if the MOM worked, and if it did not he would have administered the suppository per the house bowel protocol. He stated if the suppository had been ineffective he would have given the fleets enema as ordered. He stated he assessed Resident #1, noted absence of bowel tones and abdominal distention, and she requested to go to the hospital. He stated he notified the provider and sent her to the emergency room . Staff B stated he would absolutely not have performed a digital examination or attempted to disimpact the resident. In a telephone interview on 12/05/19 at 11:10 AM, Resident #1 was alert and stated she recalled the events of 11/22/19. She stated she had complained of constipation and stated she was unsure of the nurse's name but stated he was a nurse manager (identified as Staff A) came to help her. She said she told Staff A she was in terrible discomfort and felt constipated. She stated when she asked for help, she did not realize what he was going to do. She said he inserted what felt like 2 fingers into her rectum very hard, and did not stop, and kept pushing even when she cried for him to stop. She stated his touch was not gentle, and she does not believe any lubrication was used. She said Staff A finally stopped and said he had not evacuated (removed) any stool. She stated she had some bleeding down her leg. She stated she did not think he had tried to be abusive, but he was not gentle. She stated This could have been very dangerous; I still feel traumatized. I absolutely refuse to ever go to any nursing home again! Reference: (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure one of three residents (#5) reviewed for abuse/neglect/mistreatment remained free from verbal abuse by a staff member. The facility's failure to not use verbal abuse with a resident placed the resident at risk for fear, shame, intimidation, and for not expressing her needs and preferences. Findings included . Resident #5 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Annual Minimum Data Set assessment dated [DATE], showed she had moderate cognitive impairment and required extensive assistance with activities of daily living (bed mobility, transfers, toileting, bathing, locomotion, dressing). Review of a facility investigation dated 08/27/19 showed Staff A, Nursing Assistant (NA), had witnessed Staff B, NA, verbally abuse Resident #5. The facility substantiated verbal abuse and terminated Staff B. Review of a statement dated 08/27/19 and signed by Staff A showed on 08/26/19, Staff B told her she was tired of Resident #5 always complaining about her. Staff A stated on 08/27/19, Staff B asked her to go to Resident #5's room with her to talk. Staff A stated she thought Staff B was going to apologize to the resident, however when they got to the resident's room, Staff B started verbally attacking the resident about the complaints she had lodged against her. Staff A stated she tried repeatedly to get Staff B to stop. Review of an Employee Performance Review dated 08/14/19, showed Staff B was given a final notice, for violation of company policy regarding treatment of [REDACTED].#5 appropriately and her behavior had not improved after several verbal warnings. On 09/17/19 at approximately 2:00 PM, Resident #5 stated when Staff A and B came to her room a few weeks ago, she was told Staff B was going to apologize to her, but stated she had not apologized at all. She said Staff B yelled at her and told her she was mean and a racist and asked how could she live with herself. She said she was half asleep at the time and at first was not sure what was going on and was shocked. She said it was clear Staff B was not happy with her. She stated she understood Staff B no longer worked at the facility and said she felt very relieved. When asked how she was doing, she stated she liked to get along with everyone, but said she would be fine. On 09/17/19 at 4:45 PM, the Director of Nursing Services acknowledged Staff B had verbally abused Resident #5. In a telephone interview on 09/18/19 at 3:15 PM, Staff A stated on 08/27/19, she observed Staff B, yell at Resident #5. She stated Staff B yelled at the resident about why she had complained about her, called her a bully and a racist, and asked her if she felt peaceful in her life with the way she treated people. Staff A stated she tried repeatedly to get Staff B to stop but she continued to yell mean things at Resident #5. She said she finally had to physically push Staff B out of the room. Staff A stated Resident #5 was very quiet and looked shocked and helpless. Reference: (WAC) 388-97-0640 (1)(3)(a)

Based on interview and record review the facility failed to ensure each resident was free from abuse for one of eight residents (#1) reviewed for abuse. This failure resulted in harm to Resident #1 who experienced psychosocial distress and skin abrasions as the result of care from a staff member. Findings included . Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was alert and oriented. Additionally, the resident was frequently incontinent of bowel and bladder and required extensive assist with toileting. Review of facility investigation initiated on 04/17/19, revealed Resident #1 reported she received rough peri care by Staff A, Nursing Assistant (NA) on 04/17/19 resulting in discomfort and bleeding. Resident #1 stated when she had asked Staff A to be more gentle with the wash cloths because it was hurting her, Staff A did not verbally respond and continued to be rough. Per the investigation summary, the facility was unable to determine abuse/neglect due to Staff A's statement that she cared for the resident appropriately. The NA was terminated due to Resident #1 statement that she did not feel safe with Staff A in the facility. Review of a statement dated 04/17/19 and signed by Staff B, NA, showed while providing peri care on 4/17/19 Resident #1 informed her of rough peri care provided by Staff A in spite of the resident repeatedly telling Staff A she (Staff A) was hurting her. Staff B documented she observed torn skin around the resident's anus which was swollen, bleeding, and tender to touch. Staff B's statement revealed the skin issues were not present prior to this date. Review of progress note dated 04/18/17, late entry for 04/17/19, signed by Staff F, Registered Nurse/Resident Care Manager, showed she assessed the residents' bottom and observed four small abraded areas on the residents' inner right butt cheek. Review of the the residents record revealed no evidence the abrasions on Resident #1's inner right butt cheek were present prior to 04/17/19. In an interview on 04/26/19 at 10:55 AM, Resident #1 stated Staff A had provided very rough incontinent care to her on 4/17/19. The resident stated she had diarrhea and Staff A washed her very roughly with washcloths. The resident stated when she asked Staff A to not be so rough, she continued as she had been and did not respond to her. Resident #1 said the care caused cuts on her bottom and vaginal area which bled and stung. Resident #1 stated she felt unsafe with Staff #1 and felt she did not like her job. On 04/29/19 at 3:30 PM, an anonymous staff member stated she had worked with Staff A and said she had observed her to tend to be rough with providing care to residents. Reference: (WAC) 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure that residents were free from significant medication error for 1 of 2 residents (27) observed during medication administration observation. The facility failed to ensure that licensed nurses (staff A and staff B) observed during medication administration understood and followed nursing professional standards for safe and accurate administration of medications. Staff A administered medications to Resident 27 without verifying the medication order/ physician orders, and Staff B had to be stopped by the surveyor to avoid administration of the wrong dose of insulin to the resident. These failed practices resulted in an Immediate Jeopardy on 02/02/18 related to significant medication errors. In addition, the facility failed to ensure that 1 of 3 residents (10) reviewed for medication errors receive the correct dose of medication as ordered by the physician in a timely manner resulted in harm, and negative effect to the resident mood and overall health status. Findings included: According to Lippincott Drug Guide for Nurses 2017, there are 7 rights of medication administration for keeping resident safe. Medication safety can be managed by consistently using the seven rights of drug administration: right drug, right route, right dose, right time, right patient, right response, and right documentation. Resident 27 Resident 27 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) Assessment, dated 12/08/17, identified the resident as having intact cognition, and able to make her needs known to staff and others. During an observation on 02/02/18 05:03 AM, Staff A, Licensed Practical Nurse (LPN), was observed preparing medications in the med cart. Staff A took 3 tablets of pills out of the cart from 2 different medication/bingo cards, and a medication bottle and placed them in a small medicine cup. During this time, the medication cart computer screen was off and the top screen was closed/folded down. There was no other documents or records observed on top of the med cart to reference and verify what medications were being given, and to whom the medications would be administered to. Staff A proceeded to Resident 27's room and gave the medications in the cup. In an interview with Staff A at approximately 5:10 AM, Staff A was asked to whom he administered the medications he just delivered. Staff A stated, It was for room [ROOM NUMBER], Resident 16. When asked what medications were administered, staff A was not able to answer but stated he could look in the computer to verify. Staff A turned the computer on and logged in to PCC (Point Click Care) the facility electronic medical record software. After reading the MAR (Medication Administration Record), Staff A stated, I'm sorry I gave the meds to Resident 27 not to Resident 16). Staff A stated that he gave Resident 27 [MEDICATION NAME] 112mcg tablet ([MEDICAL CONDITION] medication), [MEDICATION NAME] 150mg tablet (stomach acid reducer), and Vitamin B12 500mcg (supplement). In a review of Resident 27 physician orders [REDACTED]. During the second medication administration observation at 5:15 AM, Staff A, started the medication preparation by opening the computer in the cart, and verifying the physician orders [REDACTED]. Staff A proceeded with the medication pass, and documented the medication administered in PCC. In a follow-up interview with Staff A at approximately 5:30 AM, Staff A was asked about the medication administration process of the facility. Staff A stated, 5 rights, right? You verify the patient, the name of the drug, the time, the dose and frequency. Staff A further stated, I do it 3 times to make sure. Staff A was asked if he followed this process when he administered the medications for Resident 27. Staff A stated that he did not followed this process because sometimes the computer in the cart did not work. Staff A added, I know the residents by heart. When asked if this practice was acceptable, Staff A stated, No. I made a mistake. During the third medication administration observation with Resident 27, Staff B, LPN at 6:56 AM, Staff B took Resident 27's blood sugar for monitoring. Resident 27's blood sugar reading was 179. Staff B entered the resident blood sugar in PCC, verified the physician orders, and prepared/administered the short acting insulin (Humalog [MEDICATION NAME]) per sliding scale order (dose per blood sugar). At 7:14 AM, Staff B reviewed the physician orders [REDACTED]. Staff B calibrated the insulin pen at 15 units. The Surveyor asked staff B if he was sure that the insulin pen was accurately calibrated at 14 units as ordered. Staff B relooked at the insulin pen and stated, Yes, this is 14 units. Staff B prepared the resident's skin with alcohol swab and informed Resident 27 that he was about to administer her long acting insulin. The surveyor asked Staff B to once again verify the insulin pen calibration and the dose prior to administration. Staff B stated, Yes it is 14 units. When Staff B was about to administer the insulin, the surveyor intervened and requested to have staff B step out of the room for a minute before administering the insulin. Staff B and the surveyor consulted another staff member in the unit to verify the dose. Staff C, MDS coordinator/LPN, looked at the insulin pen and verified the dose currently calibrated to the pen. Staff C stated that the insulin pen was calibrated at 15 units instead of 14 units as ordered. Staff B apologized and told the surveyor, I'm sorry. I thought it was 14 units. Thank you so much. I almost administer the wrong dose. Thank you for stopping me and letting me know. During a joint meeting with the facility Administration, Regional Operations Manager, Regional Nurse Consultant and Director of Nursing Services (DNS) at 8:27 AM, they were informed about the medication administration findings and safety concerns. The facility administration stated they would immediately educate and provide in-services/training to all nurses specifically to Staff A and Staff B to address the safety concerns. Resident 10 Resident 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In a review of the resident most recent significant change MDS assessment dated [DATE] showed the resident having intact cognition, and being able to make her needs known. In a review of the facility Medication Error Log for December 2017 on 02/02/18 at 3:00 PM, revealed the resident was involved in a facility medication error report dated 12/14/17 related to medication omission. In a review of the facility medication error investigation report dated 12/16/17, revealed the resident did not received [MEDICATION NAME] 2mg (anti-anxiety medication) tablet twice per day for 2 days. Incident report showed, Gradual dose reduction of 5mg [MEDICATION NAME] for resident's [MEDICAL CONDITION] was changed on 12/13/17 to 2mg yet did not receive through 12/15/17. Considering that the medication was not available by the pharmacy until resident spoke to and alerted MD that she was feeling more dizzy than usual during facility visit. The investigation report summary dated 12/21/17 showed the resident had been on this medication regimen since 3/31/17. Investigation summary further stated, Given that the resident did not receive her [MEDICATION NAME] for her [MEDICAL CONDITION] for the last 3 days with her complaints of dizziness being expressed as at a worsening level, Staff D (Medical Doctor) had reinstated the previous 5mg dose BID. In a review of the resident progress notes dated 12/14/17, documented, Unable to give [MEDICATION NAME] 2mg this evening (as new order) due to we do not have in E-kit, pharmacy called/faxed the order and requested to pharmacy to send as soon as possible, made aware to resident and ARNP. Subsequent nurses and progress notes did not show any evidence that the resident mood, [MEDICAL CONDITION], or dizziness were monitored. In a review of the resident care plan from December 2017 to January 2018, showed no evidence that the resident missed medications were either identified or addressed in the plan of care. In an interview with the resident on 02/05/18 at approximately 10:00 AM, the resident was not able to recall the details of what happened with her medications last December. The resident stated, All I can remember, I was very sick and dizzy at that time, and I wasn't able to function and even stand up or sleep. I don't know, it's been awhile. Resident further stated, she was very dependent to this medication ([MEDICATION NAME]) for her [MEDICAL CONDITION] and any change or missed dose can really affect her health. In an interview with Staff D on 02/05/18 at 2:20 PM, Stated, I found this med error and immediately contacted the previous DNS to report my findings. Staff D further stated that he received reports that the resident had increased/worsening [MEDICAL CONDITION] related to the sudden medication change. Staff D reported that he visited and did an evaluation to the resident to address this concern. In a review of the Physician/ARNP note dated 12/15/17 showed the resident was evaluated by staff D and the order for [MEDICATION NAME] was reinstated. Refer to F610 - Investigate/prevent/correct Alleged Violation for more information related to inaccurate and incomplete investigations. Reference: WAC 388-97-1060 (k)(iii) -1300(1)(b)(ii)(3)(a)(4)(a)(i)

Based on observation, interview and record review, the facility failed to comprehensively assess and revise interventions as needed to prevent significant weight loss for 1 of 2 sampled residents (25) reviewed for nutritional status and weight loss. This failure caused harm, and placed the residents at significant risk for decline in nutritional status and related complications. Resident 25 was admitted to the facility in August 2017. [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) assessment, dated 12/01/17, showed the resident needed 1 person assistance from staff with bed mobility, transfers, and set up help with eating. In a review of the resident care plan dated August 2017, showed the resident had limited physical mobility related to weakness and neuromuscular disease. Resident was identified to be at risk for potential nutritional problems, with Interventions to include: Monitor weights per protocol, RD (Registered Dietician) to evaluate and make diet recommendations PRN (as needed), and to provide, serve diet as ordered. Monitor intake and record every meal. In a review of the resident's Weight Summary showed the following weights: 08/26/17: (admission) 129.8 pounds (lbs.) 12/01/17: 134.8 lbs. 12/19/17: 132.8 lbs. 12/27/17: 131.0 lbs. 01/02/18: 130.0 lbs. 01/14/18: 131.4 lbs. 01/19/18: 123.2 lbs. 01/29/18: 126.0 lbs. 02/05/18: 118.8 lbs. The resident weight on 12/01/17 was 134.8 lbs. The resident weight on 01/19/18 was 123.2 lbs. A loss of 11.6 lbs. in 50 days, an 8.61% loss of body weight. The resident's weight continued to decline. The weight on 02/05/18 was 118.8 lbs. which totaled a significant weight loss of 16.0 lbs. from 12/01/17 to 02/05/18, an 11.87% loss of body weight. In a review of the Nursing Assessment Admission Profile completed on 08/25/17, showed the resident had mild tooth deformity, and that a dental referral was needed. In a review of the resident's clinical records on 02/01/18 at 2:37 PM showed no dental consultation was made or attempted since admission. There was no dental care plan initiated, and no information in the resident's clinical records found on whether the resident was seen by dentist or not. In an interview with Staff H, Social Services Director at approximately 3:00 PM, Staff H was asked if the resident had been referred to the dentist. Staff H stated, she was not aware of any dental consultations. Staff H further stated, I just started on this role, so I don't know but I can follow-up. In a review of the dietary assessment/Nutrition at Risk Review, dated 12/07/17 completed by Staff G, Registered Dietician (RD) stated, The resident is at nutrition risk r/t (related to) advanced age, mechanically alt (altered) diet, dysphagia dx (diagnosis), [MEDICAL CONDITION], depression. In a review of the Physician/ARNP (Advanced Registered Nurse Practitioner), / PA (Physician Assistant) Note dated 12/25/17 stated, I am asked to see this patient for follow up of altered mental status. He apparently was difficult to arouse this morning but apparently was not sleeping well per Nursing. In a review of the Physician/ARNP/PA Note dated 01/02/18 showed the resident was seen by the ARNP and reported problem with nausea, and had abdominal fullness but denied constipation. The note stated, When I go to see him he says that he has abdominal fullness but he does not feel constipated. He says his last bowel movement was Saturday. An abdominal x-ray was ordered during the visit and showed mild constipation. In a review of the Nursing Progress Notes dated 01/09/18 stated, LN (Licensed Nurse) reported res (resident) needs to have enema related to distended abdomen per ARNP order. The note indicated that the resident refused the enema, and took the routine Senna 3 tablets (stool softener) instead. In a review of the Nursing Progress Notes dated 01/10/18 showed the resident had an episode of altered mental status while being visited by his family. A follow up note dated 01/11/18 showed that the resident altered mental status had unclear etiology, labs (laboratory) are unremarkable. In a review of meal monitors from 01/07/18 to 02/04/18, showed the resident was consuming approximately 25-75% of meals, with meal consumptions averaging 50-80%. The resident had 11 days total of consuming less than 50% of his meals. Review of the supplement offered from the dates above showed no substitute meals or snacks were provided and documented in the resident's clinical records. In a review of the resident fluid intake within the same time frame showed the resident consumed less than 1000mL for at least 22 days in the past 30 days. There was no evidence that the resident received any other fluids/hydration documented in the resident clinical records. In an interview with the resident on 01/30/18 at 2:11 PM, the resident stated he had gum and teeth problems, and it bothers him. The resident stated, he has pain on his gum at the left side. In an interview with Staff B, Licensed Practical Nurse (LPN) at 2:30 PM, stated, the resident had no dental concerns or problems. Staff B further stated, I am not aware of any dental problem for Resident 25. During an observation on 01/31/18 at 8:37 AM, the resident was eating alone in his room. The resident was observed having difficulty eating independently, and was chewing food to right side of his mouth. In a follow-up interview with the resident during the observation, the resident stated, tooth pain while pointing to the left side of his mouth. The resident had cracked and dry lips, with very dry oral mucosa, sunken eyes and very dry skin. During an observation on 02/01/18 at around 12:30 PM, the resident was having lunch in his room alone. The resident was struggling to hold the cup and put the food in his mouth because of mild tremors on his upper extremities. In an interview with the resident during the observation, the resident was asked, If he needed some help to eat? The resident stated, No. Pain, gum pain. The resident was asked if his gum was bothering him, and the resident responded, Yes. In a joint interview with Staff B and Staff I, LPN at around 2:30 PM, both staff were asked if they were aware of any gum, or dental problems for the resident. Both staff denied any pain concerns, food intake problems, or weight concerns for the resident. In a review of the resident Physician orders [REDACTED]. Pain monitoring on the MAR indicated [REDACTED]. In a review of the resident most MDS dated [DATE], showed the resident had no obvious or likely cavity/broken natural teeth and no other dental problem was assessed. In an observation at 11:15 AM, Staff C assessed the resident's oral cavity. The resident opened his mouth wide and the surveyor was able to observe a cracked/broken molar to the lower left side of the resident mouth, including a poor oral condition with white and gray matter in between the teeth. Staff C was asked if she observed any concerns to the resident oral cavity, and Staff C responded, I do not see any oral concerns at all. In a joint interview with the DNS (Director of Nursing) and RCM at 11:37 AM, both staff denied any knowledge of the resident weight loss, and tooth/dental concerns. In a phone interview with Staff G at 1:30 PM, stated, she was aware of the resident nutritional concerns and weight loss. According to Staff G, she had reviewed the resident weight change together with the previous RCM's and that a Nutrition at Risk Note was completed. Staff G stated, I believe we put the resident on weekly weights to monitor his weight. Staff G was asked if there were any other interventions put in place to address the resident's weight loss, Staff G stated, No interventions or supplement was added since we are still monitoring the accuracy of the weight. Staff G further stated she was not aware of the resident's recent poor oral and fluid intake but would make sure to follow-up on the next visit. In a review of the Nutrition at Risk Note completed by Staff G on 1/25/18, stated, Reviewed wt (weight) pattern w/ (with) IDT (Interdisciplinary Team). Slight wt loss noted between 1/14 and 1/22, w/ 1/19 wt ?'d (questioned) for accuracy. Res (resident) w/ recent med changes and therapy orders now in place. Med changes could possibly alter weight or intake. Will CTM (continue to monitor) intake and weigh weekly or as able. Will continue to encourage good intake. RD/IDT prn (as needed). In an interview with Staff D, Medical Doctor at 2:20 PM, stated, he assessed and saw the resident today. Staff D added, I assessed his oral cavity and teeth today. I saw a cracked molar but he denied pain. Staff D was asked if he was aware of the resident weight loss, staff D responded, No. I was only notified about his weight loss today. Staff D was asked if monitoring weight on a weekly basis was sufficient to address a resident weight loss, Staff D stated, No. We could have added additional interventions. In an interview with the facility ARNP on 02/06/18 at 9:40 AM, stated, I was not aware of the resident recent weight loss, and I was notified until today. In a follow-up review of the resident clinical records on 02/07/18 at 9:29 AM, there was no documentation found whether the resident or his responsible party were notified of the resident's recent weight loss and nutrition decline. The resident most recent laboratory values completed on 02/06/18 at 1350 showed an elevated BUN (Blood Urea Nitrogen) that can be an indicator/sign of dehydration. There were no other interventions available in the resident entire clinical record during this review, and the resident's nutrition care plan was still not updated. In an interview with Staff H at 9:49 AM, Staff H was asked if the resident's son was aware of the resident's recent nutritional decline, broken tooth, and if any refusal to seek a consultation was documented in the resident's clinical record, Staff H stated, No. Staff H was asked if there was any attempt made to offer or discuss the dental visit to the resident, Staff H responded, No. We always talk to his son. The last documented weight in the clinical record dated 02/05/18 was 118.8 lbs. There were no further documentation in the clinical record to follow up on the resident's concerns of weight loss. The resident continued to lose weight, and there was no documentation in the clinical records that a thorough assessment, consultations, or follow-up were made to address and rule out the root cause of the resident's continued decline in nutritional status, poor oral and fluid intake, and dental/pain concerns. Further review of the resident medical records showed no further interventions or documentation in the clinical record that any additional noninvasive/ non-aggressive nutritional interventions were either discussed and/or attempted for the resident. There was no clear documentation that the resident was on either comfort/palliative care, and/or hospice and what was the goal of care and treatment. There was no evidence that the resident's wishes were considered or honored when developing his plan of care, and when making decisions on a day-to-day basis. Reference WAC: 388-97-1000 (1)(b)(2)(k) - 1060 (3)(h)

