Every finding on record at Willow Springs Care and Rehabilitation

Based on observation, interview and record review the facility failed to protect a resident's right to be free from verbal and physical abuse for 1 of 3 residents (Resident 1) reviewed for abuse investigations. This failure placed residents at risk for further abuse, injury, and diminished quality of life.Findings included .Record review of the facility's policy titled, Abuse Prevention Program, dated 10/01/2021, showed that the residents had the right to be free from abuse and the facility would protect residents from abuse by anyone including other residents. Resident 1 Record review showed Resident 1 was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a potentially disabling disease of the brain and spinal cord) and depression. Record review of the 03/12/2026 comprehensive assessment showed that Resident 1 had moderate cognitive impairment and used a wheelchair for mobility. Record review of Resident 1's 03/09/2026 care plan showed they enjoyed socializing one-to-one with staff, small groups and visitors. Resident 1 was encouraged to engage in peer interactions during hallway or common area encounters when the resident was willing. Further review showed Resident 1 was at risk for impaired skin integrity related to impaired circulation and dry fragile skin. Resident 2 Record review showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), delusional disorders (a fixed false belief that is resistant to reason or confrontation), and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). Review of the 03/21/2026 comprehensive assessment showed the resident had moderate impaired cognition. Resident 2 was at risk for physical and verbal behaviors directed towards others that put others at risk for physical injury. Record review of Resident 2's care plan, dated 05/01/2026, showed the resident would have verbal abusive outbursts toward staff and residents. The interventions included removing Resident 2 from the situation and taking them to an alternative location. Record review of an incident report dated 05/11/2026 showed while residents were waiting for the dining room to open for breakfast, Resident 1 and Resident 2 had a verbal altercation that became physical and Resident 1 received some scratches on their arm. During a concurrent observation and interview on 05/26/2026 at 11:00 AM, Resident 1 was observed in their wheelchair in their room. The resident stated that [Resident 2] was giving another resident the bird and I went near [Resident 2] to find out what was going on and got grabbed on the arm by [them]. Resident 1 pulled up their left sleeve and showed a three centimeter (cm) by five cm steri-strip (a thin, sticky bandage made of special tape that you can put across a small cut or wound to help the two sides of the skin stay together as it heals) dressing on the left forearm that was clean and intact. Resident 1 stated they were waiting for it to heal. During an interview on 05/26/2026 at 11:18 AM, Staff B, Licensed Practical Nurse, stated that they heard Resident 1 and Resident 2 shouting at each other, came around the corner and saw Resident 2 holding onto Resident 1's left forearm. Staff B assisted Staff C, Director of Rehab, to separate the two residents. Resident 1 had three skin tears (a traumatic wound caused by friction, shearing or blunt force that separated the top layers of the skin, the epidermis and dermis) on their left arm that were bleeding. Staff B stated they cleaned and steri-stripped the wound. During concurrent observation and interview on 05/26/2026 at 1:00 PM, Resident 2 was observed in their room on the bed. They stated they did not recall grabbing anyone and added I would never do that. During an interview on 05/26/2026 at 2:00 PM, Staff C, stated they heard the yelling from their office and came out to find Resident 2 had grabbed Resident 1 on the arm while they continued to yell at one another. They were both very angry and separated by myself and Staff B without further incidents. Staff C stated they had heard Resident 2 yell at staff, but this was the first they were aware of physical contact with another resident. Record review of a 05/11/2026 at 8:29 AM progress note by Staff B showed that Resident 1 received three skin tears on the left forearm that were each two cm, four cm and two cm. The wounds were cleansed, dried, approximated (the two sides of a wound were brought together so they were touching and fit neatly), and steri-strips were applied. During an interview on 05/26/2026 at 3:15 PM, Staff A, Administrator, stated no further incidents had occurred and it was the first time they were aware Resident 2 had been physical with another resident. Reference: WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) that did not have the proper labels and dates for food safety tracking, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1of 1 kitchen reviewed and 3) ensure the dishwasher sanitizer concentration was effective for sanitation for 1of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses. Based on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) that did not have the proper labels and dates for food safety tracking, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1of 1 kitchen reviewed and 3) ensure the dishwasher sanitizer concentration was effective for sanitation for 1of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses.Findings included .Review of the Washington State Retail Food Code [PHONE NUMBER]6(1)(2)(a,b)(3)(4), dated March 1, 2022 showed ready-to-eat or refrigerated, time/temperature control for food safety must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises. Prepared foods must have the date or day of preparation, with a procedure to discard the food on or before the last date or day the food can be consumed