Based on observation, interview, and record review, the facility failed to ensure 3 of 4 residents (25, 16, and 51) received appropriate care and services necessary to maintain and avoid loss of bowel and bladder functions. This failed practice caused harm to Residents 25 and 16. Resident 25's bowel and bladder function declined from always continent to incontinent resulting in diminished quality of life, feelings of frustrations, embarrassment and humiliation. Resident 16's bowel and bladder program was care planned but not implemented accordingly per the plan of care resulting in feelings of embarrassment, humuliation and diminished quality of life. Findings included: RESIDENT 25 Resident 25 was admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. In a review of the resident's admission assessment profile dated 08/25/17, the facility identified the resident as continent of bowel and bladder. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident's urinary continence as occasionally incontinent, and bowel continence as continent. The resident was identified needing 1 person assistance from staff for bed mobility, transfers and toileting. The MDS also showed the resident was not on a toileting program, and no trial of toileting program had been attempted since admission or since urinary incontinence was noted in the facility. In a review of the Bladder Incontinence Evaluation dated 09/23/17, identified the resident to have urge incontinence, overflow and functional incontinence. Complications of Incontinence included falls, and sleep disturbance. Incontinent management included, Continue with current P(NAME) (plan of care), check and change and answer call light when resident calls for assistance. In a review of the Physician order [REDACTED]. In a review of the facility incident report log from November 2017 to January 2018 showed the resident had a total of 6 falls during this time frame. The resident's most recent falls dated, 01/24/18, 01/23/18, and 01/21/18 were all related to the resident's incontinence, and attempts to use the bathroom without staff assistance. In a review of the facility's most recent Bladder Incontinence Determination dated 10/12/17, identified the resident to have urge incontinence, overflow and functional incontinence. Summary notes stated, Resident has mixed incontinence. In a review of the most recent Bladder Incontinence Evaluation dated 12/18/17, showed the resident was incontinent of bladder and the recommended incontinent management plan included Prompted voiding: candidates are aware of urge to void, occasionally or frequently incontinent and limited to extensive assist with toileting. In a review of the Urinary and Continence and toilet use documentations from 01/03/18 to 02/01/18 showed the resident was documented to be incontinent of urine for at least 18 days during the time frame. In a review of the Bowel Movements and Continence documentations from 01/03/18 to 02/01/18 showed the resident was documented to be incontinent of bowel for at least 6 days during the time frame. In a review of the Bowel Care Plan initiated on 09/23/17 showed the resident has potential for bowel incontinence related to weakness. Interventions included: a. Check resident every two hours and assist with toileting as needed, observed pattern of incontinence. b. Observe pattern of incontinence, and initiate toileting schedule if indicated. c. Provide Bedpan/Bedside commode. d. Provide loose fitting, easy to remove clothing. e. Provide Peri-care after each incontinent episode. f. See care plans on Mobility, ADL's (activities of daily living), Cognitive Deficit, and Communication. All interventions were initiated and developed on 09/23/17. No goals or revisions were made to reflect the most recent bowel incontinent episodes, and no trial of toileting program has been attempted since bowel incontinence was noted/identified. Record review of the Mobility, ADL's, Cognitive Deficit, and Communication plan of care showed no interventions to address/manage the resident's bowel incontinence. In a review of the Bladder Incontinence Care Plan initiated on 09/23/17 showed the resident had mixed bladder incontinence related to confusion, impaired mobility and physical limitations. Interventions included: a. Clean Peri-area with each incontinence episode. b. Encourage fluids during the day to promote prompted voiding responses. c. Ensure the resident has unobstructed path to the bathroom. d. Monitor and document intake and output as per facility policy. e. Report signs and symptoms of UTI to Medical Doctor. All interventions were initiated and developed on 09/23/17. No goals or revisions were made to reflect the most recent bowel incontinent episodes, and no trial of toileting program had been attempted since bladder incontinence was noted/identified. In an interview with the resident on 01/30/18 at 2:29 PM, the resident was asked, Are you incontinent? The resident responded, No. A follow-up question was asked, Do you know why you are incontinent? and What is the facility doing to try and help you become more continent? The resident stated, I poo and pee in bed. The resident further stated, that no one will come to help him, he cannot get help and when he stands up, he got dizzy. The resident stated he can still feel the urge to urinate but he cannot get help. The resident smelled of urine during the interview. The resident was asked if he needed to be changed, the resident stated, Yes. I pee in my brief. The resident was tearful during the interview. The surveyor asked if he was ok, and the resident stated, Feel bad, embarrassed. During an observation on 01/31/18 at 8:37 AM, the resident was observed eating alone in his room. The resident was struggling to eat his breakfast due to some mild hand tremors. The call light was not within resident reach. The resident smelled of urine. During an observation at 10:05 AM, the resident was still sitting on his wheelchair. The resident was asleep, and the call light was not within reach. During an observation at 3:23 PM, the resident was observed sleeping in his room, with TV on. The room drapes were closed. The resident had incontinent smell of urine which can be smelled for at least 3-5 feet away. During an observation on 02/01/18 at 8:31 AM, the resident was visited in his room. The call light was on the floor, not within the resident reach. The resident had incontinent smell of urine while in bed. In an interview with Staff T, Nursing Assistant Certified (NAC), at 8:48 AM, Staff T was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff T stated, He is not on a toileting program. I am not sure. He can tell you that he needs to go the bathroom. During an interview at 9:00 AM, a urine odor was present during this interview. The resident was asked if he was wet, and the resident stated yes. In an interview with Staff X, NAC at 9:08 AM, Staff W was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff W stated, We toilet him in the morning. Staff X further stated, the resident was usually wet in the morning and the staff will change him. According to Staff X, the resident will use his call light if he needed to go to the bathroom. In an interview with Staff I, Licensed Practical Nurse (LPN), at 9:17 AM, Staff I was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff I stated that he believed the resident was continent. He calls for help, sometimes he does sometimes he doesn't and that is why he had multiple falls. Staff I further stated, He has incontinent episodes. Most of his falls are going to the bathroom. He is not on a toileting program that I am aware of. In a joint interview with Staff E, Director of Nursing (DON), and Staff F, Resident Care Manager (RCM), at 10:12 AM, Staff F stated, the resident was occasionally incontinent of bowel, and that the resident was on a check and change schedule. Staff E and Staff F were asked if they will consider a change and change schedule as a toileting program developed specifically to either maintain, improve or regain the resident's continence, stated, No. We wouldn't consider it as a toileting program. Staff F further stated, the facility had been trying to change the resident's medications, and that the resident can still feel the urge to urinate and have a bowel movement. In a follow-up interview with the resident at 10:45 AM, the resident was asked on how incontinence affected his mood, and his day to day activities. The resident stated, he felt humiliated every time this happened, and was tearful during the interview. The resident further stated, this was the reason why he goes to the bathroom alone but he was not strong enough, that was why he fell . In an interview with Staff Y, NAC at 2:23 PM, Staff Y was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff Y stated, the resident will use the call light sometimes, and sometimes not. The resident felt embarrassed if he's wet and he will feel bad about himself. Staff Y further stated, He fell so many times because he needs to go to the toilet, he will lose his balance. In an interview with Staff D, Medical Doctor (MD), on 02/05/18 at 2:20 PM, Staff D was asked if he was aware of the resident's incontinent problem and if any trial of toileting program had been attempted to address the resident's incontinence. Staff D stated, he was not aware of the incontinent problem. In an interview with Staff DD, Advanced Registered Nurse Practitioner (ARNP) on 02/06/18 at 9:53 AM, Staff DD was asked if she was aware of the resident's incontinent problem and if any trial of toileting program had been attempted to address the resident's incontinence. Staff DD stated, she was not aware of the resident's incontinent problem. In summary, there was no documentation the facility had identified, comprehensively and accurately assessed, or treated/addressed Resident 25's bladder and bowel incontinence which resulted to the resident's feeling of self-humiliation, sadness, and attempts to use the bathroom to avoid shame and embarrassment that a reasonable person will feel during a bowel/bladder accident. Resident 25's bowel and bladder incontinence issues were not accurately care planned, not person centered to identify the resident's strengths, goals and were missing interventions to address the root cause of the incontinent problem. There was no documentation in the medical record that the facility had attempted, initiated or considered a trial for bowel and bladder retraining to further improve or restore continence. In addition, there was no documentation in Resident 25's medical record from admission to 02/06/17 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to achieve or maintain as much normal bowel and bladder function as possible for Resident 25. Resident 16 Resident 16 was admitted to the facility in November 2016 with [DIAGNOSES REDACTED]. In a review of the admission Bowel Incontinence Evaluation dated 11/04/16, showed the resident was continent of bowel. In a review of the admission Bladder Incontinence Evaluation dated 11/04/16, showed the resident was frequently incontinent of bladder. In a review of the Minimum Data Set ((MDS) dated [DATE] indicated the resident had intact cognition, and able to communicate and make her needs known to staff and others. According to the MDS, the resident required one person assistance with most of her ADL's (Activities of Daily Living) to include ambulation, toileting, personal hygiene and transfer. Further review of the MDS showed the resident was incontinent of bowel and bladder, and was not on a toileting program, and no trial of toileting program had been attempted since admission or since urinary incontinence was noted in the facility. In a review of the most recent Bowel Incontinence Evaluation dated 12/19/17, showed the resident was frequently incontinent of bowel. In a review of the most recent Bladder Incontinence Evaluation dated 12/22/17, showed the resident was frequently incontinent of bladder. In a review of the resident current care plan initiated on 11/04/16 showed the resident was able to use the toilet independently, needs assist with hygiene after bowel movement at times, and was able to call for additional assistance when needed. The Bowel and Bladder plan of care showed the resident was on a prompted voiding schedule in the morning, before lunch, at approximately 3:00 PM, before evening meals and at bedtime. The Plan of care also showed that the resident was and on a scheduled check and change every 2 hours. The care plan was revised on 07/01/17. In an interview with the resident on 01/31/18 at 10:26 AM, the resident was asked, Are you incontinent? The resident responded, No. A follow-up question was asked, Do you know why you are incontinent? and What is the facility doing to try and help you become more continent? The resident stated, she can still feel the urge but she cannot get to the bathroom on time. The resident further stated, that she was not aware of any program to help her address this concerns. During the interview, the resident was observed to go to the bathroom independently without staff assistance. The resident stated sometimes she can do it alone, sometimes not. The resident was observed from the time of the interview will 12:30 PM. The resident received her lunch in her room. The resident was not toileted or offered to be toileted, nor have any staff asked if the resident was wet, or needed to go to the bathroom. During an observation on 02/01/18 at 8:31 AM, the resident was observed having breakfast in her bed. The resident was interviewed and asked if she was toileted or had been to the bathroom this morning. The resident stated, No. I haven't. In an interview with Staff T, NAC at 8:42 AM, Staff T was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff T stated, the resident was not on a toileting program, and the resident wears a pull-up. Staff T added, She does let you know when she needs to go the bathroom. She will be wet at times, but she preferred woman. In an interview with Staff V, Registered Nurse (RN) at 8:55 AM, Staff V was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff V stated, the resident was continent most of the time. She wears briefs for accidental dribbles. She knows when to call. She usually knows when to call for help. She is not on a toileting program. In an interview with Staff X, NAC at 9:04 AM, Staff X was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff X stated, She goes to the toilet by herself. She is not on a toileting program. In a joint interview with Staff E, DON, Staff F, RCM, and Staff EE (Interim DON/Regional Nurse) at 9:54 AM, Staff F was asked on what was the bowel and bladder assessment/care planning process of the facility. Staff F stated, the facility assessed the resident's bowel and bladder functions on admission, quarterly and if there was a change of condition. Staff F was asked if Resident 16 has any incontinent issues, and if the resident was on a toileting schedule/program. Staff F stated, Resident was occasionally incontinent and was on a prompted voiding schedule in the morning, before lunch and before evening meals. Staff F further stated, It is on her care plan and Kardex. Staff F was asked on how this toileting plan gets communicated to the floor staff. Staff F stated, They report it every end of shift and it should be on the Kardex. In a follow-up interview with Staff T, V and X at 1:46 PM, all 3 staff stated they were not aware of the toileting program for the resident and reiterated that the resident will take herself to the bathroom independently and will occasionally call for help and assistance if needed. In a follow-up interview with the resident at approximately 1:48 PM, the resident stated she needed help to the bathroom at times, and she was not on any schedule to take herself to the bathroom. The resident stated, It is embarrassing to get yourself wet so I take myself to the bathroom if I can. The resident added, This happened a few times, and I felt bad and sorry for myself. In an interview with Staff Y, NAC at 2:17 PM, Staff Y was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff Y stated, the resident is incontinent of bowel and bladder. Staff Y added, the resident will sometimes call for help, and sometimes not. Staff Y further stated, Sometimes it is too late by the time she get to the toilet, she is wet already. She is not on a toileting program. In an interview with Staff W, NAC on 02/02/18 at 6:16 AM, Staff W was asked on what were the toileting needs for the resident, and if the resident was on a toileting schedule or program. Staff W stated, She is incontinent. She is not on a toileting program. In a follow-up interview with the resident at 8:45 AM, the resident was asked on how incontinence affect her mood, and her day to day activities. The resident stated, she felt embarrassed every time this happened. The resident further stated, she do not want to have any accident especially with her husband around. It is embarrassing. In summary, there was no documentation the facility had comprehensively and accurately assessed, or treated/addressed Resident 16's bladder and bowel incontinence which resulted to the resident's feeling of self-humiliation and embarrassment. Resident 16's bowel and bladder incontinence issues were care planned, however it was not person centered to identify the residents strengths, goals and were missing interventions to address the root cause of the incontinent problem. There was no documentation in the medical record that the facility had implemented a trial for bowel and bladder retraining to further improve or restore continence. In addition, there was no documentation in Resident 16's medical record from admission to 02/06/17 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to achieve or maintain as much normal bowel and bladder function as possible for Resident 16. RESIDENT 51 Resident 51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, was extensive 2 person assist to toilet, was always incontinent of bowel and bladder and was not on a bowel or bladder toileting program. The MDS assessment dated [DATE] documented the resident was now cognitively intact, required extensive assistance 2 person assist to toilet and was always incontinent of bowel and bladder. The resident was not on a bowel or bladder toileting program. The physician's orders [REDACTED]. The Admission Profile dated 11/05/17 documented the resident had impaired mobility, was alert, had no obvious bladder or bowel problems, and used pads or briefs. The Admission Profile dated 01/07/18 documented the resident had cognitive and mobility impairments but was alert and orient x 4, was incontinent of bladder and bowel and used pads or briefs. The Bladder Incontinence Evaluation dated 11/05/17 documented the resident was always incontinent, had a history of [REDACTED]. The evaluation documented the resident was on diuretics and narcotics (water and pain medications) which could affect incontinence. The evaluation further documented the resident was alert but did not mark if she was aware of the urge to void. She required extensive assistance and hoyer lift to transfer and was on a check and change management plan. Check and change is appropriate for candidates that are not aware of the urge to void (urinate), always incontinent and dependent for toileting. The Bladder Incontinence Evaluation dated 01/07/18 documented again the resident was always incontinent but included no documentation of her history of incontinence. It marked the resident as both alert and oriented and confused. It further documented she was not aware of the urge to void and remained on a check and change incontinence management plan. The review of the Bowel Incontinence Evaluation dated 01/07/18 documented the same information as the above bladder evaluation. The resident had a history and was always incontinent of bowel, was alert and oriented and confused, and was not aware of the urge to evacuate. She was on a check and change bowel management program as she was not aware of the urge to evacuate. The Comprehensive Care Plan identified the resident had bowel/bladder incontinence due to activity intolerance, impaired mobility, and physical limitations which were initiated on 12/09/17. The interventions included: -Clean perineal area with each incontinence episode -Check and change every 2 hours and as required for incontinence -Monitor/document for signs/symptoms of bladder infection -Monitor/document/report as needed any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects The resident care plan did not reflect the results of the resident's assessment and include resident specific interventions for any potential reversible causes of the incontinence or incorporate resident specific interventions for the management of the incontinence. The NAC's Kardex of care directive documented resident care as follows: -Check every 2 hours as required for incontinence, wash rinse and dry perineum. Change clothing as needed -Total dependence x 2 for toileting; hoyer lift for transfer x 2 staff assist documented on page 3 of Kardex -Transfers documented on page 1 of Kardex as stand pivot with limited to extensive assistance with front wheeled walker to commode or bedside commode at HS (hours of sleep) The review of the urinary and bowel continence flow sheet for 01/09/18- 02/07/18 showed 5 episodes of urinary continence and 5 episodes of bowel continence. Further review of the clinical record showed no documentation that the history of her incontinence was investigated, possible causes of her ongoing incontinence or an evaluation of the incontinence management plan. In an interview on 01/31/18 at 10:37 AM the resident stated I know when I have to go, but the issue is I haven't been able to get up with the aides yet so I just go in the diaper. They offered a bedpan once but it didn't work too well so they just check me and change me if I'm wet or I'll call them and let them know I need to be changed. The therapists haven't let the aides transfer me without that lift due to safety. I have a commode, but not using that right now. It's funny, but after you go in the diaper for awhile you kind of forget about it. In an interview on 02/02/18 at 12:00 PM the resident stated the staff was starting to get her up to the bathroom now. In an interview on 02/05/18 at 9:54 AM, Staff P, NAC, stated yes, she knows when she has to go to the bathroom but therapy just started to let us get her up ourselves. Now we can get her to the bathroom. Before that she would just go in her brief or use a bedpan. In an interview on 02/05/18 at 10:39 AM, Staff BB, NAC stated I've worked with her since she got here. She was always incontinent of bowel and bladder when she first came here, she was really confused and wasn't able to tell us. Now, since she has become oriented she can let us know. She has been able to let us know when she has to go as soon as the confusion went away awhile back. Now therapy has cleared us to transfer her so now she is wearing regular panties during the day and we are getting her up to the bathroom. In an interview on 02/06/18 at 10:09 AM Staff L, Resident Care Manager, stated I see she is on a check and change program, at the very minimum they should be offering her a bedpan, not just letting her go in her brief. The staff should be prompting her to void. She shouldn't just be on a check and change program like this. Reference: (WAC) 388-97-1060 (2)(a)(iii) (3)(c)

Based on observation, interview and record review, the facility failed to comprehensively assess and monitor the need of physical restraints (wander guard) for 1 of 1 resident (16) reviewed for physical restraints. In addition, the facility failed to document ongoing re-evaluation for the need of the restraint, and to ensure least restrictive interventions were attempted prior to use of the restraint. This failed practice caused harm to resident in the form of: diminished quality of life, feelings of sadness, seclusion and imprisonment. Findings included: Resident 16 was admitted to the facility in November 2016 with [DIAGNOSES REDACTED]. In a review of the Minimum Data Set ((MDS) dated [DATE] indicated the resident had intact cognition, and able to communicate and make her needs known to staff and others. According to the MDS, the resident required one person assistance with most of her ADL's (Activities of Daily Living) to include ambulation, bed mobility and transfer. Further review of the MDS showed the resident reported of feeling bad about herself, and of feeling tired or having little energy. In a review of the analysis findings of the CAA (Care Area Assessment) Worksheet dated 11/30/17, showed an adverse reaction to restraint use were identified/marked, Depression, withdrawal, diminished dignity, social isolation, (I , I5900 from record). However, the care plan decision was marked as N/A (not applicable). In a review of the resident current care plan initiated on 11/04/16 showed the resident required 1 person assist with ambulation, and used a standard wheelchair for long distances. The care plan was revised on 07/01/17. The resident's wander guard care plan indicated that the resident used a wander guard as a safety device r/t (related to), history of verbalizing wishes to attempt to leave the facility. The care plan did not indicate any past alternatives used by the facility to address this concern, and no plan in place to reduce/remove the wander guard when no longer warranted. In a review of the resident's Elopement Assessment Review dated 02/16/17, showed the resident was not at risk for elopement. Subsequent Elopement Review dated 05/14/17, and 08/23/17 showed the resident was not at risk for elopement. The resident continued to use the wander guard despite not being an elopement risk. In a review of the Interdisciplinary Care Conference note dated 11/27/17 showed the resident did not participate in the meeting, and the physical restraints/wander guard use was not discussed or reviewed. In a review of the resident nurses progress notes dated October 2017 to December 2017 showed the resident had 1 episode of suicidal ideation dated 12/15/17. There was no follow-up documented in the clinical record on why the resident was suicidal, if the doctor or the responsible party were made aware of the situation, and what follow-up was made to address this sudden/unprovoked behavior and safety concern. In a review of the Enabler/Restraint Consent #1 form dated 12/18/17, showed the resident's daughter/power of attorney and not the resident consented the use of the wander guard for the possible benefits, Allows resident to recognize limitations. In an interview with the resident on 01/31/18 at 8:47 AM, the resident was asked, Describe any instances where staff made you feel afraid or humiliated/degraded? The resident responded, Yes. Look at this The resident showed her left wrist with a wander guard bracelet on to the surveyor. The resident was asked, What was the bracelet for and why she had one on? The resident stated, I had spell in the past. I got lost and forgot where I'm at. They use this to track me. The resident added, she does not like the bracelet as it causes her arm to itch, and she do not remember agreeing to have it on but they put it on her so she had no choice but to wear it. The resident was asked how she felt about wearing the bracelet, the resident responded, I feel trapped. I don't like it at all. In a follow up interview with the resident at 10:29 AM, the resident was asked, If the bracelet was restricting her ability to move freely in the facility, and if it affects her day to day activity. The resident stated, she does not feel the staff trust her, and she never had any instances of wandering in the past, I feel trapped here. In a review of the resident's behavior monitoring for November 2017, December 2017, and January 2018, showed no documented behavior of wandering, exit seeking or elopement. In an interview on 02/01/18 at 8:34 AM, Staff V, Registered Nurse was asked if she was aware of the resident exit seeing or wandering behavior. Staff V stated, No. She never wanders or exit seeks. Staff V was asked if she was aware of the reason why the resident had a wander guard on. Staff V stated that the resident's daughter and granddaughter were concerned that the resident may elope because she was confused at times. Staff V further stated, I don't think she was exit seeking. In an interview with Staff T, Nursing Assistant Certified at 8:42 AM, Staff T was asked if he was aware of the resident exit seeing or wandering behavior. Staff T stated, No she never wanders and she is mostly in her room. Never had she verbalized going home. Staff T further stated, I believe this is just a precaution. In an interview with Staff X, Nursing Assistant Certified at 9:01 AM, Staff X was asked if she was aware of the resident exit seeking or wandering behavior. Staff W stated, No. I only remember one episode she was confused. During a joint observation with another surveyor at 9:20 AM, the resident was observed taking herself to the bathroom. The resident stood up, looked at the surveyors while pointing her right index finger to the wander guard bracelet shaking her head. In a follow-up visit with the resident at 9:34 AM, the resident continued to verbalized she did not want the bracelet, and it bothered her, it was loose, and she needed to keep pulling it down her wrist. The resident stated that, I feel trapped in the building like a prisoner. The resident further stated, I feel like the staff here don't trust me. The resident was tearful during this conversation and it was witnessed by her husband, who lives with her in the same room. The resident husband stated, Please take that bracelet off. It was making her life miserable. These concern of the resident was shared with the facility management staff immediately per the resident and her husband request. In an interview with Staff Y, Nursing Assistant Certified at 2:19 PM, stated, I remember she got lost to a different room (She went to 215 instead of 217) which is one room apart. She never wandered and I am surprised a wander guard was put on. She is contact guard assist with walker so there is no way she can elope. In a follow-up interview with the resident at 3:30 PM, the resident stated, she was not allowed to leave the building without permission from the staff, and it was against her will to have it, and he feels trapped and imprisoned here. During the survey, there were multiple observations of the resident just in her room lying in bed. The resident was observed ambulating independently using her front wheel walker between her room and the bathroom. The resident used a manual wheelchair when outside the room, and would always be accompanied by her husband and a staff member. There were no observations of resident attempts to exit the building during the survey period. In an interview with Staff E, Director of Nursing at approximately 3:45 PM, Staff E stated she was not aware of the wander guard placement, and that they would immediately address this problem. Staff E further stated that if the resident's assessments showed and indicated that she did not need a wander guard, then they would definitely remove the bracelet. In an interview with Staff H, Social Services Director on 02/02/18 at 11:33 AM, Staff H was asked about the resident's depression and mood. Staff H stated, that the resident's assessments dated 08/10/17 and 11/13/17 indicated she had depression. Staff H was asked if she was aware of the resident wander guard and if there was any on-going interventions/monitoring to address the resident mood. Staff H stated, she was not aware that the resident had a wander guard and not aware of any specific interventions for the resident depression. In a review of the resident entire clinical record at 11:45 AM showed no mood and behavior plan of care to address the resident mood, history of suicidal ideation, and depression. Although the resident had an antidepressant care plan, the focus, goals and interventions were not resident specific, resident centered and did not include specific interventions on how to meet the resident needs. In a follow-up interview with the resident and her husband at approximately 12:33 PM, the resident stated she no longer had the bracelet. The resident stated, Thank you so much. I am free. In summary, the facility did not ensure that the resident was informed of the physical restraint prior to use and that a comprehensive assessment was completed to evaluate the need of the wander guard. There were no documented interventions or less restrictive alternatives attempted and shown to be ineffective prior to use of the wander guard. Additionally, the facility failed to monitor and document ongoing re-evaluation of the need for the restraint. Reference: (WAC) 388-97-0620 1(a)(b) 2(d) 3(b) 4(a)(b)(c)

Based on observation, interviews and record review, the facility failed to consistently assess and monitor 1 of 5 residents for a change of condition (1). Failure to assess Resident 1 in a timely manner and/or document assessments resulted in Resident 1's rapid medical deterioration resulting in emergent surgical procedure and hospitalization . Findings included: Fournier's gangrene (FG) is a rare but life threatening disease. FG has been shown to have a predilection for patients with diabetes. The development and progression of the gangrene (localized death of body tissue) can rapidly cause multiple organ failure and death. Because of potential complications, it is important to diagnose the disease process as early as possible. Although antibiotics and aggressive debridement (removal of damaged tissue) have been broadly accepted as the standard treatment, the death rate remains high. RESIDENT 1: Resident 1's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] showed she was alert and required assistance of one person for transfering and toileting. The record showed that Resident 1's blood sugar levels usually ran below 200. According to record review, Resident 1 had a perineal boil on 11/21/17. On 11/21/2017, the physician visited the resident and noted Resident 1 had a small perineal boil. The plan was to use warm compresses. The physician documented nursing was informed to monitor closely for change in vital signs and to monitor the perineal boil for any increase in size. The note showed that Resident 1 would be monitored clinically. During an interview on 12/27/17, Resident 1 was observed resting in bed. Resident 1 stated she was in bed because she now needed dressing/packing dressings since her emergency surgery. Resident 1 stated an area on her buttock started as a small area and then got enlarged. She stated she was sent to the hospital and required surgery due to the type of wound. Review of a nurse's progress note dated 11/22/17 (day shift) showed Resident 1 had refused her shower, and was just not up to having one. The progress note from the evening shift dated 11/22/17 showed Resident 1 remained in bed all shift. She did not have a temperature (98.3 F), she had a headache, ear ache, dry cough, and felt shivers. The Licensed Nurse (LN) encouraged fluids and rest. There was no documented progress notes from night shift regarding the vital signs or an assessment of the perineal boil. The next progress note dated 11/23/17 (day shift) showed the physician had been notified that Resident 1 was feeling awful and her temperature was from ranging from 99.6 to 101.2. Tylenol was administered, however her temperature would go back up. In addition, her blood sugar was higher than normal. There was no documentation evidence that LNs had assessed or informed the physician regarding whether the perineal boil had increased in size. A evening nursing progress note for 11/23/17 showed that tylenol was given for general pain and was effective. This note documented will continue to monitor but there was no documented evidence regarding assessment of the perineal area. Review of the nursing progress notes from 11/21/17 to 11/23/17 and the November 2017 Treatment Administration Record (TAR) revealed there was no documented evidence the perineal area had been assessed and/or monitored or that the application of warm compress to the site was done. On 11/24/17 at 11:07 AM, an alert note indicated Resident 1 felt awful all over. Her temperature was 100.8, blood pressure was 112/64 and a heart rate (pulse) was 98 beats per minutes, and blood sugar elevated (206). The LN assessed the perineal boil, and the area had enlarged greatly with the perianal area and labia being red and very hard. The physician was notified and ordered Resident 1 to be transferred for incision and drainage, and evaluation of the perineal boil. The hospital's emergency room (ER) report dated 11/24/17 showed Resident 1's temperature was 100.9, her blood pressure dropped to 94/80, and her pulse rate was high at 144 per minute. The perineal area was erythemic (red) on the labia and up along her perineum onto her right buttock with a small opening draining fluid. A CT scan showed necrotizing fascitis. The radiology report showed the impression was Fournier's gangrene. The ER note documented Resident 1 was critically ill and septic due to the gangrene. A surgical consult note dated 11/24/17 showed Resident 1 stated that she had felt cold for the last 3 days, and had experienced pain while sitting. She stated she was unable to see the painful area and asked caregiver(s) to look at the area and then was sent to the ER. During an interview with Resident 1 on 1/19/18 at 10:31 A.M., Resident 1 stated that staff did not look at the boil for several days. She stated only one LN had looked and checked the area. She stated that on the prior Tuesday, 11/21/17 the LN checked the area and then not until Friday, 11/24/17 the same LN looked at the boil site (perinea area) and informed her that the sore on her bottom had changed, it was much bigger. Resident 1 returned from the hospital on [DATE]. The physician documented Resident 1 developed soreness in groin on 11/21/17. Over course of few days time she developed fevers over 101, and a significant enlargement of her abscess area. She was sent to the ER for evaluation and the CT suggested the need for emergent surgery with debridement (removal of dead tissue) and a course of antibiotics. review of the resident's medical record revealed [REDACTED]. On 01/19/17 at 3:44 P.M., the Director of Nursing (DNS) stated the physician had assessed Resident 1 on 11/21/17 regarding the boil. The DNS stated there was no additional documentation by LNs regarding the assessment and monitoring of the area until 11/24/17, 4 days after the initial assessment. Reference: (WAC) 388-97-1060

Based on observation, interview and record review, the facility failed to ensure hot food was served at a safe temperature. Failure to ensure of a safe temperature resulted in harm for Resident 1 who sustained a burn. Findings included RESIDENT 1 Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that he required assistance with eating and oral hygiene and had moderate cognitive impairment. On 5/24/17 at 11:45 A.M., Resident 1 was observed in bed and wore a splint on his left hand. When asked about feeding himself, he stated not so good. He stated he had burnt his lips as the food was too hot. He stated the burn hurt really bad, I screamed in pain. The nursing progress note dated 5/2/17, documented the Licensed Nurse (LN) observed red bubbled burn to Resident 1's lower lip. The LN documented he stated that during breakfast yesterday (5/1/17) his assigned care giver was going too fast and the hot cereal burnt his lip and he had pain. Resident 1 stated his pain was a 5 on a scale of 1 to 10, 10 being the most severe pain. The LN documented area is red, with old blood, measuring 1.3 centimeter (cm) by 1.0 cm, with smaller blisters around surrounding lip area. The nursing note for 5/3/17 revealed Resident 1 remained on alert charting due to burnt lower lip. The note documented lip shows evidence of healing. The facility's investigative report dated 5/2/17 indicated Resident 1 sustained a burn. Resident 1 was assessed to have a reddened lip with skin peeled back appearing to be a second degree burn. The report included a written statement from the NAC indicating that she had set-up Resident 1's breakfast tray, and then fed other residents. The NAC documented that Resident 1 stated his cereal was still hot! so she put some milk in to cool it down. He's maybe hungry that why he feed too fast. A statement from evening shift LN on 5/1/17 stated Resident 1's lip was reddened. Review of the Weekly Steam Table Temperature Sheets in the facility' investigative report documented from April 16, 2017 to May 1, 2017 the recorded temperature for the hot cereal was recorded as being over 200 degrees. On May 1, 2017 the documented temperature was 201 degrees. During an interview on 5/24/17 at 12:00 p.m., with a restorative aide (RA), stated Resident 1 can feed himself but will wait for assistance if people are there. RA A stated he wears a splint on his left hand. She also stated it is hard for him to eat independently due to his abdominal girth and splint. During an interview and review of the Weekly Steam Table Temperature Sheets 5/24/17 with the day shift kitchen staff (Staff B), she stated the recorded temperatures for the hot cereal/oatmeal were only obtained while on the stove. Staff B stated no temperatures were taken prior to the hot cereal leaving the kitchen. Staff A stated since Resident 1's burn, a new policy and form has been initiated. During an interview on 5/24/17 at 11:05 a.m., the Director of Nursing (DNS) stated Resident 1's burn on his lip was from the oatmeal, the hot cereal was served at over 200 degrees. The DNS stated Resident 1 can feed himself and if food is placed in front of him, he will eat anything in front of him. The DNS stated following the incident with Resident 1, the facility changed their policy regarding tray line temperatures to avoid further burns. Reference: WAC 388-97-1060(1) (3) (g)

Based on observation, interview and record review the facility failed to maintain an effective Infection Control Program (ICP) that included monitoring and maintenance of blood glucose meters and staff practice in cleaning the meters to prevent cross contamination and spread of infection. The failed practice placed 20 of 23 sample residents (75, 69, 26, 39, 18, 44, 14, 43, 46, 101, 24, 57, 98, 22, 4, 99, 37, 42, 41 and 35), reviewed for blood glucose monitoring, as well as other residents, staff and visitors at risk for infectious disease. Immediate Jeopardy was determined on 12/15/16 related to the deficient practice. Findings include: Review of the facility's Disinfection of Resident Care Devices - Blood Glucose Meters policy dated 11/07/16, indicated the blood glucose meters may transmit pathogens if the device was not cleaned and disinfected between uses. The policy directed the Licensed Nurse (LN) to disinfect the meter between resident uses with Micro-Kill Germicidal Bleach wipes. The solution was to remain on the meter and air dry. Review of the Even Care G3 Blood Glucose Monitoring System user's guide revealed the meter should be cleaned and disinfected between each patient and allowed to air dry. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. On 12/14/16 at 4:40 PM, Staff V, LN, was observed to test Resident 75's blood glucose. Staff V washed his hands, put on a pair of gloves, pricked the resident's left ring finger and placed a drop of blood on the glucometer strip. After the blood glucose reading, Staff V removed the glucometer strip, removed his gloves and placed the meter in his pocket on the right hand side. At 4:45 PM, Staff V then washed his hands, went to the second medication cart on the first floor and placed the meter in the top drawer. Staff V then proceeded to document the resident's blood glucose reading in the electronic medical record. At 4:50 PM, Staff V stated the meters were cleaned daily on the night shift. Staff V stated there was a notebook at the LN station documenting the information. At 5:55 PM, the Director of Nursing Services (DNS) and Staff K, Regional Director of Clinical Operations, stated the facility had multi-use meters. The DNS stated the meters were cleaned after they were used with a specific micro-type wipe. The DNS stated the LN's were in-serviced on how to clean the meters in November. In an interview on 12/14/16 at 6:14 PM, Staff C, LN, stated he cleaned the meters with an [MEDICATION NAME] alcohol pad after each use. At 6:30 PM, the facility's medication carts were observed. There were two medication carts on the first floor and one medication cart on the second floor. Each medication cart had an Evencare G3 meter. There were only two LN's on duty who administered medications (one on each floor). RESIDENT RECORD REVIEW Resident 75's blood glucose was monitored three times a day before meals. Resident 69's blood glucose was monitored daily. Resident 69 had a [DIAGNOSES REDACTED]. Resident 26 blood glucose was monitored twice daily. Review of a lab report dated 01/14/16 revealed Resident 26 had possible hepatitis B. Resident 39 was a former resident who had his blood sugars monitored four times a day. Resident 39 had a [DIAGNOSES REDACTED]. Resident 24's blood glucose was monitored twice daily. Review of Resident 24's medical record revealed the resident had a [DIAGNOSES REDACTED]. Resident 18's blood glucose was monitored daily. Resident 44's blood glucose was monitored daily. Resident 14's blood glucose was monitored three times a day. Resident 43 received daily blood glucose monitoring. Prior to 12/06/16, Resident 43's blood glucose was monitored three times a week. Resident 46's blood glucose was monitored daily. Resident 101's blood glucose was monitored four times a day. Resident 57's blood glucose was monitored twice daily. Resident 98's blood glucose was monitored four times a day. Resident 22's blood glucose was monitored daily. Resident 4's blood glucose was monitored twice daily. Resident 99's blood glucose was monitored three times a week. Resident 37's blood glucose was monitored daily. Resident 42's blood glucose was monitored weekly. Resident 41's blood glucose was monitored three times a week. Review of Resident 35's blood glucose was monitored as needed. Prior to December 2016, Resident 35's blood glucose was monitored weekly. In an interview on 12/15/16 at 11:37 AM, the DNS stated the facility had recently received the new Evencare G3 meters. The DNS was not able to state when the new meters were implemented. The DNS stated no resident had their own meter. The facility had three meters, one on each cart that was used to check all resident's blood glucose. At 11:40 AM, the DNS and Staff K were made aware of the manufacturers recommendations that the meter should not be cleaned more than 10 times a day. In an observation and interview on 12/15/16 at 11:40 AM Staff YY, Licensed Nurse, cleaned a glucose meter with a EPA approved wipe and immediately proceeded to perform a finger stick blood glucose testing on Resident 44 in the hallway. Staff YY did not allow the meter to air dry before testing Resident 44's blood glucose. Staff YY stated, Just got new glucose monitors about a month ago. At 2:50 PM, Staff O, LN, stated she received in-service training about a month ago regarding how to check a resident's blood glucose and how to clean the meter. Staff O was not able to state who did the in-service. Staff O stated she cleaned the meter after each use. At 2:55 PM, Staff H, LN, stated she received in-service training one or two months ago regarding how to check a resident's blood glucose and how to clean the meter. At 3:05 PM, Staff C stated he had not received any in-service training regarding how to clean the meters. At 3:20 PM, the DNS stated about a month ago the facility had in-serviced all the LN's regarding how to check a resident's blood glucose and how to clean the meter. The DNS was not able to provide any documentation this was done. Review of the Blood Glucose Monitoring System Daily Quality Control Record revealed the meter identification was labeled as 1st cart and 2nd cart. The meter serial number was not identified. The facility failed to implement their own policy or follow the manufacturers recommendations regarding cleaning multi-use meters placing all 20 residents at risk for blood borne infection transmission. The two LN's on duty on 12/14/16 did not recognize how to properly clean the meters after use. The facility had three residents with known blood borne diseases. The posted 08/26/10 FDA Safety Alert on finger stick devices and point of care (POC) blood testing devises (e.g., blood glucose meters) recommendation: Finger stick devices should never be used for more than one person. POC blood testing devices should be used only on one patient and not shared. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. PERSONAL CARE Resident 34 was admitted to the facility with [DIAGNOSES REDACTED]. In an observation of personal care on 12/15/16 at 3:32 PM, Staff T, Nursing Assistant proceeded to provide care in a dirty to clean manner. Staff T cleaned the resident's rectum then proceeded to the resident's gluteal area and then to the resident's genitalia. Staff T continued providing care to the resident with the same pair of gloves and applied a barrier cream to the resident's perineal area. After Staff T applied the barrier cream, Staff T proceeded to contaminate multiple surfaces in the resident's room before removing the contaminated gloves and perform hand hygiene. Staff T failed to provide accepted standards of infection control practice for Resident 34. In an interview on 12/15/16 at 3:46 PM, Staff T confirmed inappropriate dirty to clean personal care for Resident 34. Review of the facility's nursing assistant meeting agenda form dated 09/13/16 revealed training was provided to the nursing assistants to work from clean to dirty. SECOND FLOOR SHOWER ROOM In an observation on 02/14/16 at 4:57 PM in the second floor shower room, the dirty linen bin was overflowing with multiple plastic bags with dirty linen directly on the floor. In an interview on 02/14/16 at 5:00 PM Staff N, NA stated, The dirty linen plastic bags probably should not be on the floor. OBSERVATION OF CLEAN LINEN CART On 12/15/16 at 12:55 PM Resident 40 was observed exiting her room with her 4-wheel walker. On the seat of the walker was a folded white linen sheet. Resident 40 approached the covered clean linen cart, which was parked in the hallway adjacent to her room, lifted the cover and placed the linen sheet from her walker seat on the stack of clean sheets in the linen cart. Resident 40 then proceeded back to her room.