on the premises. Additionally, the concentration of the sanitizing solution must be accurately determined by using a test kit or other device, and the results of the testing must be logged.Review of facility's undated policy titled, Food Receiving and Storage, showed foods shall be received and stored in a manner that complies with safe food handling practices. Staff were to cover, label and date all foods when they are open and the date when the food items must be used by.An observation on 07/20/2025 at 9:09 AM, showed the following items in the kitchen with no label, open date, or use by date visible: <Refrigerator> one uncovered baked goods sprinkles in a two-quart (qt- a unit of measure) container six trays of milk six trays of juice six trays of thickened liquids water/juice/milk one uncovered two qt container of honey dew melon two qt container of minced garlic six slices honey dew melon in shallow pan two trays of coffee cake one large pan with sliced salami two qt container of tuna fish 10-pound (lb- unit of measure) roll of hamburger four polish sausages unwrapped 1/2 lb of hamburger raw in roll package tied in a knot open date of 07/01 no use by date one turkey breast thigh roast one uncovered container of breaded turkey breast on a cart one uncovered container of tomato soup on same cart one uncovered container of cooked hamburger meat on same cart one uncovered container of diced potatoes on same cart one uncovered four tuna fish sandwiches on same cart one container of scrambled eggs on same cart two qt container of crushed strawberries on same cart two qt container of pico de gallo (chopped vegetables condiment) one qt container of cilantro six pack of strawberries in plastic containers two qt container of grapes two qt container of chopped watermelon <Disinfectant Buckets>Review of the manufacturer's instructions for Disinfectant Multi Quat 146 (a chemical used to kill germs on surfaces) showed the parts per million (PPM- the concentration of the disinfectant solution in water) should be between 150 and 400 and the buckets should be tested every two to four hours or when the solution becomes dirty. During an observation and concurrent interview on 07/20/2025 at 9:09 AM, Staff C, Food Service Manager, tested two of three buckets of Disinfectant Multi-Quat solution. Staff C stated the buckets of solution were used to clean the counter tops. The test strips showed the solution had no concentration of the disinfectant in the buckets. Staff C stated they expected the buckets to be tested at least every two hours and changed if needed. Staff C stated the process was not followed and the buckets of sanitizer were not effective to prevent cross contamination. <Dishwasher>Review of the July 2025 Dish room temperature and Sanitizer Log showed no testing of the dishwasher sanitizing solution were completed after breakfast or lunch on 07/21/2025. During an observation and concurrent interview on 07/21/2025 at 1:19 PM, Staff C Stated the dishwasher was a low-temperature machine and used a chemical sanitizer. Staff C tested the sanitizer concentration in the final rinse cycle of the dishwasher using a chlorine test strip (quickly measures the amount of chlorine present in a solution, usually water). The test strip did not register any concentration of sanitizer. Staff C then checked the dishwashing machine's sanitizing bucket and noted no sanitizer was flowing from the bucket through the tubes. Staff C primed the solution and noted no sanitizing solution was moving through the tubes during the priming process. Staff C stated the kitchen staff were to test the sanitizer solution three times daily. Reference: WAC 388-97-1100(3)

Based on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for 2 of 2 shower rooms (Hall Two and Hall One), 2 of 3 resident bathrooms (Hall One) and 1 of 1 laundry room reviewed for a safe and sanitary environment. This failure placed residents at an increased risk for not feeling safe and secure with their environment and unmet care needs.Findings included… <Hall Two Shower Room>During an observation on 07/20/2025 at 10:18 AM, the shower room located on hall two showed three feet (a unit of measure) along the shower wall, a black slimy substance that extended upwards three inches (a unit of measure) onto the wall tiles. To the left side of the shower entrance, there were missing tiles on the corner exposing dry wall, measuring four by five inches. To the left of the sink, a deep gauge was observed on the wall measuring three inches with drywall exposed. Further to the left of the sink, another area showed a deep gauge measuring eight inches by one inch, also with exposed drywall. Directly underneath the sink, a black substance combined with a slimy brownish substance was present on the floor tile. Further observation showed the grab bar next to the toilet was loose and not securely fastened to the wall. During an interview on 07/24/2025 at 10:18 PM, Staff A, Administrator, stated staff utilized Technology Enhanced Learning Services (TELS-an electronic system that allows for inputting and tracking maintenance tasks, ensuring they are completed on time and properly documented) system. Staff A stated they were unaware of the maintenance issues in shower room one. Staff A stated maintenance performed daily rounds, and the issues should have been identified. Staff A further stated staff should have entered the issues into the TELS system, and housekeeping should have also caught them. <Hall One Combined Shower/Resident Bathroom> During an observation on 07/23/2025 at 8:43 AM, the shower room on Hall One showed a bathtub half full of briefs, clothes hangers, rolls of clear trash bags, resident clothes and loose wheelchair pedals. To the right of the bathtub was an over the bed table with a 12-ounce cup with brown stains on the lid and side of the cup. The shower stall drain had a reddish-brown substance surrounding the two screw holes. The hand-washing sink was covered with a white, green residue on the knobs and base of the faucet , and a white paper towel dispenser that had multiple areas of rust. To the right of the sink were two brown bins without lids. One bin contained wet towels and the other contained used briefs and gloves. To the left of the shower stall was a toilet with reddish-brown stains inside the toilet bowl. On the ceiling were two vents that had bubbling paint and material. The ceiling vent near the entrance door had a two-foot by one-foot sheet of disposable wrap stapled to the ceiling. Additionally, upon entrance the shower room had a strong odor of urine. <Hall One Resident bathroom>During an observation on 07/23/2025 at 8:49 AM, showed the resident restroom on Hall One with a toilet seat lid cracked with sharp edges and a trash can that was smashed in on one side with two large holes. The hand washing sink was not secured and detached from the wall. During an interview on 07/25/2025 at 8:47 AM, Staff H, Nursing Assistant, stated when there was an area that needed repaired the process was to notify maintenance by using the walkie-talkie or verbally in the hall when they saw them. Staff H notified maintenance about the broken toilet seat lid when they walked by during this interview. During an interview on 07/25/2025 at 8:49 AM, Staff E, Maintenance Director, stated the process for repair notifications was the staff were to use the TELS system which notified them through an application and tracked all the concerns for them and management. Staff E stated they were only aware of the bathtub needing to be repaired and no other repairs had been requested. Staff E stated the ceiling vents had water leaking through them when the air conditioning was being repaired and they had not fixed the ceiling yet. Staff E stated the sink in the resident restroom became loose three weeks prior and they placed silicone around the sink to reattach to the wall. During a concurrent interview on 07/25/2025 at 9:14 AM, Staff A stated maintenance needed to make the repairs in the resident restroom. Staff A stated the sink had been repaired a few weeks ago and was now loose from the wall again. Staff B, Director of Nursing Services (DNS), stated the air conditioning repairs had been ongoing and was unsure how long the ceiling vents were in the current condition. Staff B stated the shower rooms and restrooms were for the residents’ needs and should be in good functioning condition for their use. During an observation on 07/23/2025 at 8:43 AM, the shower room on Hall one showed had a bathtub half full of briefs, clothes hangers, rolls of clear trash bags, resident clothes and loose wheelchair pedals. To the right of the bathtub was an over the bed table with a 12-ounce cup with brown stains on the lid and side of the cup. The shower stall drain had a reddish-brown substance surrounding the two screw holes. The hand-washing sink was covered with a white, green residue on the knobs and base of the faucet. A white paper towel dispenser that had multiple areas of rust. To the right of the sink were two brown bins without lids. One bin contained wet towels and the other contained used briefs and gloves. To the left of the shower stall was a toilet with reddish-brown stains inside the toilet bowl. On the ceiling were two vents that had bubbling paint and material. The ceiling vent near the entrance door had a two-foot by one-foot sheet of disposable wrap stapled to the ceiling. Additionally, upon entrance the shower room had a strong odor of urine. During an observation on 07/23/2025 at 8:49 AM, showed the resident restroom on Hall one with a toilet seat lid cracked with sharp edges. A trash can that was smashed in on one side with two large holes. The hand washing sink was not secured and detached from the wall. During an interview on 07/25/2025 at 8:47 AM, Staff H, Nursing Assistant, stated when there was an area that needed repaired the process was to notify maintenance by using the walkie-talkie or verbally in the hall when they saw them. Staff H notified maintenance about the broken toilet seat lid when they walked by during this interview. During an interview on 07/25/2025 at 8:49 AM, Staff E, Maintenance Director, stated the process for repair notifications was the staff were to use the TELS system which notified them through an application and tracks all the concerns for them and management. Staff E stated they were only aware of the bathtub needing to be repaired and no other repairs had been requested. Staff E stated the ceiling vents had water leaking through them when the air conditioning was being repaired and they had not fixed the ceiling yet. Staff E stated the sink in the resident restroom became loose three weeks ago and they placed silicone around the sink to reattach to the wall. During a concurrent interview on 07/25/2025 at 9:14 AM, Staff A stated maintenance needed to make the repairs in the resident restroom. Staff A stated the sink had been repaired a few weeks ago and was now loose from the wall again. Staff B, Director of Nursing Services stated the air conditioning repairs had been ongoing and was unsure how long the ceiling vents were in the current condition. Staff B stated the shower rooms and restrooms were for the residents’ needs and should be in good functioning condition for their use. <Laundry Room> During a concurrent observation and interview on 07/24/2025 at 2:05 PM with Staff K, Laundry and Housekeeping Supervisor of the facility laundry room, showed two separate rooms considered as the dirty and clean areas. Two washing machines and two dryers were observed on the clean side of the laundry room. One of the washing machines was broken and the front portal was covered with