Based on observation, interview and record review the facility failed to ensure residents of the facility remained free of significant errors in medication administration. The failed practice affected 1 of 8 (??) sample residents (49) whose medications were reviewed. Resident 49 was given a potassium medication by a Licensed Nurse (LN), who had been informed of a critically high potassium level prior to the time the medication was administered, resulting in harm to the resident. Immediated Jeopardy was determined on [DATE] at 5:04 PM. Findings include: Resident 49 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a lab slip dated [DATE], indicated Resident 49 had a critical potassium level. The potassium level was 6.8 (normal is 3.50 to 5.50). The lab documented Staff A, Licensed Nurse (LN), was called at 9:59 AM of the critical lab value. Review of physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Staff A administered the potassium after she received the critical lab results. At 3:13 PM, Staff Y, Advanced Registered Nurse Practitioner, stated she was not aware the resident had a critical potassium level until approximately 2:00 PM on [DATE]. Staff Y gave an order to send the resident to the Emergency Department. Staff Y stated she was not aware Staff A administered potassium even though the LN was aware the resident had a critical potassium level. Staff Y was aware the resident was showing signs and symptoms of [MEDICAL CONDITION] (an elevated potassium level). At 4:07 PM, the facility Administrator or Staff K, Regional Director of Clinical Operations, was made aware Staff A administered potassium to Resident 49 after she was notified of a critical lab value. On [DATE] and [DATE] Staff A, LN, received employee education/improvement opportunity related to medication administration. Recommendations were to orient ,[DATE] hours on the evening shift and take an on-line course on documentation. On [DATE] Staff A received a verbal warning related to an infraction described as, Standards of practice for medication administration. And on [DATE] a medication observation was completed with Staff A by the past DNS. During that observation medications were not given an hour before or after per facility policy, infection control issues were identified (not washing hands, not cleaning a glucometer after use) and inhalers not administered per facility policy. Review of the medication error log revealed no medication error investigation was done. The facility failed to identify a significant medication error when Staff A administered 30 MEQ of potassium to Resident 49 after receiving a critical lab value from the lab. The resident was sent to the ED and expired. Resident 49's [DIAGNOSES REDACTED]. Refer to CFR 483.12(a), F 224 - Prohibit Mistreatment/neglect/misappropriation

Based on observation, interview and record review, the facility's administration failed to effectively and/or efficiently use its resources to maintain the highest practicable well-being for 22 of 25 residents reviewed. Failure of the Administrator to identify neglect for 2 of 2 residents (49 and 22), failure to ensure 1 of 1 resident (49) was free of a significant medication error and failure to ensure the facility maintained an effective Infection Control Program related to the cleaning of glucose meters placed 20 of 23 sample residents (75, 69, 26, 39, 18, 44, 14, 43, 46, 101, 24, 57, 98, 22, 4, 99, 37, 42, 41 and 35) at risk for infectious disease. Findings include: 1. The Administration failed to ensure physician and family were notified immediately regarding a critical potassium level resulting and a decline in Resident 49's condition. Refer to CFR 483.10(g)(14)(i)(ii), F-157 - Notification of changes. 2. The Administration neglected to ensure staff responded aggressively to provide emergent medical services for Resident 49 who had a critically high potassium level and Resident 22 who experienced chest pain and had a pacemaker. Resident 49 and 22 were both transferred to the Emergency Department. Refer to CFR 483.12 (a), F-224 - Prohibit Mistreatment/Neglect/Misappropriation 3. The Administration failed to ensure professional standards of practice were maintained. The facility failed to follow their Infection Control policy regarding cleaning of glucose meters for 20 of 23 diabetics, failed to respond to a critical potassium level for Resident 49, failed to accurately assessed Resident 22 who was experience chest pain and failed to monitor/follow up on Resident 22's pacemaker. Refer to CFR 483.21(b)(3)(i), F-281- Services Provided Meet Professional Standards 4. The Administration failed to identify deficiencies in regards to establishing protocols to ensure Resident 49 was free of a significant medication error. Refer to CFR 483.45(f)(2), F 333 - Residents Free Of Significant Medication Errors. 5. The Administration failed to maintain an effective Infection Control Program related to the cleaning of glucose meters for 20 of 23 residents (75, 69, 26, 39, 18, 44, 14, 43, 46, 101, 24, 57, 98, 22, 4, 99, 37, 42, 41 and 35). This placed the residents at risk for infectious disease. Refer to CFR 483.80, F 441 - Infection Control, Prevent Spread, Linens The facility's administration failed to ensure staff kept residents at their highest practicable well-being by recognizing neglect for 2 residents, keeping a resident free of a significant medication error and failing to ensure the facility maintained an effective Infection Control program

Based on interview and record review the facility failed to ensure services that were provided met professional standards of quality for 22 of 25 residents reviewed. The facility failed to consistently and thoroughly assess and document to 2 of 2 resident's (49 and 22) reviewed for change of condition. Additionally, the facility failed to ensure current infection control practices were followed which included monitoring and maintenance of blood glucose meters and staff practice in cleaning the meters to prevent cross contamination and spread of infection for 20 of 23 sample residents (75, 69, 26, 39, 18, 44, 14, 43, 46, 101, 24, 57, 98, 22, 4, 99, 37, 42, 41 and 35), reviewed for blood glucose monitoring. The Licensed nurses (LN) failure to follow standards of practice for monitoring and reporting significant change of condition caused harm for Resident 49 and 22 which required Emergent Medical intervention. Findings Include: CHANGE OF CONDITION The Washington State Nurse Practice Act, WAC [DATE] (2) in part indicates nurses violate standards by: (2) Failure to adhere to the standards enumerated in WAC [DATE] which may include, but are not limited to: (a) Failing to assess and evaluate a client's status or failing to institute nursing intervention as required by the client's condition; (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and/or legibly; According to the American Nurses Association, Scope and Standards of Practice, 2011, A licensed nurse (LN) shall, in a complete, accurate and timely manner, report and document nursing assessments or observations, the care provided by the nurse for the client, and the client's response to that care. Nurses assume a liability risk if they fail to monitor a patient or to recognize changes in a patient's condition. Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient. According to the facility's policy 2015 NW GERIATRICS PROTOCOLS FOR FACILITY stated a potassium level below 3.0 or above 5.5 was critical and required immediate attention to the physician or Nurse Practitioner. According to Lippincott Manual Of Nursing Practice 10th Edition by Lippincott, Williams & Wilkins, defines a dual chamber pacemaker as a permanent pacemaker with two leads. One lead was in the atrium and the other lead was located in the ventricle. The pacemaker should have regular checkups for monitoring function and integrity of the pacemaker which included trans-telephonic evaluation of the implanted cardiac pacemaker's battery and [MEDICATION NAME] failure was available. CHANGE OF CONDITION RESIDENT 49 On [DATE] at 9:59 AM, Staff A, LN, received a phone call from the lab company identifying Resident 49 had a critically high potassium level. The potassium level was 6.8 (normal was 3.50 to 5.50). Review of Staff A's statement indicated Staff H, Resident Care Manager, was then notified. Staff H directed Staff A to wait for the hard copy to be sent over the fax from the lab company. At 10:27 AM, Staff A administered potassium 30 MEQ to Resident 49 after she was alerted to the resident ' s critical lab level. Review of the nursing progress notes revealed Resident 49 was exhibiting signs and symptoms of [MEDICAL CONDITION] (high potassium level). This included nausea and vomiting. Staff A or Staff H did not contact the Advanced Registered Nurse Practitioner (ARNP), who was in the facility until 2:00 PM. The ARNP then gave an order to send the Resident to the Emergency Department. Further review of the medical record revealed Resident 49 was not sent to the ED until 3:30 PM, one and a half hours after the ARNP gave the order for the resident to be transferred. Review of the ED records revealed the expired at 7:29 PM. The ED physician documented the final impression was [MEDICAL CONDITION] and [MEDICAL CONDITION] RESIDENT 22 The facility's policy regarding a change of condition describes the purpose to notify the physician, Nurse Practitioner or Physician Assistant when there was any symptom, sign or apparent discomfort that was an acute or sudden onset. The Licensed Nurse was to notify the physician when the resident reported chest pain/pressure/tightness that was new or an abrupt onset, unrelieved by current medications or accompanied by diaphoresis. On [DATE] at 4:40 AM, Resident 22 was calling out for help. Staff ZZ, Licensed Practical Nurse, documented the resident was holding the left side of her chest, was cold, clammy and stated she was nauseated and wanted to throw up. Review of the medical record revealed Staff ZZ gave the resident Gas X even though Resident 22 was experiencing a sudden onset of chest pain. Resident 22 had mild relief of chest pain with the administration of Gas X. At approximately 5:00 AM, twenty minutes later, Staff ZZ notified Staff PP, Registered Nurse on duty, of a .situation with a resident upstairs . At 5:05 AM, Staff PP found Resident 22 to be diaphoretic, cold, nauseated and complaining of chest pain. When Staff PP asked Staff ZZ what actions he had taken, Staff ZZ stated he had checked the resident ' s vital signs and blood glucose. Staff PP then directed Staff ZZ to notify the on call physician. The resident was sent to the ED at approximately 6:00 AM. Further review of the chart indicated the resident had a cardiac pacemaker. There was no evidence in the medical record that the facility was aware of the cardiac pacemaker. There was no assessment or monitoring of the device. The ED report documented Resident 22 expired on [DATE] at 5:35 PM. The physician documented the cause of death was [MEDICAL CONDITION] infarction and third degree heart block. Other contributing factors included pacemaker battery at end of life. BLOOD GLUCOSE MONITORING According to the Use of Fingerstick Devices on More Than One Person Poses Risk for Transmitting Bloodborne Pathogens: Initial Communication: Update [DATE] by the CDC, recommended point of care (POC) blood testing devices (glucose meters) whenever possible be used on one resident only. If this was not possible then the meter should be properly cleaned and disinfected after every use as described in the device labeling. POC blood testing devices can be a source of bloodborne infections when used on multiple residents. On [DATE] at 4:40 PM, Staff V, LN on the first floor, was observed to test Resident 75's blood glucose. After Staff V checked the resident's blood glucose, he placed the contaminated glucometer in his right front pocket of his uniform, went to the medication cart and placed the glucometer in the top drawer. Staff V did not disinfect the meter. At 4:50 PM, Staff V stated the meters were cleaned daily on the night shift. At 6:14 PM, Staff C, LN on the second floor, stated he cleaned the meters with an [MEDICATION NAME] alcohol pad after each use. At 6:30 PM, the facility's three medication carts were observe to have a multi-use Evencare G3 meters. There were two medication carts on the first floor and one medication cart on the second floor. Review of Resident's 75, 69, 26, 39, 18, 44, 14, 43, 46, 101, 24, 57, 98, 22, 4, 99, 37, 42, 41 and 35 revealed each resident received blood glucose testing at least weekly. The facility failed to ensure proper infection control practices were followed for the above resident's. Refer to CFR 483.12 (a), F-224 - Prohibit Mistreatment/Neglect/Misappropriation Refer to CFR 483.45(f)(2), F 333 - Free of Significant Medication Errors. Refer to CFR 483.80, F 441 - Infection Control, Prevent Spread, Linens

Based on interview and record review the facility neglected to respond aggressively in the provision of emergent medical assessment, evaluation and treatment for 2 of 2 residents (49 and 22) reviewed for emergent medical care. The facility failed to recognize Resident 49, who had a critical high potassium blood level, and Resident 22, who was exhibiting chest pain and had a pacemaker, received emergent medical care. This failure placed Resident 49 and 22 at imminent risk of harm, up to and including death. Findings include: RESIDENT 49 Resident 49 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a lab slip dated [DATE], indicated Resident 49 had a critically high potassium level. The potassium level was 6.8 (normal is 3.50 to 5.50). The lab documented Staff A, Licensed Nurse (LN), was called at 9:59 AM of the critical lab value. Review of the Medication Administration Record [REDACTED]. Staff A administered the potassium after she received the critical lab results. Review of a progress note dated [DATE] at 3:53 PM, revealed the resident had vomited part of her breakfast. Review of a progress note dated [DATE] at 1:47 PM revealed the resident had complained of nausea. On [DATE] at 10:46 AM, the resident had complaints of nausea and was given [MEDICATION NAME] (an anti-emetic medication). The LN documented the [MEDICATION NAME] was not effective and she continued to experience nausea. At 5:53 PM, Staff A documented the resident had nausea on the AM shift. The resident had a critical potassium level of 6.80. The Advanced Registered Nurse Practitioner (ARNP) was notified and an order was obtained to send to the Emergency Department (ED). Staff A documented the resident was sleeping in bed and noted to have . gray hands while lying flat in bed . and a respiratory rate of 22. The resident was woken up and informed she was going to the ED. The resident complained of nausea. The resident left the facility at 3:30 PM. On [DATE] at 1:30 PM, Staff H, Resident Care Manager (RCM), stated Staff A notified her that Resident 49 had a 6 point something potassium. Staff H stated Staff A did not state the potassium was critical. Staff H was not able to identify a potassium level over 6 was abnormal or cause for concern. Staff H stated she checked the computer and the lab had not been posted yet. Staff H stated she directed Staff A to wait for the hard copy to be faxed from the lab. At 1:35 PM, Staff C, LN, stated when he came on shift Staff A reported Resident 49 had an increased potassium lab level. During report, there was a fax on the fax machine, Staff A removed the fax and wanted to continue with report. Staff C directed Staff A to look at the fax. Staff A reported it was Resident 49's lab report. The lab was critical. Staff C directed Staff A to notify the ARNP immediately. Staff Y, ARNP, was in the building and on the first floor. Staff Y gave an order to send Resident 49 to the ED. Staff C stated when 911 arrived, they assessed the resident and stated she was stable and would not transport the resident to the ED. The first responders then called another transportation company. The second transportation company arrived around 3:00 PM, they stated they could not transport the resident because she required a bariatric stretcher. Staff C stated the second transportation company called a third team to transport the resident. The resident did not leave the facility until approximately 3:30 PM. Staff C was not aware if the ARNP, who was in the facility, had been contacted regarding the resident not being transported to the ED in a timely manner. At 2:09 PM, the Director of Nursing Services (DNS) was not able to state the sequence of events that occurred on [DATE] prior to Resident 49 being sent to the ED. At 2:59 PM, the facility was asked to obtain the resident's ED records. At 3:13 PM, Staff Y, ARNP, stated she was not aware the resident had a critical potassium level until approximately 2:00 PM on [DATE]. Staff Y stated she was not aware Staff A administered potassium even though she was made aware the resident had a critical potassium level. Staff Y did not know the resident was not discharged from the facility until approximately 3:30 PM, an hour and a half after she gave the order to send Resident 49 to the ED. Staff A did not notify Staff Y two transportation services did not take the resident to the ED. Staff Y stated she thought the facility had sent Resident 49 to the ED as she had directed. Staff Y was aware the resident was showing signs and symptoms of [MEDICAL CONDITION] (an elevated potassium level). At 4:07 PM, the facility Administrator and Staff K, Regional Director of Clinical Operations, were made aware Staff A administered potassium to Resident 49 after she was notified of a critical lab value. In an interview on [DATE] at 8:50 AM, Staff B, LN, stated when she received a call from the lab indicating there was a critical lab value she would notify the physician immediately. Staff B would notify the RCM and the resident's responsible party. Staff B would document the information in the resident's nursing progress notes. At 8:55 AM, Staff U, LN, stated if she received a call from the lab indicating there was a critical lab value, she would assess the resident, look up the prior lab and notify the physician immediately and family if applicable. Staff U would document the information in the progress notes. At 9:00 AM, Staff G, LN, stated if she received a critical lab value from the lab she would act upon it immediately. She would notify the physician, obtain any orders and notify the family. Staff G stated this information would be documented in the medical record. At 9:05 AM, Staff K stated the LN would document the information in the resident's medical record. Review of the ED records revealed the resident arrived at 4:37 PM. The resident's chief compliant was nausea and a abnormal lab. The resident presented with signs of [MEDICAL CONDITION] (an elevated potassium level). The resident expired at 7:29 PM. The ED physician documented the final impression was [MEDICAL CONDITION] and [MEDICAL CONDITION] The facility neglected to respond aggressively in the provision of emergent medical assessment, evaluation and treatment in response to a critical potassium level. The LN administered potassium even after receiving a phone call from the lab that the resident had a critical potassium level and was exhibiting signs of [MEDICAL CONDITION]. The facility failed to notify the physician of the critical potassium level. The facility failed to intervene when the first responders assessed the resident as stable and did not take her to the ED. The facility failed to notify the ARNP the resident was not discharged from the facility for an hour and half after the order was given or involve the ARNP to intervene when the first responders did not transport the resident. RESIDENT 22 Resident 22 was a long term care resident, admitted to the facility [DATE]. Resident 22 had [DIAGNOSES REDACTED]. Review of a progress note dated [DATE] at 7:14 AM indicated Resident 22 called out for help at 4:40 AM. Staff ZZ, Licensed Practical Nurse, documented the resident was holding the left side of her chest, was cold, clammy and stated she was nauseated and wanted to throw up. Staff ZZ gave the resident Gas X with mild relief. The resident continued to complain of pain .that radiated to her left shoulder . Staff ZZ notified the on call physician and received an order to administer [MEDICATION NAME]. The resident received one dose of [MEDICATION NAME]. Resident 22 was then sent to the ED. Staff ZZ did not document what time the on call physician was notified, what time the Power of Attorney was notified, what time the Gas X or [MEDICATION NAME] was administered or what time the resident left the facility. Review of a telephone order dated [DATE] at 7:45 AM, revealed an order by the physician to administer [MEDICATION NAME] 0.4 milligrams sublingually every 5 minutes as needed for chest pain. The LN was to administer three tablets and notify the physician if no relief (and if the LN was not able to contact the physician to send the resident to the ED). Review of the progress notes revealed the Staff ZZ administered one dose of the [MEDICATION NAME]. Staff ZZ did not document the resident's response to the medication. Review of the Medication Administration Record [REDACTED]. On [DATE] at 9:45 AM, the DNS stated she had witness statements from Staff ZZ and Staff PP. The DNS stated she had not initiated an investigation regarding the allegation of neglect. Review of Staff ZZ's statement stated he was notified by the Nursing Assistant (NA) on duty at 4:40 AM, the resident was calling for help. The LN assessed Resident 22 and found the following: the resident was diaphoretic, hand on her chest and wanted to throw up. Staff ZZ adjusted the resident in the bed, raised the head of the bed up, gave her a basin, covered her up and took her vital signs. Staff ZZ administered Gas-X to the resident at 4:50 AM (per the witness statement). Twenty minutes after Resident 22 continued to experience chest pain, Staff ZZ called Staff PP, Registered Nurse, who was on the first floor. Staff ZZ documented the resident was sent to the ED at approximately 6:00 AM. Review of Staff PP's statement stated Staff ZZ notified her at approximately 5:00 AM that . there is a situation with a resident upstairs . Staff PP was not notified Resident 22 was having chest pain. At approximately 5:05 AM, Staff PP went up to the second floor. When Staff PP entered the room, Resident 22 was diaphoretic, cold, nauseated and complained of chest pain. When Staff PP asked Staff ZZ what he had done, Staff ZZ stated he had checked the resident's vital signs and blood glucose. Staff PP then directed Staff ZZ on what to do. The on call physician was then notified. Staff PP stated in the written statement . I feel if I had not been here this resident would have died . In a progress note at 8:05 AM, the LN documented the ED called to inquire what type of pacemaker the resident had. The LN documented the Resident Care Manager was notified and will follow up. There was no further documentation regarding what type of pacemaker Resident 22 had. Review of the ED notes revealed the resident arrived in the ED at 6:25 AM. The resident was experiencing chest pain. A chest x-ray was done in the ED. A dual chamber pacemaker (Have pacing [MEDICATION NAME] in both the right atrium and the right ventricle) was identified on the x-ray report. Review of the resident record on [DATE], revealed a chest x-ray was done in the facility on [DATE], over two years prior. The x-ray report indicated there was a pacemaker in place. Review of an ARNP note dated [DATE], indicated the resident had a pacemaker in place. Review of a ARNP progress note dated [DATE], documented the resident was a poor historian secondary to dementia and the resident reported . used to have a pacemaker placed x 2 to the right chest but that this was removed . Review of an ARNP note dated [DATE], documented Pacemaker placement - states this was removed x 2??. Review of the care plan revealed no documentation the resident had a pacemaker or what monitoring the facility was doing. Further review of the medical record revealed no further evidence Resident 22's pacemaker was being assessed/monitored, what type of pacemaker the resident had or any evidence the pacemaker had been removed. In an interview on [DATE] at 11:20 AM, Staff AAA, CEO, was not aware of the allegation of neglect. Staff AAA stated an investigation would be initiated. The ED report documented Resident 22 expired on [DATE] at 5:35 PM. The physician documented the cause of death was [MEDICAL CONDITION] infarction and third degree heart block. Other contributing factors included pacemaker battery at end of life. Additionally, the facility conducted an investigation regarding the allegation of neglect on [DATE]. Review of a statement written by the DNS stated when she received the written statement from Staff PP she put it .in my drawer as I already had a statement from the Noc (night) LPN. I did not actually read the note in its entirety until ,[DATE] when complaint investigators were in the facility. Staff ZZ failed to identify a resident who was experiencing chest pain and in distress. Staff ZZ did not notify the physician or Registered Nurse on duty in a timely manner. Staff ZZ waited twenty minutes before the RN was notified and was directed by the RN in what to do next. The facility failed to identify Resident 22 had a pacemaker and what maintenance/follow up the pacemaker required. The DNS did not investigate the allegation of neglect when brought to her attention by Staff PP. Refer to CFR 483.45(f)(2), F 333 - Free of Significant Medication Errors.