plastic and sealed off with black duct tape. One of the dryers was also broken and had a piece of paper taped up to the front portal stating, “out of order”. Staff K stated both the washer and dryer had been broken “for months” and they did not know of a plan to have to them repaired or replaced. Staff K stated it was challenging to keep up with all the laundry in the facility with only one functioning washer and dryer, but they were managing so far. Further concurrent observations and interviews with Staff K on 07/24/2025 at 4:25 PM, of the laundry room showed behind the two washing machines were in an area approximately six feet in width by ten feet in length that had two doors leading to the outside of the facility. Both doors had white towels shoved under the gaps in the doors where observable daylight was coming through. The tops of these doors also had gaps in them and observable outside light could be seen. Staff K stated they put towels under the gaps in the doors to keep the weather, dirt and possible animals or snakes out. The flooring and walls in the area were dirty with observable dirt and debris on the concrete floor. The wall and floor trim in this area were lifted, coming off the walls and appeared moldy in appearance. The wall leading into the area behind the washing machines had [NAME]-rigged cords (something that has been made or repaired in a hasty, crude or makeshift way) on the opposite side of the wall where saw marks and broken plaster down to the sheetrock was observed. Observations of four ceiling vents in both the clean and dirty side of the rooms showed two vents in each room that were filled with dirt and lint. When the fan switches were turned on there were no observable working parts seen or heard. Staff K stated they had been employed as the laundry supervisor since 2019, and the fans had never worked as far as they knew and that they themselves had never cleaned the dirt, lint or debris from them. During the same observation and interview, multiple areas in both the clean and dirty sides of the laundry room had peeling paint on the walls and areas where the paint was scraped off down to the plaster. On the west wall of the dirty laundry room there was a large rectangular area that the paint had been scraped off and plastered over with a lumpy grey, brown material. The floors in both areas of the laundry room were noted to be dirty and had visible debris on them. The area in front of the working washing machines had a broken off piece of metal floor stripping that was covered in duct tape. Staff K stated they had to duct tape it down because staff kept tripping over the broken piece. During a concurrent interview on 07/25/2025 at 9:40 AM, Staff A, Administrator and Staff B, DNS, both stated they had observed the laundry room the previous day and acknowledged the laundry room washer and dryer needed to be repaired and the laundry rooms required repair and cleaning in multiple areas. Reference WAC: 388-97-3220(1)

Based on interview and record review, the facility failed to notify the physician of significant changes in condition for 1 of 3 Residents (Resident 4), reviewed for falls. This failure placed the resident at risk for delayed medical interventions and treatment. Findings included . Review of the undated policy titled Change in Residents Condition or Status showed a significant change of condition was a decline in the residents' status that would not normally resolve itself without intervention from staff. The nurse would notify the residents attending Physician or on-call Physician when there had been a significant change in the resident's physical, emotional or mental condition. <Resident 4>Review of Resident 4's medical record showed the resident was admitted to the facility with diagnoses to include heart failure and hypertension (high blood pressure, when the blood is pushing too hard against the artery walls). Review of the significant change assessment, dated 06/24/2025, showed the resident's cognition was intact and required the assistance of one- two staff members for activities of daily living (ADLs). The assessment further showed Resident 4 had a new diagnosis of a right hip fracture and required the use of pain medication. Review of the facility investigation report, dated 06/07/2025, showed on 06/07/2025 at 3:15 AM, the resident was found on the floor in their room, lying on their right side, A neurological assessment (an examination to identify any abnormalities in an individual's level of consciousness) was completed with no deficits noted. There was no documentation of range of motion (how far you can move a joint or muscle) on Resident 4's upper or lower extremities and they had a complaint of a three out of ten on the pain scale (a tool used to help people describe the intensity of their pain, zero means no pain and 10 means the worst pain imaginable) to their right arm. During an interview on 07/20/2025 at 2:08 PM, The Resident Representative (RR), stated Resident 4 fell and broke their hip at the facility. The RR stated it was four days before the facility ordered an x-ray, which then revealed a right hip fracture. The RR stated Resident 4 had been complaining of pain whenever staff attempted to move them since they had the fall. The RR stated the staff had previously attributed the pain to deep tissue bruises sustained from the fall. The RR further stated Resident 4 had not experienced any pain prior to the fall.During an interview on 07/22/2025 at 12:23 PM, Resident 4 stated they had had a fall recently. Resident 4 stated they experienced significant pain in their right hip and arm, which intensified with any attempts at movement, including transfers for therapy. Resident 4 stated their pain subsided when they received Tylenol (a pain reliever) which they preferred and when they remained still in bed. Resident 4 stated the nurse finally got an x-ray and my hip was broken. Record review of the June 2025 Medication Administration Record showed between 06/07/2025 (date of fall) and 06/11/2025 (day x-ray was ordered, four days after the fall occurred) Tylenol (the residents preferred pain reliver) was administered 10 times for mild pain. The highest pain level reported was an eight out of ten on the pain scale. Record review of Resident 4's progress notes between the dates of 06/07/2025 and 06/10/2025 showed no notification to the Primary or on-call Physician regarding Residents 4's 06/07/2025 fall, including new complaints of pain or pain medication usage after the fall. The Physician was not notified until 06/11/2025 which was four days after the fall.During an interview on 07/23/2025 at 9:24 AM Staff J, Registered Nurse, stated they worked on Resident 4's hall during the week of the fall. Staff J stated Resident 4 had been complaining of pain to their right arm and hip. Staff J stated they administered Tylenol for pain and assumed Resident 4 was hurting from the bruising that occurred from the fall. Staff J stated the process for any change in condition was to notify the Physician for further orders. Staff J stated they did not notify the Physician until 06/11/2025 when they noticed Resident 4 had a decrease in their mobility. Staff J further stated they should have notified the physician of the increase in complaints of pain, and they did not do that. During an interview on 07/24/2025 at 3:04 PM Staff B, Director of Nursing Services, stated their expectations for any complaints of pain following a fall or any change in condition was to immediately notify the Physician. Staff B stated they became aware of the need for more training on this process after reviewing falls with injuries during that time. Staff B further stated a structured nurses meeting with the nurses and the Medical Director was held on 07/13/2025, six days after the fall. Reference (WAC) 388-97-0320(1)(a)(b)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual disabilities [ID] or related disorders [RD] are not inappropriately placed in nursing homes for long term care) were corrected on admission, had the required level 2 referral sent if residents had a positive Level 1 PASARR nor corrected/updated resident PASARR as needed for 2 of 5 residents (Residents 11 and 16) reviewed for unnecessary medications. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual disabilities [ID] or related disorders [RD] are not inappropriately placed in nursing homes for long term care) were corrected on admission, had the required Level 2 referral sent if residents had a positive Level 1 PASARR nor corrected/updated resident PASARR as needed for 2 of 5 residents ( Residents 11 and 16 ) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs.Findings included .Review of the facility's undated policy titled PASARR, showed if the Level 1 screen indicated that the individual might meet the criteria for a SMI, ID, or RD, they were referred to the state PASARR representative for the Level 2 (evaluation and determination) screening process. <Resident 11>Review of Resident 11's medical record showed the resident was admitted to the facility with diagnoses to include major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble sleeping), and post-traumatic stress disorder ([PTSD]-a mental health condition that can develop after experiencing or witnessing a traumatic event that involved the threat of death, serious injury, or sexual violence.) Review of the quarterly comprehensive assessment, dated 06/29/2025, showed the resident's cognition was intact and required supervision or touching assistance of one staff member for ADLs.Review of Resident 11's PASARR, dated 10/09/2024, showed under section I, SMI/ID had one marked yes to include the diagnosis of depression. The resident had diagnoses of PTSD and insomnia that were not included. No evidence of a Level 2 referral was sent for review in the resident's medical record. <Resident 16>Review of Resident 16's medical record showed the resident was admitted to the facility with diagnoses to include major depressive disorder, bi-polar disorder (a mental condition that causes extreme shift sin mood, energy, and ability to function, alternating between periods of high and low depression), anxiety disorder (someone who experiences excessive and persistent worry, fear, or nervousness that interferes with their daily life), and borderline personality disorder ( a mental health condition where people have long lasting patterns of strong, unstable emotions). Review of the quarterly comprehensive assessment, dated 06/30/2025, showed the residents' cognition was moderately impaired and required the assistance of one staff member for ADLs.Review of Resident 16's PASARR, dated 02/26/2025, showed under section I, SMI/ID had three marked yes responses to include the diagnosis of depression, anxiety disorder, and personality disorder. Review of the additional comments section showed a Level 2 was required due to SMI's marked in section I. No evidence of a Level 2 referral was sent for review in the resident's medical record. During an interview on 07/22/2025 at 3:16 PM, Staff D, Social Service Director, stated it was their responsibility to review all PASARR's on admission and to send out for a Level 2 required assessment if needed. Staff D stated they had done a full house audit and must have missed Resident 11 and 16's required Level 2 assessment and the correct process was not followed for those residents. Reference WAC: 388-97-1915 (1)(2)(a-c)