Based on interview and record review, the facility failed to consult with a physician regarding a critically high lab level for 3 of 6 residents (49, 24 and 14) reviewed for abnormal lab levels. This failure prevented the physician and/or responsible party from being aware of the change in condition and the opportunity to alter treatment or to commence a new form of treatment and caused harm to Resident 49 who received emergent care for [MEDICAL CONDITION] (elevated potassium level) and [MEDICAL CONDITION]. The facility failed to notify Resident 24's responsible party of a critically high potassium level which required medication intervention and Resident 14's abnormal glucose lab level. This placed all residents at risk for a delay in treatment. Findings include: Review of the facility Change in Resident's Condition or Status policy stated the facility shall promptly notify the resident, their attending physician and representative of changes in the resident's medical status. Examples of a change in the resident's medical status included a need to transfer the resident to the hospital and the need to alter the resident's medical treatment significantly. The Licensed Nurse (LN) documented the information in the resident's medical record. Review of the facility's Laboratory Tests/Diagnostic Procedures INTERACT tool (a clinical practice guideline) directed the LN to report immediately to the physician a potassium level above 6.0. RESIDENT 49 Review of a lab result, dated [DATE],, revealed Resident 49 had a critical potassium level. The potassium level was 6.8 (normal is 3.50 to 5.50). The lab documented Staff A, LN, was called at 9:59 AM of the critical lab value. Review of the medical record revealed Staff A did not notify the physician or equivalent until approximately 2:00 PM on [DATE], four hours after Staff A received a phone call from the lab of the critical potassium level. Further review of the medical record revealed Staff A did not notify the resident's responsible party of the critical lab level or being transferred to the Emergency Department (ED). In an interview on [DATE] at 1:30 PM, Staff H, Resident Care Manager (RCM), stated Staff A notified her that Resident 49 had an elevated potassium level. Staff H stated she directed Staff A to wait for the lab to fax over the results. Staff H stated she did not notify the physician or responsible party of the critical lab level. At 1:35 PM, Staff C, LN, stated when he came on shift Staff A reported Resident 49 had an increased potassium lab level. Staff C stated Staff A had called the facility around 7:00 or 7:30 PM to report she had not called Resident 49's responsible party of the critical potassium level or being transported to the ED. Staff C stated he was not able to contact the family until approximately 10:00 PM on [DATE]. When Staff C called the family, they stated Resident 49 had expired. At 2:09 PM, the Director of Nursing Services (DNS) was not able to provide any information regarding if or when the physician or responsible party was notified of the resident's decline in condition. At 3:13 PM, Staff Y, Advanced Registered Nurse Practitioner (ARNP), stated she was not aware the resident had a critical potassium level until approximately 2:00 PM on [DATE]. Staff Y gave a verbal order to Staff A to send Resident 49 to the ED. In an interview on [DATE] at 9:05 AM, Staff K stated the expectation was for the LN to follow the INTERACT tool regarding notification of change. Staff K stated the LN would document the information in the resident's medical record. In an interview on [DATE] at 3:55 PM, Resident 49's responsible party confirmed they were not notified by the facility regarding the decline the resident's condition which required emergent medical care. RESIDENT 24 Resident 24 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the [DATE] basic metabolic panel results obtained at 6:12 PM, ordered on [DATE] revealed the resident had a critically high potassium level of 6.10 (reference range of 3.50 - 5.50) with a one-time order for [MEDICATION NAME] (medication to help reduce potassium) on [DATE]. review of the resident's medical record revealed [REDACTED]. Review of Staff Y, ARNP, progress note dated [DATE] revealed the resident had potassium elevations and required [MEDICATION NAME] on occasion with a prior critical elevated potassium level of 6.0 on [DATE]. Review of Staff Y progress note, dated [DATE], revealed a referral to a nephrologist could be considered, Although I'm not sure that they would have anything to offer. Review of Physician SS, progress note dated [DATE] revealed, I think we could cut back on the [MEDICATION NAME] instead of panicking every time the lab comes back high. Review of the resident's progress notes from [DATE] through [DATE] revealed the resident's medical guardian power of attorney was not notified of the critically elevated potassium level, the order for [MEDICATION NAME] or the possibility of a nephrologist referral. Yet the guardian was contacted on [DATE] to reschedule a care conference, and the financial guardian power of attorney was contacted on [DATE] to consent on a [MEDICATION NAME] order (an [MEDICAL CONDITION] medication used to treat the flu). Review of the resident's care plan revealed the resident had a guardian for healthcare and financial decision-making, with a goal to communicate with the guardian regarding the resident's care along with an intervention to call the guardian related to the resident's care, doctor appointments or emergencies while at the facility. In an interview on [DATE] at 9:52 AM, Staff O, Licensed Nurse stated, Always inform family, guardian or power of attorney of any new orders or abnormal lab values. RESIDENT 14 Review of the clinical record revealed Schryver Lab identified an elevated blood glucose (BG) of 435 on [DATE] at 10:34 AM. The lab notified Staff A, LN at that time and Staff G, RCM at 2:05 PM, reviewed the critical value. Review of the nursing progress notes, dated [DATE], revealed the physician was notified of elevated BG's of 468 and 424 on [DATE]. There was no documentation in the clinical record of physician notification of the BG level of 435 on [DATE]. Review of the clinical record revealed the laboratory identified an elevated BG level of 406 on [DATE] at 9:21 AM. Staff G, RCM at 6:18 PM, reviewed the critical value. Review of the nursing progress notes dated [DATE] revealed the physician was not notified of the critical BG level of 406. Review of the physician orders, dated [DATE], directed to call the provider for a BG greater than 400 or BG less than 60. In an interview on [DATE] at 5:04 PM, Staff K, Regional Director of Clinical Operations, stated the LN had called the doctor and Resident 14 had BG's done and the doctor adjusted the insulin dose. Staff K provided additional documentation; however, the documentation was from [DATE] and not [DATE]. In an interview on [DATE] at 8:50 AM, Staff B, LN stated if she received a call from the lab regarding a critical lab value, she would immediately notify the RCM, the physician, the resident's responsible party and document in the nursing progress notes. In an interview on [DATE] at 9:08 AM, Staff F, LN stated if she received a call regarding a critical lab value, she would notify the RCM, physician and family, if applicable, and then document in the progress notes. Refer to CFR 483.12(a), F 224 - Prohibit Mistreatment/neglect/misappropriation Refer to CFR 483.45(f)(2), F 333 - Free of Significant Medication Errors.

Based on interview and record review, the facility failed to recognize and consult with the physician regarding a change in condition for one of two residents (1). This failure prevented the physician from being aware of the change of condition and the opportunity to alter treatment or to commence a new form of treatment and caused harm to Resident 1 who required hospitalization . Findings include: The facility's policy regarding Change in Resident's Condition or Status, directed Licensed Nurses (LNs) to notify the resident's attending Physician when there has been: a significant change in the resident's physical/emotional/mental condition or a need to transfer the resident to a hospital. Resident 1's recent Minimum Data Set (MDS) assessment, dated 4/27/16, indicated she had cognitive impairments and required one person for assistance for bed mobility and transfers. While in the facility Resident 1 had a fall on 6/16/16. The Licensed Nurse (LN) assessed the resident post fall. The nursing/incident notes documented that she sustained a hematoma on her elbow measuring 6 centimeters (cm) by 4 cm by 1.5 cm in size; a hematoma on her left knee which measured 9 centimeters (cm) by 5 cm by 1 cm in size, and a bruise to her forehead which measured 1.5 cm by 1.5 cm in size. Resident 1 complained of moderate pain and a pain medication ([MEDICATION NAME]) was administered. The resident was transferred to the hospital for further evaluation of her leg and returned on 6/17/16 from the hospital with contusions and hematoma. A nursing progress note, dated 6/17/16, indicated the resident verbalized mild pain upon her return and her left knee contusion measured 10 by 6 cm in size, and was purple in color. A splint was in place on her knee. She verbalized mild pain but refused an ice pack to her knee. The left elbow contusion measured 4 cm by 5 cm in size and was green-purple in color. The discharge order indicated a narcotic pain medication ([MEDICATION NAME]) was ordered for pain every 6 hours prn (as needed). The care plan, dated 6/17/16, under contusions on the forehead, elbow and knee directed staff to monitor for swelling, increased pain and notify physician. On 6/18/16 at 3:34 am, the Licensed Nurse (LN) documented the resident complained of left leg pain which she reported as being 9 out of 10 (0 being no pain & 10 being the worst pain). The LN administered [MEDICATION NAME] and documented the medication was effective. On 6/18/16, at 5:49 a.m., the LN revealed Resident 1 had intermittent confusion and refused to go to bed. The LN documented that the resident's left lower extremity had swelling, black, brown, red color and dripping (from the contusion). There was no documentation that Licensed staff did a thorough assessment or contacted the primary care physician to report the confusion, swelling or drainage from leg. On the same day at 6:26 a.m., documentation showed the resident was crying and reported her left knee pain was 10 of 10. The resident told staff that she wanted to be sent to hospital. The LN administered [MEDICATION NAME] (a non-narcotic). The On the same day the LN documented at 7:00 a.m., the [MEDICATION NAME] was ineffective but the ice pack provided good effect. There was no documented evidence that the physician was notified regarding the swelling or drainage from left leg or that Resident 1 was requesting to be sent to the hospital. On the same day at 9:35 a.m., Resident 1 requested pain medication before the pain started. The LN administered [MEDICATION NAME] for pain she reported to be 5 of 10. At 12:43 p.m., [MEDICATION NAME] was administered for pain in her knee, elbow and generalized pain for a pain rated at 4 of 10. On 6/18/16, the day shift LN documented Resident 1 was crying at the beginning of the shift (appox. 6 - 7 am). She was observed holding her left knee and the [MEDICATION NAME] was ineffective for her pain but the ice had good effect. The nursing note indicated that she had refused both breakfast and lunch, refused an alternative meal. The LN documented the [MEDICATION NAME] and ice were effective for decreasing the pain but the [MEDICATION NAME] had been ineffective. There was no documentation the physician was contacted to report the resident was crying and refusing meals. The evening shift LN on 6/18/16 documented Resident 1's family was visiting and was highly concerned about care The LN documented she received her narcotic medication ([MEDICATION NAME]) at 8 p.m. On 6/19/16, [MEDICATION NAME] was administered at 4.06 a.m. for back pain. Her pain was severe and rated at an 8 out of 10. The LN documented Resident 1's lower extremity was swollen and had a blister formation. Even though the LE had further swelling with a blister formation, there was no documentation the physician was notified. On 6/19/16 the day shift LN documented the resident refused breakfast and ice was applied to her knee and elevated. The LN documented the swelling was less than the prior day. Licensed staff still did not contact the physician to report the pain and the resident refusing meals. On 6/19/16 during the evening shift, the LN administered [MEDICATION NAME] at 4:39 p.m. for a pain scale of 5 out of 10. On 6/20/16 at 6:38 a.m., the LN administered the narcotic medication, [MEDICATION NAME], for severe pain of 8 out of 10. On 6/20/16, the Advanced Nurse Practitioner (ARNP) was at the facility and the LN requested an assessment for Resident 1, 3 days after her re-admit. The ARNP's note read: patient seen urgently for new complaint of lethargy and minimal intake in past 24 hours. The ARNP documented that Resident 1's LUE (left upper extremity) was deep purple bruising down entire length of arm to fingertips; LLE (left lower extremity) deep purple to black bruising down entire length of leg with blisters over knee. The ARNP's assessment revealed Resident 1 had an altered level of consciousness / lethargy and that she appeared dehydrated in setting of poor intake, uncontrolled pain and severe hematomas. During an interview on 7/4/16 at 8:40 a.m., Resident 1's family stated when her mother returned from the hospital (6/17/16), her pain kept on increasing and the swelling of her knee kept increasing and it was leaking. She stated her mother's bruising on her elbow was the size of a baseball. She stated the weekend before she was transferred to the hospital, she was not eating or drinking. During an interview on 7/22/16 at 12:49 p.m., Resident 1's friend stated he visited Resident 1 frequently and after she returned from the hospital on [DATE], her leg got more swollen, and she was in tremendous, extreme pain. Staff did not tend to her. The emergency hospital note, dated 6/20/16, documented Resident 1's knee was very large with a contusion / hematoma extending from knee to thigh and shin. The left upper extremity with large ecchymosis of entire forearm and all fingers x 5th finger. The note documented she had only obtained minimal relief from the narcotic medications prior to admit. The resident was admitted with [DIAGNOSES REDACTED]. The DNS was interviewed on 07/13/16 and was unable to provide any further information. The facility failed to recognize that the resident was having a change of condition due to severe unrelieved pain and refusal of meals. The facility did not contact the physician for consultation which lead to a delay in treatment and pain.

Based on interview and record review, the facility failed to consistently monitor 1 of 3 residents (1) change of condition. Failure to monitor Resident 1 resulted in possible delay in treatment. Findings: The facility's policy for Change in Resident's Condition or Status directed staff to promptly notify the attending physician of changes in the resident's medical/mental condition and/or status. The policy stated that Licensed Nurses (LNs) would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Resident 1 was admitted on [DATE] for care following a [MEDICAL CONDITION] and had [DIAGNOSES REDACTED]. The hospital admission and discharge notes, dated 1/25/16, revealed Resident 1 was a full Code. The Minimum Data Set (MDS) assessment, dated 2/4/16, indicated Resident 1 had no cognitive impairment and required 2 person maximum assist for bed mobiliy and transfers. The Treatment Administration Record (TAR) for February 2016 revealed Licensed Nurses (LNs) were to assess the resident for shortness of breath and to keep his oxygen saturation level above 92%. Review of the vital sign record for February 2016 documented that Resident 1's oxygen saturations ranged from 93-95% with and without the use of oxygen. A nursing note, dated 2/17/16 at 9:01 p.m., documented that Resident 1 had been found with no pulse, no blood pressure or no respirations. Prior to discovering Resident 1, the Licensed Nurse (LN) had been notified at 5:32 p.m. that Resident 1's oxygen saturation levels had decreased during skilled therapy. A facility investigative note, dated 2/18/16, documented by the LN who discovered Resident 1 to be without a pulse revealed that the Resident Care Manager had informed him that Resident 1's oxygen level was between 85-89% and if the resident exhibited respiratory distress that he should be sent to the hospital. The LN's note revealed Resident 1 was on 3 liters of oxygen,and had no respiratory distress when he administered his pills between 7:30 p.m. to 8:30 p.m., his oxygen saturation was 90%. Even though the LN's investigative note revealed Resident 1 had been assessed, there were no nursing entries regarding these assessments. During an interview on 3/17/16 at 12:50 p.m., the Director of Nursing stated even though the Licensed Nurse stated he had assessed and monitored Resident 1, there was no documented evidence noted in the clinical record. Facility staff failed to aggressively monitor or document Resident 1's condition.

Based on interview and record review, the facility failed to provided services according to the standards of nursing practice for one of 3 residents (1). Failure to provide basic life support, including cardiopulmonary resuscitation (CPR) or activate the emergency medical services for Resident 1 resulted in consequences that did not honor the resident's wishes. Finding include: Review of the facility's Licensed Practical Nurse (LPN) job description and essential position duties indicated that the LPN would provide intermittent nursing services within the scope of license and state regulations, notify physician as permitted by state regulations and have knowledge regarding nursing and medical practices as well as laws, regulations and guidelines that pertain to nursing care facilities. Review of the facility's investigative report, dated [DATE], documented that the LN had not initiated CPR or called 911 (emergency activation) when Resident 1 was discovered without a pulse and was gray in color and had fluids coming out of mouth. On [DATE], during an interview with the Acting Director of Nursing (Staff 2) she stated licensed nurses (LNs) working in the faciltiy should be certified in CPR. Staff 2 stated the facility had scheduled a CPR certification class for Licensed Nurses. A facility fax, dated [DATE], revealed 15 of 21 LPNs currently employed at the facility held current CPR certification. See further details in F 309

Based on interview and record review, the facility failed to follow their advance directive policy and ensure a resident's choice was honored for 1 of 3 residents (1). Failure to follow policy and failure to initiate CPR (Cardio-Pulmonary Resuscitation) for Resident 1 resulted in consequences that did not honor the resident's wishes. Findings included: The facility's Advanced Directives/POLST (Physician order [REDACTED]. Resident 1 was admitted on [DATE] for care following a [MEDICAL CONDITION] because he declined surgical repair for the fracture while in the hospital. The Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident 1 had no cognitive impairment and required 2 person maximum assist for bed mobility and transfers. The hospital admission and discharge notes, dated [DATE], revealed Resident 1 was a full Code. The Advanced Registered Nurse Practitioner (ARNP) notes for [DATE] and [DATE], documented Resident 1 was capable of making his own decisions and was without cognitive impairment. The ARNP documented that he had elected to remain a full code but elected to not fill out the POLST form A nursing note, dated [DATE] at 9:01 p.m., documented that Resident 1 had no pulse, no blood pressure, no respiration. There was no documented evidence that Resident 1's wishes were honored or whether CPR (cardiopulmonary resuscitation) had been initiated. A facility investigative report, dated [DATE], documented that the LN had not initiated CPR or called 911 (emergency activation) when Resident 1 was discovered to be without a pulse. During an interview on [DATE] at 12:50 p.m., the Director of Nursing stated the Licensed Nurse should have initiated CPR and called 911. During an telephone interview on [DATE] with the ARNP, she stated Resident 1 was full code status. The nursing note, dated [DATE], documented Resident 1's assessment revealed no pulse, no blood pressure and no respirations were present and DNS (Director of Nursing) attested to the fact that resident is dead.