Based on interview and record review, the facility failed to ensure the actual hours worked were documented on the daily nursing staff posting for 27 of 45 shifts reviewed for accuracy of posted nursing hours. This failure prevented residents, family members and visitors from knowing the actual hours worked by nursing staff. Findings included. Review of the facility's daily (days, evenings and nights) nurse staff posting forms from 07/01/2025 thorough 07/15/2025 showed on 27 of 45 shifts the posted nursing hours were not accurate and did not reflect the actual hours worked by nursing employees. During an interview on 07/24/2025, at 2:21 PM, Staff, I, Assistant Director of Nursing stated they were unaware that the daily nurse postings were not accurate, and their expectation was that the postings match the schedules of actual hours worked. Reference WAC 388-97-0020

Based on interview and record review, the facility failed to ensure funds were reimbursed to the State Office of Financial Recovery (OFR), within 30 days of a resident's discharge or death, for 4 of 4 residents (Residents 252, 253, 254, and 255), reviewed for personal funds. This failure placed the state department at risk for loss of funds and interest accumulated. Findings included . Review of the undated policy titled, Resident Trust Funds, showed within 30 days of death of the resident, the facility would return the resident's personal funds. If the resident received long-term care services paid by the department, the personal funds would be sent to the Office of Financial Recovery. <Resident 252> Review of Resident 252's medical record showed they were admitted to the facility on [DATE] and passed away on 06/08/2024. The resident had $100.08 personal funds remaining in their trust account. Review of Resident 252's trust account showed the balance of $100.08 had not been returned to the Office of financial Recovery, (OFR) within 30 days of the resident's death as required. Additional review of the account showed the check for $100.08 was returned to the OFR on 08/21/2024, 44 days after the required conveyance of funds timeframe. <Resident 253> Review of Resident 253's medical record showed they were admitted to the facility on [DATE] and passed away on 05/12/2024. The resident had $40.33 personal funds remaining in their facility held trust account. Review of Resident 253's trust account showed the balance of $40.33 had not been returned to the OFR within 30 days of the resident's death as required. Additional review of the account showed a check for $40.33 was returned to the OFR on 08/21/2024, 71 days after the required conveyance of funds timeframe. <Resident 254> Review of Resident 254's medical record showed they were admitted to the facility on [DATE] and passed away on 02/17/2024. The resident had $70.79 personal funds remaining in their facility held trust account. Review of Resident 254's trust account showed the balance of $70.79 had not been returned to the OFR within 30 days of the resident's death as required. Additional review of the account showed a check for $70.79 was returned on 04/18/2024, 31 days after the required conveyance of funds timeframe. <Resident 255> Review of Resident 255's medical record showed they were admitted to the facility on [DATE] and passed away on 05/17/2024. The resident had $1678.83 personal funds remaining in their facility held trust account. Review of Resident 255's trust account showed the balance of $1678.83 had not been returned to the OFR within 30 days of the resident's death as required. Additional review of the account showed a check for $1678.83 was returned to the OFR on 08/21/2024, 66 days after the required conveyance of funds timeframe. During an interview on 09/06/2024 at 9:43 AM, Staff F, Business Office Manager, stated the process was to return remaining funds in resident accounts within 30 days to the OFR upon a resident's death and these refunds should not have been delayed. Reference: WAC 388-97-0340(5)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) were corrected on admission, had the required level 2 referral sent if residents had a positive Level 1 PASARR nor corrected/updated resident PASARR as needed for 4 of 9 residents (Resident 21, 27, 47 and 49) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive level one PASARR screen (that would then require a referral for a level two PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or Sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, nursing facilities will ensure residents with a positive level one PASARR screen have been evaluated by the designated state-authority through the level two PASARR process and approved for admission prior to admitting to the nursing facility. Review of the facilities undated policy titled PASARR showed all residents PASARR would be reviewed and updated as needed. <Resident 21> Review of Resident 21's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble sleeping), and anxiety (a feeling of worry, nervousness, or unease). Review of the quarterly comprehensive assessment, dated 08/02/2024, showed the resident's cognition was moderately impaired and required extensive assistance of two staff members for ADLs. Review of Resident 21's PASARR, dated 04/02/2024, showed under section I, SMI/ID had one marked yes to include the diagnosis of depression. The resident had diagnoses of anxiety disorder and insomnia that were not included. No evidence of a Level 2 referral was sent for review in the resident's medical record. <Resident 27> Review of Resident 27's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include depression, insomnia and anxiety. Review of the quarterly comprehensive assessment, dated 06/29/2024, showed the resident's cognition was severely impaired and required extensive assistance of two staff members for ADLs. Review of Resident 27's PASARR, dated 06/21/2024, showed under section I, SMI/ID had one marked yes to include the diagnosis of anxiety. The resident had diagnoses of depression and insomnia that were not included. The medical record showed no documentation that a Level 2 referral was sent for review in the resident's medical record. 