Based on interview and record review, the facility failed to ensure the plan of care was followed for one of 4 sample residents (Resident 1). This failure resulted in harm to Resident 1 who experienced fracture and placed other residents at risk for injury. Findings include: RESIDENT 1: Resident 1 had [DIAGNOSES REDACTED]. Resident 1 also had a short cast on her right lower leg due to a recent fracture. The Minimum Data Assessment (MDS) assessment, dated 11/13/15, revealed the resident required 2 person extensive assistance with bed mobility, transfers and toileting/pericare. The current plan of care, dated 6/8/15, and the kardex used by nursing assistants (NAC) indicated Resident 1 required max assistance of 2 staff for turning and repositioning in bed and for toileting. A nursing progress note, dated 12/27/15, documented that Resident 1 fell out of bed onto her back while being changed. The resident stated she hit her head and complained of left shoulder and right lower leg pain. The emergency system (911) was called and she was transferred to the hospital for evaluation. The facility's investigative report, dated 12/27/15, revealed Resident 1 rolled out of bed. Prior to the fall, only one NAC assisted the resident with removal of the bedpan and repositioning in bed. The report indicated the NAC had repositioned Resident 1 to remove her bedpan, left the resident slightly lying on her back and then went to the other side of the bed to get supplies. The NAC stated she saw the resident reaching for something. She told the resident not to move, as she did not want the resident to fall. The NAC stated she was unable to stop the fall. The bed was not in a low position at the time of the fall. The NAC reported the bed height was just above her waist. (slightly elevated position) to assist her while removing Resident 1's bedpan. On 1/6/16 at 2:00 p.m., during a telephone interview with the Director of Nursing (DNS), she verified the NAC who provided care for Resident 1 on 12/27/15 was aware of the plan of care requiring 2 person staff assist with toileting/pericare, bed mobility and positioning. The DNS stated the NAC had stepped away from Resident 1 after removing the bedpan by herself because Resident 1 was adamant about being taken off the bedpan due to pain. The emergency room report, dated 12/27/15, revealed Resident 1 had sustained 3 fractures (right lower leg and left clavicle).

Based on observation, interview and record review, the facility failed to perform safety assessments per policy and establish necessary interventions for a newly acquired power wheelchair (PWC) to ensure safety for one of one residents (1). Failure to ensure safety assessments were completed prior to the use of the PWC and to revise the plan of care when Resident 1's safety was comprised, resulted in harm of a fracture. Findings include: Resident 1 was admitted to the facility in 2012 with [DIAGNOSES REDACTED]. The resident used an PWC for mobility. The Minimum Data Set (MDS) assessment, dated 4/27/15, documented that Resident 1 had short term memory deficits and had difficulty with decision making in new situations. Facility policy was to perform assessments to ensure safety to operate a PWC. This involved three assessments to be completed on three different days. Resident 1's last assessments for the use of her PWC safety, were performed in 2012. Additionally, an informed consent was signed by Resident 1 regarding the risk and benefit/rules for the PWC. The facility's Risk and Benefits informed consent for PWCs revealed upon assessment from the interdisciplinary team, the facility has the right to prohibit residents to operate their power wheelchair if the use compromises their safety. On 5/21/15, Resident 1 received a new PWC. A progress note, dated 5/21/15, by skilled occupational therapist (OT) documented the resident had received a new PWC and that adjustments to the chair were performed by the wheelchair technician and the first assessment for operating the PWC was completed. The PWC safety assessment performed on 5/21/15 revealed Resident 1 understood the rules governing powered mobility use once explained to her. During an interview on 7/2/15 at 3:30 p.m., the OT who performed Resident 1's PWC assessment for the new chair stated Resident 1 needed help to lift her right leg on the foot pedal of the PWC and was cognitively aware at times. The OT stated the resident was explained the rules for the PWC. The OT stated the rule would be; if the resident was assessed to not safely use the PWC; if she hit someone or furniture, the PWC would be removed until another set of PWC safety assessments was completed. The OT verified that she had only completed one assessment for her new PWC as she had a prior PWC. OT stated the procedure is to perform 3 separate assessments on three different days to observe maneuvering of the PWC. Resident 1 did not want the required set of assessments completed to ensure safety as she had already used a PWC. There was no documented paln to follow up regarding safety when she refused. A nursing note, dated 5/21/15 at 10:06 p.m. documented Resident 1 was using her new PWC. Another entry, recorded as a late entry dated 5/22/15 at 8:37 p.m., documented the resident complained that her leg was bothering her and had informed the licensed nurse (LN) she had bumped her foot maneuvering her wheelchair. The next late entry, dated 5/23/15 at 1:58 p.m., documented Resident 1 informed the LN that she had bumped her right foot on wall using her electric wheelchair. The LN asked Resident 1 if she would be more comfortable with a manual w/c until she got more comfortable with her new electric one. Resident 1 stated she would think about it. The LN informed the nursing assistants (NACs) to monitor Resident 1 to keep her safe from exposing her foot when sitting in doorway and monitor for complications. Another late entry note for 5/23/15 at 8:41 p.m., documented Resident 1's foot was bumped by another resident in the hallway. The LN documented she encouraged her to sit further back in her room when watching the hallway traffic. The same LN wrote another note, dated 5/23/15, which was later striked out on 5/28/15. The note read: Resident has new electric wheelchair. Her feet hang over foot pad and are vulnerable to being hit by herself and others. She was unable to withdraw them when threatened by injury. She bumped her right foot last night, . today a resident bumped her foot lightly because she was sitting in the entry way to her room and he was going up and down the hallway. She was unable to back up when threatened with injury, .encouraged her to park further back from entrance. When I asked her if she felt comfortable maneuvering her wheelchair or felt that a manual wheelchair would be better she was very undecided. She said she is having trouble maneuvering it and gets anxious. The foot plate does not protect her feet from injury. There was no documentation that a referral was made for a further PWC assessment after any of the above incidents or that the resident's care plan was revised to ensure safety. An investigative report, dated 5/24/15, indicated Resident 1 had run into the door with her wheelchair which she had done the prior evening (5/23/15). At this time, the resident's right lower extremity was swollen and bruised. An x-ray was ordered. A statement from a nursing assistant(NAC), dated 5/27/15, documented she had worked with Resident 1 on 5/24/15 and Resident 1 had informed her that she had run into the door and hurt her leg. The Licensed Nurse's (LN) statement, dated 5/22/15, documented Resident 1 complained of right foot/leg pain because she bumped into a wall with her new PWC. The x-ray report, dated 5/25/25, revealed a spiral fracture of the tibia and fibula (lower right extremity bones). On 6/23/15 at 1:33 p.m., Resident 1 was observed seated in a manual wheelchair in her room. She had a cast on her right leg. When asked if her new PWC was similar to her old PWC, she stated the new PWC was different from her old PWC and difficult to manuver. On 7/2/15 at 8:58 a.m., Resident 1 stated that while she was in her new PWC another resident hit her leg with their wheelchair. She stated she had been sitting in doorway of her room and had to grab her leg as it hurt when bumped into. On 7/2/15, the Director of Nursing (DNS) verified Resident 1 had bumped her foot/leg on 5/22/15 and then on 5/23/15 another resident touched her foot with his wheelchair without real force. Even thought Resident 1 had several incidents/accidents after new PWC was used, the staff failed to perform the required assessments to ensure safe operation of the new PWC and/or revise the plan of care to ensure safety was not compromised for a resident who had difficulty making decisions.

Based on observation, interview and record review, the facility failed to implement or follow a plan of care to protect residents from aggressive behavior for 4 of 8 sampled residents (Residents 1, 2, 3, 5) and to recognize sexual exposure as an unwanted behavior between 2 residents (Residents 3, 5). Failure to take appropriate action to avoid Resident 3's repeated physical aggressiveness, and to ensure adequate supervision for Resident 1 and 2 were maintained resulted in a repeat incident of physical contact. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Care Guide informed staff that she had short term memory loss and required 2 person assists for transfers and bed mobility and assistance with wheelchair mobility. Resident 2 was admitted to the facility on [DATE] from an assisted living facility (ALF). Resident 2 was the spouse of Resident 1. He had [DIAGNOSES REDACTED]. An ALF provider note for Resident 2 documented he had worsening memory, intermittent aggressive behaviors witnessed toward spouse, and plans to quit smoking. The note documented he was on no medications for his depression and/or behaviors. The note also documented that ALF staff had observed Resident 2 being rough with his spouse, Resident 1, and yelling at her. The nursing notes from 7/24/14 to 7/30/14 revealed Resident 2 was independent with care, forgetful, and requested his cigarettes. The Care Guide informed the staff that he was independent with transfers and ambulation, wandered and requested to go outside to smoke frequently. Review of Resident 1's progress notes had the following entries: -On 7/28/14, the licensed nurse (LN) documented Resident 2 was observed standing behind Resident 1, holding Resident 1 up saying " walk woman. " Resident 1 was unsteady on her feet and swaying. Resident 2 seemed "very agitated" that Resident 1 could not walk. -Another entry on 7/28/14 revealed Resident 1 was on the floor mat in a shared room with Resident 2 "nearby." Resident 2 informed the LN that Resident 1 had "slipped and fell ." -A note for 7/29/14, documented Resident 2 was standing nearby when Resident 1 was again discovered on the floor in their room. Resident 1 was " not distressed but was looking around as if confused. " -On 7/29/14, the LN indicated Resident 2 was attempting to pick up Resident 1. The LN documented the Resident 1 had two scratches found on her back. One on the left lower back which measured 6 cm by 0.2 cm in size and the other scratch on her lower spine measured 4.5 by 2 cm in size. -On 8/1/14, Resident 1 was discovered on the floor matt in her room. When the LN was assessing Resident 1, Resident 2 stated that he was helping Resident 1 with her pants. The facility's investigative report, dated 8/5/14, documented the LN observed Resident 1 and 2 in their room. Resident 2 was observed to move his hand toward Resident 1, "aggressively, heard physical contact, " and Resident 2 muttered to Resident 1, " you better shut up or find somewhere else to live. " The report documented a new bruise was noted on Resident 1 ' s shoulder which measured 5.4 centimeters (cm) by 2.3 cm in size. On 8/6/14, the corporate nurse stated she did not know who reviewed Resident 2 ' s clinical record prior to admission. She stated she was unsure who reviewed the admission record and LNs at the facility are " learning " and needed training on how to identify patterns of behaviors in order to develop a plan of care to protect residents. There was no written evidence in the clinical record regarding how the facility was to monitor for Resident 2 ' s behaviors or interventions necessary to provide a safe environment for Resident 1. After the 8/5/14 incident, Resident 1 was moved to another room on the first floor and Resident 2 remained in a room on the second floor. On 8/6/14, the facility moved Resident 1 back to the second floor to share a room with her spouse Resident 2. The plan of care included 1:1 supervision. During an interview on 8/15/14 at 1:20 p.m., the Resident Care Manager (RCM) verified 1:1 supervision was to have "eyes on at all times." On 8/15/14, the administrator revealed another incident between Resident 2 and 1 had occurred on 8/7/14 at 6:30 p.m. during dinner. The facility ' s investigative report for the 8/7/14, documented both Resident 1 and 2 were seated at the same dining room table. The report indicated Resident 1 had requested staff to push her around the hallway and kept unlocking her wheelchair (WC). Resident 2 kept locking the WC, became frustrated and "hit " Resident 1. Even though the nursing assistants (NACs) were providing 1:1, the NACs told Resident 1 to wait until after dinner to be pushed in the hall and did not identify Resident 2's frustration as a triggered response prior to the actual physical contact of hitting Resident 1. The report documented after the verbal and physical altercation, the LN was notified. Even though the facility ' s plan was to monitor both Residents, ensure Resident 1 was protected from Resident 2 ' s known aggressiveness, the facility failed to recognize what Resident 2's triggers contributed to his behavior toward his spouse. 2. Resident 3 ' s clinical record revealed the resident had a history of [REDACTED].#3 was observed to seek out residents of the opposite sex, wandered into other residents ' rooms, thinking other resident items belonged to her and exhibited agitation when she was provided a room mate. Resident 3's Minimum Data Set (MDS) assessment, dated 5/20/14, indicated she was cognitively impaired and required 2 person assist for transfers, bed mobility and toileting. The Plan of Care informed staff to notify Licensed Nurse (LN) of inappropriate interactions with males or entered a male room. A facility " Event & Occurrence Report " form, dated 4/12/14, revealed an incident of " sexual exposure had occurred. The report revealed Resident 3 was observed next to Resident 5 with his body exposed. The report documented Resident 5 was " standing with no pants on, " in Resident 3 ' s room. The report documented Resident 3 had " asked him to come in. " Resident 5 had [DIAGNOSES REDACTED]. He required 2 person assist with bed mobility and transfers and one person assist to walk in the hallways. The Plan of Care for Resident 3 , dated 4/12/14, for resident 3 was to separate resident and monitor for wandering behaviors. The facility failed to recognize the behavior of sexual exposure as an unwanted behavior between cognitively impaired residents. After the 4/10/14 incident, review of the multidisciplinary notes for Resident 3 revealed the following incidences: -4/10/14, observed going through her roommate' s items -4/29/14, noted in another resident ' s room going through the drawers. -6/29/14, was confused, with aggressive verbal outbursts. -6/30/14, wandering into other residents ' room -7/1/14, "wandering into other people ' s rooms " -7/6/14, the LN documented at 5:57 a.m., Resident 3 took her clothes off, naked in the room, resident went to man's room at the beginning of the shift but admitted that she was looking for her room. -7/6/14, the day shift found Resident 3 in a male resident's room, "yelling and grabbing." -7/10/14, no attempt to go to male resident's room, -7/11/14, Resident 3 was moved to a semi private room near the nursing station without a roommate because of her "inappropriate behavior." -On 7/12/14, Resident 3 yelled and kicked when the staff attempted to change her pants -7/13/14, again attempted to go into a male resident ' s room During an interview on 8/15/14, the administrator stated no investigation had been completed regarding the altercations on 7/6/14. Even though the facility was aware of Resident 3's behaviors, adjustment of interventions based of repeated behaviors were not implemented to prevent further altercations with other residents. On 7/25/14, Resident 3 got a roommate. The roommate, Resident 4, was dependent on staff for bed mobility and transfers. Resident 4 was alert with [DIAGNOSES REDACTED]. According to a progress note, dated 7/28/14, two days after sharing a room, the LN documented Resident 3 was yelling at her new roommate, Resident 4. The note revealed Resident 3 was attempting to remove Resident 4's personal items, stating "these belong to me." On 7/28/14, a progress note for Resident 4 documented that she informed staff that she wanted room-mate (Resident 3) "out of the room." On 7/31/14, two days later, Resident 3 again went through her roommate's dresser, arguing with Resident 4. Resident 4 stated she felt "threatened and scared" of Resident 3. Not until after the second altercation did the facility take appropriate action to protect Resident 4 from Resident 3's aggressive behavior. The social service (SS) note, dated 7/31/14, documented that Resident 3 had reportedly "grabbed, hit and threatened her room mate", (Resident 4). Per SS's documentation mental health crisis staff were contacted. An entry by SS for Resident 4 revealed she reported that her " roommate grabbed her shoulder, hit her left shoulder and then threatened to kill her." Even though Resident 3 had a documented history of resident to resident altercation when a room mate was placed in her room, the facility continued to provide room mates and even after an altercation on 7/28/14, the facility did not revise a plan of care to protect both residents involved. Only after SS interviewed Resident 4 regarding the difficulty adjusting to new roommates did the facility recognize the need to revise a plan to protect Resident 4 and to accommodate Resident 3's need for a private room.

Based on interview and record review, the facility failed to ensure the plan of care was followed for one of 4 sample residents (Resident 1). This failure resulted in harm to Resident 1 who experienced avoidable injury and placed other residents at risk for injury. Findings include: RESIDENT 1: Resident 1 was admitted to the faciltiy on 8/20/13 with [DIAGNOSES REDACTED]. The Minimum Data Assessment (MDS) assessment , dated 4/2/14, revealed the resident required 2 person extensive assistance with bed mobility, transfers and toileting. The plan of care, dated 1/20/14, and the resident care guide, dated 11/24/14, indicated she required extensive assistance of 2 staff for bed mobility,transfers and toileting. The nursing notes, dated 5/29/14, documented the resident "took fall out of bed while NAC (nursing assistant) doing care". The resident was alert and crying, "oh my leg,..my leg". The facility's investigative report, dated 5/29/14, documented the NAC who provided care to Resident 1 did not follow the plan of care which stated the resident was to have two person assist with care and bed positioning. The report indicated the resident experienced pain, an abrasion on her upper back and the x-ray report, dated 5/29/14, revealed she had sustained a fracture of her hip. Resident 1 was transferred to the hospital. On 6/5/14, the Director of Nursing (DNS) confirmed Resident 1's plan of care had not been followed and the NAC did not follow Resident #1's plan of care which required 2 person assistance with turning and positioning in bed.