43280 <Resident 47> Review of the resident's medical record showed they were admitted to the facility on [DATE] with a diagnosis including heart failure and depression. Review of the 08/01/2024 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 47's PASARR, dated 07/21/2024, showed that the PASARR was completed outside of the facility and no SMI had been checked even though the resident had a diagnosis of depression. <Resident 49> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including bipolar disorder, anxiety, delusional disorders (a mental health condition where an individual is unable to tell what is real from what is imagined), and schizoaffective disorder (a mental illness that has schizophrenia symptoms and mood disorders symptoms). Review of the 08/16/2024 comprehensive assessment showed the resident had a severely impaired cognition and was taking a psychotropic medication for their mental health conditions. Review of Resident 49's undated PASARR, showed that SMI indicators were check marked for schizophrenia, mood disorder (like bipolar or depression) and other disorders, but was not checked for anxiety. The PASSAR section for service needs showed a Level 2 evaluation would be needed. There was no documentation of a referral sent for review in the resident's medical record. During an interview on 09/04/2024 at 11:00 AM, Staff E, Social Service Director and Staff R, Social Service Assistant, stated they did not know about a resident's PASARR until they were admitted to the facility and were unaware that any SMI marked on a resident's PASARR would have required a Level 2 evaluation prior to a resident's admission to the facility. Staff E stated they checked to make sure a resident had a completed PASARR on admission but that none of the facility's resident's PASARR had been reviewed for accuracy. Staff E stated that no Level 2 PASARR referral was sent for Resident 49, nor other residents that might have needed one sent. Staff E and Staff R stated they did not have a good process in place and would need to audit all facility resident's PASARR documents for accuracy. During an interview on 09/09/2024 at 7:38 AM, Staff B, Director of Nursing Services, stated they were unaware of the PASARR process in the facility and the SSD was responsible for PASARR review. Staff B stated the expectation would be that all regulations regarding PASARR would be followed and all Level 1 PASARR's needing a Level 2 referral should have been completed and sent for review. Reference: WAC 388-97-1975 (1)(2)(3)(4), -1915 (1)(2)(a-c)

Based on observation, interview, and record review the facility failed to ensure medications were discarded when expired for 2 of 3 medication carts (Team 1 and Team 3). The facility also failed to ensure consistent monitoring of temperature for the medication storage refrigerator located in the medication storage room. These failures placed residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications and vaccines. Findings included . Review of the policy titled, Medication Storage in the Facility, dated 07/2021, showed outdated, contaminated, or deteriorated medications are immediately removed from inventory and disposed of according to facility procedures for medication disposal. The policy also showed medications, biologicals and vaccines were stored at their required temperatures. Additionally, vaccines stored in the medication refrigerator were to be monitored twice daily per the Center for Disease Control (CDC). Review of the CDC guidance titled, Vaccine Storage and Handling, dated 04/03/2024, showed to ensure safety of vaccines, the refrigerator must have a reliable temperature monitoring device with the recommended use of a recording device called a digital date logger (DDL-a device that records temperatures at least every 30 minutes). The guidance further showed when a DDL was not used, then the facility should monitor and record the vaccine refrigerator temperature at a minimum of twice daily. <Medication Carts> During an observation and interview on 09/09/2024 at 12:17 PM, with Staff I, showed the Team 1 medication cart contained the following expired medications: Four Albuterol inhalers (medication that is inhaled to increase airflow to the lungs), expired on 04/16/2024, 06/19/2024, 07/03/2024, and 07/21/2024. Two tubes of Arthritis (joint pain) pain gel expired 06/13/2024 and 06/19/2024. Staff I, Licensed Practical Nurse, (LPN), stated nurses were to dispose of expired medications and reorder when required. During an observation and interview on 09/09/2024 at 12:53 AM, with Staff H, showed the Team 3 medication cart contained the following expired medications: Two bottles of ondansetron (anti-nausea) medication, expired on 07/28/2024 and 08/06/2024. One pack of Ipratropium (a drug taken to increase airflow to the lungs) medication, expired 08/04/2024. Staff H, LPN, stated when expired medications were found, nurses were to dispose of the expired medication in the medication storage room. <Medication Storage Room Refrigerator> During an observation and interview on 09/09/2024 at 11:03 AM, with Staff D, showed the medication storage room refrigerator contained the following vaccines: 20 vials of influenza vaccine. Eight syringes of pneumococcal vaccine. Staff D, Resident Care Manager, stated the refrigerator temperature were checked and recorded on the log sheet by the night shift nurses. Review of the documents titled, Refrigerator Temperature Chart, for the months of July 2024 through September 2024, showed an area for one time a day temperature documentation. Further review showed the facility received 10 pneumococcal vaccines on 07/22/2024 and 20 vials of influenza vaccine on 09/06/2024. Additionally, after the date the facility received the vaccine there was no documentation that twice daily temperature monitoring was being completed. During an interview on 09/09/2024 at 1:05 PM, Staff B, Director of Nursing Services, stated the medication carts should be reviewed by nurses and expired medications should be removed and taken to the medication storage room to be destroyed. Staff B stated the facility had one medication refrigerator that held medications and vaccines. Staff B stated the facility's process was the night shift nurses were to monitor, record the temperature, and record onto the log sheet. Staff B stated this process was done once a day. Reference: WAC 388-97-1300(2)