Based on observation, interview and record review, the facility failed to thoroughly assess and develop an individualized plan of care for pressure relief measures and interventions for pressure sore/ulcer healing for 3 of 3 residents (Resident 1, 2, 3) who were at risk for skin breakdown. Failure to develop, implement and evaluate interventions for wound healing resulted in actual harm for Resident 1 who developed avoidable painful pressure sores and placed Residents 2 and 3 at risk for delay in healing of existing pressure sores. Findings include: The facility's procedure for the Weekly Ulcer Report directed staff to complete an incident report for acquired wounds, and to update care plans for monitoring and services for residents with pressure ulcers. The facility's policy read: " To ensure that residents who enter the facility without a pressure ulcer do not develop pressure ulcer unless their clinical condition demonstrates the pressure ulcers was unavoidable, the facility with have care plan development to prevent skin breakdown and monitor interventions to determine effectiveness". The policy guidelines for the implementation of care and services to prevent residents from developing pressure ulcers included the following interventions to minimize pressure for residents in bed: (1) repositioning, at a minimum, every 2 hours, (2) use wedges and pillows to maintain good body alignment and avoid skin-to skin contact, (3) use pressure redistribution mattresses, (4) keep heels off bed ' s surface, (5) limit the number of layers between the resident and pressure redistribution mattresses. For residents in wheelchairs: (1) "Instruct resident to shift position every 15 minutes if able, (2) reposition every 1-2 hours if resident unable to reposition independently, (3) use pressure redistribution cushions, (4) maintain good body alignment in wheelchair". RESIDENT 1: Resident 1 was admitted [DATE] with a [DIAGNOSES REDACTED]. The quarterly nursing assessment, dated 10/23/13, documented the resident' s skin was in good condition and she was continent of bladder and bowel. A nursing note entry, dated 11/1/13, documented Resident 1 had no skin integrity issues this quarter. The Skin assessment scale for 8/23/13 and 10/23/13 revealed she was at low risk for skin breakdown. The quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had no pressure ulcers and required 2 person assistance with bed mobility, transfers and toileting. The MDS indicated she was at risk for pressure sore development due to immobility, had a pressure reducing device in her chair and bed. The Care Plan goal was for the resident to have no avoidable pressure ulcers/sores. On 1/7/13 at noon, Resident 1 was observed seated in her wheelchair. The seat of her wheelchair had a cushion covered with a bath towel that was double folded on the seat of the cushion. She stated she had the towel on her cushion as she was unable to get positioned correctly due to the sore on her bottom. The resident stated she was unable to get into bed on her own, she required one person assistance of staff for transfers and she needed help for repositioning in bed. During this interview, the resident informed the surveyor that she had recently been " dehydrated and " laid in bed for 4 days ". She stated she had a sore on her buttock and it "hurt" and "burns all the time," especially when changing the dressing covering the wound. She also stated her bed had a foam type pad which sat on top of her mattress, which a family member had provided. Review of the clinical record revealed the resident had [MEDICAL CONDITION] of her lower extremities, swelling of ankles and foot pain beginning 11/2/13. Nursing notes indicated antibiotics and pain medication were initiated for this change in condition. Nursing notes entries from 11/12 to 11/14/13, documented the resident's condition changed. She required antibiotics, she experienced nausea, an elevated temperature, confusion, low blood pressure requiring oxygen and intravenous fluids (IV). In addition to these changes, she was noted to have changes to her skin on her buttock. The skin was described on 11/14/13 as being "purple in color, non blanchable" on her coccyx area. At this time, Resident 1 was also refusing to eat, was less responsive and spent more time in bed. Even though Resident 1 had a condition change with a decrease in bed mobility and was identified to have alterations in skin integrity, there was no documented evidence a plan of care was developed to prevent pressure on her coccyx and/or to avoid further skin breakdown. There was no documented measurement of the Stage 1 pressure ulcer to her buttock. (Stage 1 pressure ulcer-area of persistent redness, the ulcer may appear with persistent red, blue, or purple hue). The nursing note, dated 11/17/13, documented Licensed Nurse (LN) applied barrier cream on the Resident ' s buttock and coccyx due to skin breakdown and episodes of loose stool. The Treatment Administration Record (TAR) for November 2013 revealed the resident was on weekly skin checks. On 11/19/13 the Licensed Nurse (LN) documented the resident now had a Stage 2 pressure ulcer on her buttock which was assessed to be still present on 11/27/13. (Stage 2-partial thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough.) Review of the facility's Weekly Ulcer Measurement Tool, dated 11/18/13 documented the resident had a Stage 2 pressure ulcer that measured 0.5 by 0.3 in size and the wound bed contained 100% granulation, without any drainage. On 11/21/13, the Stage 2 pressure ulcer had decreased in size. By 11/25/13 the ulcer was documented as healed, but the periwound area (tissue around wound area) was described as fragile with purple discoloration. Nursing notes, dated 11/25//13, documented the resident complained of pain to her coccyx and upon assessment of the skin, the pressure ulcer on her coccyx was enlarged to 4 centimeters (cm) by 2 cm in size. There was no description of the wound bed, if drainage was present or the periwound skin condition. Another entry, dated 11/30/13, documented the wound had increased in size and depth. Barrier cream was applied and the physician was notified regarding the wound with a request to "culture " the area. The Weekly Ulcer Measurement Tool, dated 12/4/13, documented the resident had developed two Stage 3 pressure ulcers (Stage 3-full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) while in the facility. The Stage 3 on the left buttock was 3.2 cm by 1.5 cm in size, the wound bed contained 100% slough (dead tissue) and had periwound [DIAGNOSES REDACTED] (redness). The right buttock/coccyx pressure ulcer measured 3 cm by 2.5 cm with 0.2 depth and contained 30% slough. The periwound area around each pressure ulcer was " purple " in appearance. Not until the pressure area(s) deteriorated from Stage 1 to Stage 3 ulcers did the facility assess the resident' s wheelchair cushion. The physician's orders [REDACTED]. On 1/7/13 at 1:15 p.m., the Director of Nursing (DNS) was interviewed regarding how Resident 1 developed pressure sores. She stated the pressure ulcer was a result of Resident 1 ' s immobility due to her [MEDICAL CONDITION] and being bedridden. The plan to prevent further decline included a special cream to the skin and LNs were to monitor the area. The DNS had no information regarding other care plan interventions to address the impact of the resident's decreased mobility on the resident's skin. The Director of Nursing stated the pressure ulcer deteriorated and was unavoidable due to the resident's compromised positioning in her wheelchair, and preferring to lie on her "backside" when positioned in bed. The DNS verified the specialty cushion was not initiated on 12/4/13. On 1/7/14 at 2:30 p.m., the corporate consult (CC) reviewed the clinical record. She stated the resident had a decline from 11/14 to 11/19/13 and Resident 1 was noted to not be getting out of bed or eating. The skin assessment for 11/18/13 revealed a Stage 2 pressure ulcer with 100% granulation in the wound bed and on 11/25/13. The DNS and Resident Care Manager (RCM) noted the same area to be purple discoloration and when the resident complained of discomfort, the area was assessed as "reopening" and measured 4cm to 2cm in size. The Treatment Administration Records (TAR) and nursing notes revealed LNs documented application of a barrier/cream to her buttock/coccyx and special cream, along with daily shift monitoring of the coccyx area. By 12/4/13, the area being monitored had deteriorated. The two documented pressure sores's of the buttocks contained 100% slough (dead tissue). When the DNS and CC were asked on 1/7/14 about individually appropriate pressure relieving interventions, the DNS stated a specialty (roho) cushion was not placed in Resident 1' s wheelchair until 12/4/13 and the resident had a pressure reducing mattress on her bed (foam overlay provided by her family). At 3:30 p.m., Resident 1's wheelchair cushion and mattress were observed with the DNS and CC. During this observation, the resident stated her wheelchair cushion was uncomfortable. When the CC assessed and lifted her wheelchair cushion, it was discovered the resident had two cushions in her wheelchair. The foam mattress pad was observed on top of her pressure relieving mattress. On 1/9/14, the DNS verified the specialty cream was not ordered by the physician until 1/8/14 which was being applied by LNs every shift for the Stage 2 pressure area. The specialty cream order was hand written on the TAR for November and December 2013, however the monthly signed physician orders [REDACTED]. The DNS had no additional information regarding the lack of timely and appropriate interventions to address skin breakdown for Resident 1. RESIDENT 2: Resident 2 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The wound specialist's note, dated 8/19/13, documented the pressure ulcer on the right heel measured 5 centimeters (cm) by 6cm in size and there were two pressure ulcers on her left heel. One measured 4cm by 4.5 cm and the other measured 2 cm by 2cm in size. The wound specialist recommended Resident 2 be followed weekly. The Minimum Data Set (MDS) assessment, dated 11/5/13, indicated Resident 2 was dependent on staff for repositioning in bed and transfers, was at risk for skin breakdown and had pressure ulcers on admit. On 1/7/14 at 10:00 a.m., Resident 2 was observed in bed. Both heels rested against the surface of the mattress. A cushion device was under her knees. She stated her heels hurt. When she lifted her legs, two areas of black eschar were noted on her left heel and one area of eschar on her right heel. The physician's orders [REDACTED]. Review of the facility's pressure ulcer healing chart from 8/20/13 to 12/4/13 indicated the pressure ulcers on the right heel and the two pressure ulcers on the left heel remained unchanged since admission on 8/20/13. The three pressure sores contained 100% eschar (dead tissue) and revealed there was no improvement in the last 5 months. According to the care plan and physician's orders [REDACTED]. The facility's weekly ulcer measurement tool documented the pressure ulcers on her heels were Stage 4 pressure ulcers and their wound beds contained 100% eschar (black, brown, or tan tissue that adheres firmly tothe wound bed). On 1/9/14 at 10:45 a.m. during an interview with the DNS, she stated the treatment plan for Resident 2 ' s pressure ulcers had not changed since October 2013. On 1/10/14 at 9:25 a.m., the DNS verified the physician's orders [REDACTED]. On November 6, 2013, the resident was seen by a podiatrist for evaluation of her feet as she was at risk of skin breakdown due to her [MEDICAL CONDITION] and diabetes. The podiatrist recommended the facility continue to observe the residents' feet, provide heel support, a foot cradle in bed and follow up for wound care for her heel ulcers. There was no documented evidence, the LNs had coordinated care with the podiatrist regarding care and intervention to promote wound healing. Even though the resident's physician ordered a wound consult 8/13/13, and a podiatrist recommended a follow up on 11/6/13 due to her heel ulcers, there was no documented evidence the facility had followed through on these orders/recommendations. The LNs directed treatment plans for Resident 2's pressure ulcers. The current Care Plan directed staff to "float heels" and the Care Guide read: "floating device under heels". There was no documented evidence the facility evaluated whether the plan of care was appropriate for the healing of Resident 2's heel ulcers or coordinated care (as ordered) with a wound specialist until 1/13/14. RESIDENT 3: The facility's policy for residents with pressure sores indicated that the Registered Dietitan (RD) needed to evaluate residents' daily caloric, protein and fluid needs. Resident 3 was re-admitted to the facility on [DATE] with multiple pressure ulcers. Review of Resident 3's admit weekly ulcer measurement tools, dated 12/12/13, documented her right hip had a Stage 3 pressure ulcer. The pressure ulcer contained 100 % slough in the wound bed with maceration and discoloration around the ulcer. Three Stage 4 pressure ulcers (Stage 4- full thickness tissue loss with exposed bone, tendon or muscle) were assessed on the left hip, sacrum and right ishial area. On 12/13/13 her hemoglobin values were noted to be low. Record review revealed the resident frequently refused her medications, and her tray monitoring for Decmenber 2013, indicated refusal of meals or staff failure to document meal and fluid intake. Resident 3's nutritional and hydration needs for wound healing were not assessed by the RD until 12/24/13, almost 2 weeks after the resident was readmitted . At that time, the RD recommended health shakes with meals, a nutritional supplement three times a day and to check the resident's iron panel due to the low hemoglobin laboratory values obtained on 12/13/13.

Based on interview and record review, the facility failed to assess, and/or monitor hydration status for two of 2 residents (Resident 1 and 3) who were at risk for dehydration due to gastrointestinal symtoms, infections, and/or fever. Failure to monitor, document, assess and care plan for hydration status resulted in harm for Resident 3 who developed acute [MEDICAL CONDITION] that required hospitalization . Failure to accurately monitor Resident 1 placed the resident at risk for inadequate fluid intake to meet hydration needs. Findings include: RESIDENT 3: Resident 3 was re admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. She had a supra-pubic catheter for urine drainage, a [MEDICAL CONDITION] for stool collection and a peripherally inserted central catheter (PICC) for intravenous antibiotics. The IV order sheet, dated 12/12/13, directed staff to monitor the resident's intake and output. The re-admit nursing assessment revealed Resident 4 had multiple pressure sores, was dependent on staff for repositioning in bed and eating and received two intravenous (IV) antibiotics. Resident 3's blood levels were to be drawn from her PICC line to monitor and determine the effectiveness of the antibiotic. The laboratory (labs) levels were to be performed to ensure renal (kidney) function was not being affected by the IV antibiotics to avoid toxicity and possible [MEDICAL CONDITION]. The resident's renal blood levels for 12/16/13 were within normal range. Review of the nursing notes, from 12/14 to 12/25/13, documented the resident had periods of lethargy, refusal of meals, loose stool, and episodes of nausea with vomiting. On 12/22/13 at 1330 the nursing notes revealed the resident was lethargic and had a drop in her systolic blood pressure (BP) to 100. The physician was notified. An order was received to monitor the blood pressure and if "blood pressure continues to drop, send to emergency room ." Review of the facility vital sign flow sheet revealed the BP for 12/22/13 at 0900 was recorded, and the low pressure of 100 was documented in the nursing notes. There was no further documented evidence the LNs recorded the BP readings even though the Licensed Nurse (LN) documented " checked BP every hour " . A nursing note entry, dated 12/23/13 at 0600, documented the resident's blood pressure was low (systolic of 98) at midnight and the BP was being checked hourly. There was no documented record regarding these BP readings. The physician was notified and an order was obtained to infuse fluids continuously per the resident's IV line. On 12/23/13, Resident 3's renal blood levels were found to be elevated. The Medication Administration Record [REDACTED]. Additional nursing notes, dated 12/23 and 12/24/13, documented the resident continued to have nausea with vomiting and an altered mental status. On 12/25/13, when she was found to be unresponsive, she was transferred to the hospital. Review of the tray monitor (TM) for December 2013 was incomplete since her re-admit to the facility on [DATE]. The TM revealed she had refused meals from December 22 until December 25, 2013, when she was transferred to the hosptial. Even though Resident 3 continued to refuse meals, her hydration status was not assessed or monitored. Her intake and output flow sheet was incomplete and had no adequate hyration parameters. Review of the plan of care revealed no evidence of identification of hydration status as an issue or concern for her, even though she required additional IV fluids, had vomiting, loose stools, multiple wounds and a change in level of consciousness. On 1/9/14 at 11:30 a.m., the Director of Nursing (DNS) was interviewed regarding the facility ' s policy and procedure for assessing and monitoring hydration status. The DNS stated if a resident received IV fluids, was at risk for dehydration, had poor intake, a urinary catheter, gastrointestinal symptoms such as nausea with vomiting or diarrhea, she expected nursing staff to assess the data for hydration status and develop a care plan. On 1/10/13 at 9:50 a.m., the Resident Care Manager (RCM) was interviewed regarding Resident 3' s hydration. She stated prior to the resident being discharged to the hospital on [DATE], she had loose stools, watery vomit and IV therapy. The RCM stated Resident 3' s cognitive status had declined with medication changes and she now required staff to hold her emesis pan to contain her emesis. The RCM verified the LNs should have assessed and/or monitored the resident's hydration status. The hospital's emergency room history and physical , dated 12/25/13, documented the resident was in acute [MEDICAL CONDITION] and had an urinary infection related to dehydration due to poor intake and persistent nausea with vomiting. The hospital note revealed they aggressively hydrated Resident 3 to address her renal status and the antibiotic dosage was adjusted/changed. RESIDENT 1: Resident 1's quarterly nursing assessment for 10/23/2013 revealed her appetite was good and she was on a regular diet. The area for fluid intake was blank. Record review revealed the resident developed a Stage 1 pressure ulcer on 11/14/13 that deteriorated to two pressure ulcers which the facility documented as Stage 3 . Review of the nursing notes for November 2013, revealed the resident had received three antibiotics,had loose stools, refused meals and had a temperature. Nursing note entries for 11/13 and 11/14/13 revealed the resident exhibited cognitive changes, muscle tremors, weakness and fatigue. On 11/13/13, a referral to the Registered Dietitian (RD) was made due to Resident 1 ' s infection ([MEDICAL CONDITION]).The RD indicated her weight was stable at 131 pounds and her fluid goal was 1800 cc per day. On 11/14/13, the physician ordered a IV infusion to rehydrate Resident 1. The Medication Record for November 2013 indicated Resident 1 required a total of 3000 cc of IV fluids from 11/14 to 11/16/13 due inadequate oral intake, fever and cognitive changes. Review of the Resident 1's tray monitor for November 2013 documented her intake as follows: 420 cc for 11/12; 480 cc for 11/13; blank for 11/14 and 600 cc intake for 11/15/13. Review of Resident 1's intake and output (I & O) record for November 14, 15, 16, 2013, when she was receiving intravenous fluids was incomplete and did not reflect fluid intake at meals. There was no documented evidence the facility had assessed and/or monitored for adequate hydration status. On 1/9/14 at 11;30 a.m., the Director of Nursing (DNS) stated residents with IVs, poor intake, nausea and vomiting should be on I&O to assess residents' for adequate hydration. On 1/17/14 at 11:05 a.m., the DNS verified the facility did not have a hydration policy. She stated I&O flow sheets should be in place when residents need IV fluids.

Based on interview and record review, the facility failed to meet the mental health needs for 1 of 6 sample residents (Resident 1). Failure to update the resident ' s plan of care to include individual interventions for behaviors of yelling out and self-mutilation resulted in harm for the resident and placed other residents at risk for diminished quality of life. Findings include: Resident 1 was admitted to the facility in 2010 with [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED].. The resident's plan of care (POC), dated 9/2/10 identified a problem with "Mood state related to [DIAGNOSES REDACTED]." Interventions included: "Redirect as needed by asking her to stop picking and then request her to express her current feelings of agitation" and "Communication is key...Work with her to resolve her feelings and/or refer her to Social Services." On 6/12/12 the facility provide a summary of the resident's behavioral history. The resident had been seen for mental health services by one mental health group until 7/6/11. The resident's POC, dated 1/31/11 identified a problem with "behavioral Symptoms related to [DIAGNOSES REDACTED]. 1) to express why she is anxious and picking." On 7/6/11 the resident requested transfer to a different mental health service. The facility summary indicated the resident exhibited behaviors of calling out, being rude and "verbally abusive" to staff. The facility's quarterly psychoactive medication quarterly evaluation of 11/15/11 identified interventions of "redirection," "activities," "decreased distraction and stimuli," and "1 on 1 interaction" were "ineffective." The resident's antipsychotic medication was increased at that time with "no effect." On 12/12/11 the facility Social Worker (SW) contacted the mental health service group to discuss a higher level of mental health treatment. The resident was discharged to a mental health facility for further treatment. The facility's psychotropic medication review, dated 2/17/12, indicated the resident's behaviors of "refusal of care," "scratching self," "calling out," and "crying" remained stable. Mental health services were discontinued on 2/17/12 due to the resident's ongoing wound needs. The resident's antipsychotic medication was again increased. Review of the Social Services Progress Notes reveal no documentation related to attempt to obtain mental health services for the resident. On 3/13/12 the resident was transferred to another mental health treatment center. During that hospitalization , the resident was seen for a geriatric neuropsychologic evaluation. The physician documented on 3/16/12, "The current cognitive results suggest her behavior problems in her facility are more related to emotional and personality issues versus an organic basis." The resident returned to the facility in early April 2012. The resident's POC was not updated following this hospitalization . On 5/29/12 the resident was transferred to a 3rd mental health treatment setting. The facility progress note, dated 5/29/12 at 11:00 am indicated the Director of Nursing (DNS) asked the resident is she wanted to go to the hospital. The progress noted indicated the resident stated ,"yes I would love that. They need to look at my wounds and I've had a migraine and can't sleep for 2 weeks." The DNS informed the resident she would be sent to a hospital in another county "because they can also help with your counseling and other issues." The resident was not informed she would not be able to return to the nursing home following her hospitalization . During an interview on 6/14/12 with the DNS, he stated the resident was sent to the hospital for her cellulitis and self mutilation. The DNS stated that by sending the resident to the hospital, her psychiatric condition could be evaluated as she yells and scream out and would pick her legs and scalp until they bled. The DNS stated the resident was observed to take combs and self-inflict wounds on her face and legs. Review of the clinical record revealed that the transfer to the hospital was not an emergent need. There was no documented evidence the resident had a significant change in condition. Review of the nursing notes for May 2012 indicated that the resident continued to be abusive to staff and a danger to herself by driving her wheelchair into the street and refusing to listen to staff instructions. The resident's physician's note, dated 5/18/12, documented that the resident "must take responsibility for her own behaviors". The DNS stated the resident's physician had been notified regarding Resident 1's behaviors and redness of her leg and an order was received to transfer the resident to the hospital on [DATE]. Review of the hospital's psychiatric consultation, dated 5/30/12, read: "The patient's nursing director at her skilled facility was very concerned about these chronic behavioral issues. They felt she needed psychiatric intervention and specifically sent her to hospital for that". The psychiatric recommendations read: " I do not feel psychiatric hospitalization is warranted. The patient's chronic self-injurious behaviors are longstanding and baseline, and not something that would be really addressed in a short-term inpatient psychiatric setting". The hospital note, dated 5/30/12, indicated Resident 1 was ready to be transferred back to the facility. On 6/11/12, the hospital's social worker verified that she had notified the facility the Resident was ready for discharge but was informed by the facility that they were unable to take her back. As of 6/29/12 the resident remained in the hospital. On 6/29/12 the facility SW was contacted for the resident's most current POC. She stated that she placed an updated care plan in the resident's record on 4/26/12 as indicated by the social services progress notes. She agreed to fax the current POC to the department. The POC provided by the SW was the POC dated 9/2/10 and 1/31/11. There was no evidence the facility updated the resident's POC and attempted additional interventions following the resident's inpatient hospitalization s in 12/2011 and 03/2012. In addition, neither the resident's multi-disciplinary progress notes nor the social service progress notes identify what recommendations were made for her treatment following hospitalization . The failure of the facility to consistently evaluate the effectiveness of behavioral interventions, implement and assess the effectiveness of different and/or additional interventions and seek mental health professional interventions other than hospitalization resulted in the unnecessary discharged and prolonged hospitalization of Resident 1.

Based on observation, interview and record review, the facility failed to ensure 4 of 14 sample residents (1, 8, 12, & 13), received necessary supervision. Failure to put in place interventions to decrease the number of falls and mitigate the risk for falls; failure to evaluate interventions in place and the plan of care after repeated falls; and failure to thoroughly analyze data and implement progressive measures to ensure resident safety resulted in harm for Resident 1 as evidence by repeated fall. In addition, failure to supervise Residents 1 & 8 resulted in repeated resident to resident altercations; Failure to supervise Resident 12 & 13 resulted in verbally abusive behavior by Resident 13 & fear expressed by Resident 12. Findings include: Resident 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had long and short term memory loss and was dependent on staff for daily decision making. Admission documentation in the progress notes included family had made the facility aware the resident had 14 falls while at the previous living environment. The resident was blind in her right eye. Her medication included a diuretic, 2 different anti-anxiety medications, and pain medication. The resident's care plan for falls was developed on 11/15/10 and had an update on 2/3/11 directed staff to "rule out potential cause of fall (infection, medication, [DIAGNOSES REDACTED]. The plan did not include how her medications may increase her risk for falls or increase her anxiety or agitation. On 4/4/11 the resident's room was observed to have a bed against the wall and mat on the floor next to bed (neither was on care plan). Record review revealed the following: 1. On, 11/16/10 at 6:10 am; the day after admit Resident 1 was in her bedroom and found sitting on the floor next to her bed. The resident was not interviewed to determine why or how she got on the floor. The Preliminary Investigative Summary indicated the resident was sitting on the floor next to her bed and a Nursing Assistant (NA) provided incontinence care at 5:30 am. The Preliminary Intervention/Action Plan was to monitor the resident, continue the use of the fall alarm and consider the use of a fall mat. The Interdisciplinary Team (IDT) concluded the source was established, she was on frequent checks, has a history of falls prior to placement Source established. Will care plan to monitor for taking off alarm. There was no documentation related to the personal alarm placement or activation. 2. On 11/16/10 at 1:30 pm, the resident was in the dayroom and staff heard a noise in the dayroom, the Licensed Nurse (LN) and NA found on the resident on the floor and the wheel chair was tipped onto its side. The clip alarm was off and they were unable to activate it. The preliminary Investigative Summary was left blank The Preliminary Intervention/Action Plan was left blank The IDT team concluded the resident tipped out of her wheel chair. The resident was attempting to leave day room area. The resident was on 15 min checks and they would continue to evaluate. Analysis of the fall did not include when the last time they observed the resident or who or if the alarm was placed correctly. 3. On 11/17/10 at 11:30 pm, the resident was in her bedroom seen on the floor with her feet still in the bed. The resident complained of pain in her left shoulder, ribs, spine, and arm. The resident was not interviewed. The preliminary Investigative Summary indicated the resident had been in bed 15 minutes prior to the fall and the personal alarm was sounding. The Preliminary Intervention/Action Plan indicated the resident may benefit from fall mats, pressure alarm, and a room closer to the LN station and or a sitter and continues on 15 minute checks for safety. The IDT team concluded the resident was placed on a low bed, pressure alarms were ordered, an x-ray was ordered and they would continue frequent checks. Abuse and neglect ruled out. The x-ray indicated the resident had compression at T 11 & 12 but they were unable to determine the age of the compressions. 4. On 11/20/10 at 1:15 pm, the resident was in her room sitting in her wheel chair. The resident "decided to get up out of her wheel chair" and fell to the ground. The resident stated she did not know what happened. The preliminary Investigative Summary indicated the resident was "very impulsive", was unable to lay her down at the time because of nausea. The Preliminary Intervention/Action Plan was to leave her with staff at all times when she was sitting in her wheel chair. The IDT team concluded the resident put on therapy (RT-OT) for safety. Abuse and neglect was ruled out and there were no care plan changes. The analysis did not include when the last time the resident was seen, if the alarm was attached or working or that she had fallen out of her chair 4 days earlier and left in her room alone. 5. On 11/28/10 at 1:00 pm, the resident was in the living room and asked another resident to help her get out of her chair. The other resident attempted to stand her and they both fell to the ground. The preliminary Investigative Summary the other resident had removed Resident 1's alarm. The Preliminary Intervention/Action Plan indicated the LN spoke with other resident about trying to help transfer someone else. The IDT team concluded the source was established and they would continue to frequently monitor the resident. The resident was working with therapy for strengthening. 6. On 11/30/10 at 4:00 pm, the resident was in her room and was found on the floor. Her personal alarm was on and sounding. The resident was attempting to self transfer. The resident was not interviewed. The Preliminary Investigative Summary indicated the resident was attempting to get out of bed and tumbled onto the mat beside her bed. The Preliminary Intervention/Action Plan was blank The IDT team concluded there was no care plan change. Her safety was appropriate and the fall to mat was anticipated. Abuse and neglect was ruled out. The analysis did not include the last time the resident was seen. 7. On 12/4/10 at 5:00 pm, the resident was in the dayroom on the floor with a pillow behind her head. The resident stated she laid on the floor. The preliminary Investigative Summary indicated the resident got out of her wheel chair and laid onto the floor. The Preliminary Intervention/Action Plan was to do a head to toe assessment, place the resident back into bed and ensure all safety measures were in place. The IDT team concluded the resident was trying to get out of her chair. The team will consider a wedge cushion as stated on fall of 12/5. The resident was in a common area for observation but she is impulsive. The analysis did not include mention of the personal alarm or where the resident got the pillow or why the resident was not being frequently checked. 8. On 12/5/10 at 7:30 am, again the resident was found on the floor in the T.V. room and the LN found the resident sitting in front of her wheel chair. There was no mention of the alarm. The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was blank The IDT team concluded the resident was in a common area and has poor safety awareness. The source was established and she would continue to work with therapy for increased strengthening and safe transferring. The team will try wedge cushion. 9. On 12/6/10 at 7:15 am, the resident was observed in the hallway and "just decided to slide down" to the floor from her wheel chair. The preliminary Investigative Summary indicated the resident slid out of chair. The Preliminary Intervention/Action Plan was the resident needed a wedge to help her not slide. The IDT team concluded a wedge cushion was currently in place. The resident is working with therapy, safety was appropriate, the source was established and abuse and neglect were ruled out. 10. On 12/10/11 at 11:00 am, the resident was in her room seen scooting across the floor. The resident stated "I didn't know" The preliminary Investigative Summary indicated the resident was agitated heading toward the bathroom. The resident had been toileted prior to being laid down. The Preliminary Intervention/Action Plan was the LN was recommending a pressure alarm. The IDT team concluded the Resident was trying to go to hallway, got herself out of bed and transferred herself. The Care plan was being followed and they would try noodles for her mattress. There was no evidence the noodles were ever tried. 11. On 12/10/10 at 4:00 pm, the resident was in her room and an NA found her on the floor. The resident was not interviewed. The preliminary Investigative Summary indicated the resident crawled out of bed. The Preliminary Intervention/Action Plan indicated the resident had a low bed with bed alarm, and mats on both sides of the bed. The IDT team concluded the Care plan was appropriate and being followed. Mats were in place, the resident continued to have no injury and abuse and neglect were ruled out. The care plan did not include the mats or the noodles from the previous fall. There was no evaluation if the mats may be causing the resident to fall. 12. On 12/12/10 at 5:00 pm, the resident was in the hallway in front of the nurse's station. Her alarm was sounding and the resident was unable to describe what happened. The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was blank The IDT team concluded they would evaluate the wheelchair sitting cushion for a possible pummel or larger wedge. The source was established and abuse and neglect was ruled out. 13. On 12/13/10 at 8:40 am, the resident was in the dining room, stood up, turned and fell down. The resident was not interviewed. The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was blank The IDT team concluded they would evaluate the wheelchair cushion. The team was still considering a larger wedge or other alternative. The source was established and abuse and neglect was ruled out. 14. On 12/20/10 at 2:45 pm, the resident was in her room, a therapist walked by and saw the resident on the floor. The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was blank The IDT team concluded a urinary analysis was pending and the resident was on an antibiotic that was started on 12/28/2010. New orders for an increase in anti-anxiety medications were received secondary to the resident ' s anxiety and agitation. Abuse and neglect was ruled out. The analysis of the fall did not include evaluating any of the previous interventions or if the medication may contribute to the fall. 15. On 12/20/10 at 3:30 pm, the resident was taken to the bathroom, left alone, then was found on the bathroom on the floor. The resident received an abrasion to her mouth, and a bump to the back of her head. The preliminary Investigative Summary indicated to see NA witness statement The Preliminary Intervention/Action Plan The IDT team documented a urinary analysis was done. The care plan would be changed to not leave the resident unattended in the bathroom and the care plan was being followed. There was no evidence the care plan was changed. 16. On 12/21/10 at 10:00 am, the resident was in her room yelling "help me, help me". Another resident decided to go into the room and try and help and both residents ended up on the floor. The preliminary Investigative Summary "Resident climbing out of bed per usual on to her mat" The Preliminary Intervention/Action Plan indicated the LN documented "?? Don ' t know!!" The IDT team concluded there was safety plan in place. Staff would anticipate further falls. The facility would continue to protect. The care plan goal was for the resident to have falls without injury. The analysis did not include how they would continue to protect. 17. On 12/28/10 at 3:00 pm a therapist walked by the room and found the resident on the floor. The resident stated "I want to go to the bathroom." IDT team concluded there was a urinary analysis pending and the resident had been started on antibiotics on 12/28/2010. There were new orders for anxiety medications were received secondary to anxiety and agitation. Abuse/Neglect ruled out. The analysis did not include if the resident was previously on anti-anxiety medications how they would monitor the effects of the medications. 18. On 1/17/11 at 2:45 pm the resident was in the hallway and was attempting to get out of her wheel chair, she lost her balance and fell into a resident's door. The resident was unable to describe what had occurred. The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was to have a one on one NA throughout the evening. The IDT team concluded the resident continued with impulsive behaviors and had poor safety awareness. She wanted to go home and continued to attempt ambulation. A safety belt would increase her agitation and a wedge won ' t work. The facility would continue with current care plan, even though the facility had not made any changes to the plan of care. 19. On 1/21/11 at 8:30 pm the resident was in her room when staff heard a "thump". The resident was found on the floor between her bed and the closet. The resident was asked if she hit her head and she stated "yes, my head hurts." Two LNs noted bruises on her left arm, but they looked old. There was no mention of the personal alarm The preliminary Investigative Summary was blank The Preliminary Intervention/Action Plan was blank The IDT team concluded the source of the fall was identified. The resident was impulsive and her alarm was changed to pressure alarm. No new interventions were appropriate at that time. 20. On 2/5/11 at 9:20 am, the resident attempt to self-transfer from her wheel chair to another chair in the resident s room. The resident complained of pain in her low back and bottom area. The resident was barefoot because she had previously removed her socks. The preliminary Investigative Summary indicated the resident's alarm was sounding and the LN & NA rushed into the resident's room and saw the resident fall. The resident was not wearing socks. The NA had put the resident in the room for a moment, with the intention of coming back. The Preliminary Intervention/Action Plan indicated the resident was checked for injury and none were found. The resident was placed back in the chair. The LN would communicate with staff to put the resident in the room only if they were taking her to bed, otherwise to keep her in a common area. The IDT team concluded Abuse and neglect were ruled out. Safety devices were in place and recent medication changes were done approximately one week prior. The team would see if that that changed behaviors and would continue to monitor impulsiveness. The analysis did not include why the resident had been left alone in her room in a wheel chair if she was so impulsive and had poor safety awareness. Again medications were not reviewed. 21. On 2/5/11 at 1:45 pm, the resident was last seen in her wheel chair with her alarm attached. Staff heard her alarm and found the resident on the floor sliding on her bottom calling for help and she had removed her socks. The preliminary Investigative Summary indicated the resident was found on the floor between her wheel chair and a stationary chair. The Preliminary Intervention/Action Plan indicated the resident was checked for injury, placed in the wheelchair and taken out to the nurse's station. The IDT team concluded the Safety devices were appropriate and staff would anticipate further falls. The resident was impulsive and had poor safety awareness. The care plan was being followed the resident was not attempting to toilet but was self transferring. The facility would continue with the current care plan. Again care plan was not being evaluated or revised. 22. On 2/12/10 at 9:30 pm, the resident was in the dayroom found on the floor. The resident was not interviewed, but there was a witness mentioned, but no witness statement attached to the investigation. The Preliminary Investigative Summary indicated the resident was found on the floor by her wheelchair and according to the witness the resident fell out of her wheelchair. The Preliminary Intervention/Action Plan was blank The IDT team concluded there were recent medication changes also they had increased pain medications. The resident was sleeping more during day. All interventions were in place the alarm functions, and possibly removed by resident. Abuse and neglect were ruled out. There was no evidence that pain medications were increased or changed. 23. On 2/18/11 at 4:40 pm, the Preliminary Investigative Summary indicated the resident was in her room with the door closed and staff heard knocking on her door and she was yelling for help. The resident had fecal matter on the floor next to her. The alarm was still attached to the resident but had not come unclipped from the battery base box, so the alarm was not sounding. The Preliminary Intervention/Action Plan was blank The IDT team concluded the care plan was being followed. Safety precautions were in place and the resident was impulsive. The facility would continue with the plan of care and continue to monitor behaviors. The analysis did not include why her door was shut if she was on frequent checks. 24. On 2/23/11 at 11:30 am, the preliminary Investigative Summary indicated the resident was in her room calling for help. Staff entered the room and found the resident on the floor. The resident stated she fell from her wheelchair and complained of pain in her arm. The resident had an abrasion to the left elbow. The alarm did not go off, but was working in the wheelchair the last time staff was with her. The Preliminary Intervention/Action Plan was to monitor the resident by keeping her closer to staff and in public areas to prevent self transfers and to check the alarm more frequently. The IDT team concluded the resident's alarm was heard going off 10 minutes prior. The resident had poor safety awareness. The facility would get a therapy evaluation and continue to closely monitor the resident. Again the resident was in her room and in her wheelchair unsupervised. 25. On 2/24/11 at 6:00 pm, the preliminary Investigative Summary indicated the resident was in the hallway when she tried to self transfer from her wheelchair to another resident's wheelchair and fell . The Preliminary Intervention/Action Plan was blank The IDT team concluded the source of the fall was established. The resident was impulsive and without safety awareness. The facility would continue to monitor. The facility would get a therapy evaluation and Abuse and neglect was ruled out. 26. On the same day at 8:20 pm, the preliminary Investigative Summary indicated the resident was in the dayroom, went to transfer to her wheel chair and sat on her bottom. The resident was unable to describe what happened. The Preliminary Intervention/Action Plan was to have one to one NA staff with her. The IDT team concluded the source of the fall was established. The resident self transfers, she had an increase in activity that day with 2 falls and was closely monitored. The resident had recent medication changes. The fall was related to multiple strokes. The resident's anti-anxiety medication was increased on 2/22/11. The facility did not review the medications to see if they contributed to the falls. 27. On 3/22/11 at 6:00 am, the resident was in her room, found on the floor and was unable to describe what happened. The preliminary Investigative Summary indicated this was not witnessed because of change of shift. The Preliminary Intervention/Action Plan was to assign one to one staff. The IDT team concluded the resident got out of her wheelchair. The resident was in the day room. The fall was reasonably related to her condition. She had been toileted just prior and has poor safety awareness. 28. On 3/24/11 at 2:10 pm, the preliminary Investigative Summary indicated the resident was found on the floor in her bathroom The Preliminary Intervention/Action Plan was blank The IDT team concluded the event happened at the change of shift. The fall was reasonably related to the resident's condition and there were no care plan changes at that time. 29. On 3/31/11 at 11:30 am, the preliminary Investigative Summary indicated the resident was in her room and the alarm was sounding. The resident was not interviewed but received an abrasion on her left knee. The Preliminary Intervention/Action Plan was to monitor the resident at frequent intervals. If the resident was awake in bed staff would offer to get the resident out of bed for toileting and assist her to the wheelchair. The IDT team concluded the care plan was appropriate and being followed. The resident continued with her impulsive behaviors and abuse and neglect was ruled out. 30. On 4/5/11 at 10:00 am, the preliminary Investigative Summary indicated the resident was sitting on the floor in front of her bed. The resident's alarm was in place but unhooked. The Preliminary Intervention/Action Plan indicated that all safety interventions were in place after incident. The LN reminded the resident to ask for assistance in transferring. The IDT team concluded the resident had just been laid down approximately 4-5 minutes prior. Safety devices were appropriate. The resident's condition was impulsive, not focused and she did not have any safety awareness. The facility would continue with the current care plan. Abuse and neglect were ruled out. 31. On 4/7/11 at 4:15 pm, the preliminary investigative summary indicated the resident was being toileted by the Resident Care Manager (RCM). The RCM went to the door of her room to ask for assistance and the resident stood up and fell . The Preliminary Intervention/Action Plan indicated the care plan was being followed at the time of the incident and all safety devices were in place and functioning. The IDT team concluded the fall was unavoidable at residents due to her clinical condition. The resident was not unattended and continues with impulsive behaviors. The facility would continue with the current care plan. The analysis did not include why the resident was left alone even though on 12/20/10 the facility documented the care plan would be changed to not leave the resident alone in the bathroom On 4/8/11 a "Fall Intervention" form was completed and indicated the safety interventions were: Resident was to wear non-skid footwear in bed Do not leave the resident alone in the bathroom or on commode Body pillows / positioning pillows Move bed against on wall PVC low bed Cushioned mat next to bed Alarm in bed Alarm in wheelchair Under to Comments section: there was documentation "Current safety interventions appropriate" and "Falls related to resident's condition" There was no evidence this form had been filled out after any of the other falls. The Nursing Assistant (NA) "Resident Care Guide" written on 11/15/10 indicated: "Safety" use clip alarm in bed and wheelchair, toilet upon rising, before and after meals / bed and do not leave alone in bathroom. The NA "Resident Care Guide" rewritten on 2/3/11 indicated for: "Safety" uses pressure alarm in bed and wheelchair, toilet upon rising, before and after meals / bed and do not leave alone in bathroom. Special equipment: Bedside Mat and Bed in the lowest position. In an interview on 4/8/11 at 3:30 pm, The DNS stated "the resident had a history of [REDACTED]. The facility did not thoroughly analyze interventions or how they impacted the resident. The resident had multiple increases in her anti-anxiety medications without determining if they could cause a fall. The resident also had pain that was not evaluated to determine if it could cause anxiety. Resident 8 Resident 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's last Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was independent in all of his activities of daily living, including ambulation throughout the facility. Resident's 1 and 8 lived in different hallways. Resident 1 would have to propelled past the nurse's station and SSDs office to get to Resident 8's room. On 3/22/11 an LN documented on an incident report that Resident 8's door was opened by Resident 1. Resident 8 got very upset, started yelling and was threatening Resident 1. The residents were isolated at that time, but 10 minutes later the same occurrence happened. The preliminary plan was to provide 1:1 staffing with Resident 1. The SSD interviewed Resident 8 the following day on 3/23/11. Resident 8, who had cognitive impairments, agreed that if he had a problem with Resident 1 he would report it to staff. Two days later on 3/24/11, an LN documented on an incident report she observed Resident 8 "showing increased anger regarding Resident 1 in front of the nurse's station." It was reported that Resident 1 had entered Resident 8's room, uninvited multiple times. After one of the incidents Resident 8 came up from behind Resident 1, grabbed her wheel chair and "shook it with force." NA 3 documented on a witness statement that Resident 1 opened Resident 8's door repeatedly and it frustrated Resident 8. "They were very unusually angry." The facility failed to provide enough supervision for Resident 1 or Resident 8. Resident 1 & 8 both still resided in the facility. Resident 8's care plan was reviewed and there was no revision to care plan after any of the above incidents. Resident 12 On 11/28/10 an LN documented on an incident report that Resident 12 stated he was getting his meal tray when Resident 13 said, "You're out of line, you're going to get it" Resident 12 told Resident 13 he was going to get his and leave him alone. Resident 12 went to his room and stated he felt "scared" of Resident 13. The LN also documented on the incident report that Resident 12 was alert and oriented x 3, there was no apparent injury and he went back to his room. He stated he was very upset and he planned on staying in his room the rest of the evening. On a witness statement written by NA 1 there was documentation that NA 1 interviewed Resident 12 after the incident. Resident 12 stated there had been an ongoing problem with Residents 12 and the other resident (13). The NA documented Resident 13, for whatever reason had been harassing and been somewhat of a bully to Resident 12. Of course, this is only one side of the story, but it seemed something needed to be done to ensure quality of living. There was no investigation into the harassment or bullying by Resident 13. In a question/answer statement with Resident 12, he was asked "What happened next? Resident 12 replied "I went back to my room and he went back to his. I don't like it when he drinks. Another question was "Are you afraid of Resident 13?" Resident 12 responded by saying, "Ya, I'm afraid he will hurt me." On 4/11/11, the SDC stated Resident 13 did drink alcohol and that was something that was being worked out with the Ombudsman, the DNS, the SSD and care planning. The facility had knowledge that Resident 13 consumed alcohol and had a physicians order allowing the resident to drink one beer everyday. The facility had not developed a plan of care to increase supervision to prevent Resident 13 from verbally abusing residents. See F 225 for failure to consistently & thoroughly investigate accidents and incidents.

Based on observation, interview and record review, the facility failed to administer services effectively and efficiently in order to attain, and/or maintain, each resident's optimal physical, mental and psychosocial well-being. This failure resulted in harm one resident (1) and placed the other residents at risk for abuse, neglect and a decreased quality of care. Findings include: 1. The Administrator failed to ensure incidents were thoroughly investigated or allegations of abuse were reported to the appropriate entities as required. No action was taken to protect residents from further potential abuse. Named staff in the allegations of abuse were allowed to continue to have unsupervised access to the residents, thus perpetuating the potential atmosphere of fear and intimidation. Refer to F 225 Investigate/Report Allegations/Individuals 2. Administration failed to ensure the facility provided adequate supervision and maintained an environment that was as free as possible from accident hazards for 1 resident and also failed to provide enough supervision to prevent resident to resident altercations. This failure resulted in harm for one resident related to repeated falls with injuries and created an atmosphere of fear for another resident. Refer to F 323-Accidents and supervision