Based on observation, interview and record review the facility failed to ensure staff maintained components of an infection prevention control program to prevent the development and transmission of infections with, 1) hand hygiene for 4 of 8 staff (Staff P, G, H and O) reviewed during medication administration and entering/exiting isolation precautions (a process used to reduce the transmission of infectious bacteria and organisms in the healthcare setting), 2) implementing appropriate transmission based precautions (TBP, safeguards put in place to help prevent staff and residents from spreading infectious diseases) when providing care for 2 of 3 residents (Resident 33 and 34) reviewed for standard precautions, 3) cleaning/disinfecting of resident equipment and furniture for 3 of 4 types of equipment (chairs, sofa and mechanical sit-to-stand devices) and residents general/isolation precaution rooms with an Environmental Protection Agency (EPA) registered disinfectant for 3 of 3 staff (Staff G, P, O) reviewed for environmental cleaning and disinfection. These failures placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of an undated facility policy titled, Handwashing/Hand Hygiene, showed hand hygiene was to be implemented to help prevent harmful spread of infections in the nursing home. The policy showed common situations that required staff to perform hand hygiene were before/after contact with a resident, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, before/after assisting a resident with meals, after touching the resident's environment, before/after preparing or handling medications, before/after entering isolation precaution settings and immediately after glove removal. Review of the undated facility guidelines titled, Enhance Barrier Precautions (EBP, indicated with high contact resident care activities with an infection, a long-term wound, central line device or colonization [the presence of a bacteria that has not yet started its infection process] of an multi drug resistant organism), showed that all staff were to perform hand hygiene before entering and when leaving a room. Staff were to .wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line (a tube for medications to be administer right by the heart), urinary catheter (a tube that drains urine from the bladder), feeding tube (a tube that delivers food to the stomach), tracheostomy (a tube and/or opening made in the neck to help with breathing), wound care: any skin opening requiring a dressing. Review of the facility guidelines titled, Contact Enteric (related to or occurring in the intestines of the body) Precautions (a specific type of TBP), dated 05/30/2019, showed anyone that entered the enteric, also known as Clostridium Difficile (C. diff, a type of bacterium that causes an infection of the colon, the longest part of the large intestine and when outside of the body they become inactive and are known as spores) must clean hands with sanitizer when entering room .wash with soap and water upon leaving room . Additionally, the guidelines stated that when cleaning a room that was on contact enteric precautions a Sporicidal-based (a specific type of substance or chemical that kills the C. diff spores) disinfectant was to be used. Review of the undated facility guidelines titled, Contact Precautions (a specific type of TBP), showed that everyone must clean their hands before entering and exiting the room. The guidelines stated that staff must also put on a gown and gloves before entering the contact precaution room. Review of Centers for Disease Control and Prevention (CDC) recommendations titled, Guidelines for Environmental infection control in Health-Care Facilities, updated July 2019, showed that cleaning and disinfecting environmental surfaces is fundamental in reducing their potential for transmission of diseases. Environmental surfaces can be medical equipment surfaces or .housekeeping surfaces (e.g., floors, walls, and tabletops), and need to go through a cleaning and disinfecting process. Environmental surface disinfectants are regulated by the EPA and labeled with an EPA registration number. Review of facility's policy titled, Cleaning and Disinfecting Residents' Rooms, dated June 2023, showed that environmental surface would be clean/disinfected on a regular basis (e.g., daily, three times per week) ., and the facility's environmental service director, Infection Preventionist (IP) and administrator would select appropriate disinfectants. Additionally, the policy showed when cleaning a resident room .utilize disinfectant solution based on type of precaution, and that all high-touch areas would be disinfected. <Hand Hygiene> During a concurrent observation and interview on 09/03/2024 at 3:44 PM, Staff P, Housekeeper, was cleaning a contact enteric precaution room, with Staff G, Housekeeping Supervisor, in the hallway outside the TBP room. When Staff P exited, they did not perform hand washing and instead used hand sanitizer. When inquired about specific hand hygiene requirements when exiting a contact enteric precaution room, Staff P and Staff G both were unaware of the requirement to wash their hands after exiting a C. diff positive TBP room. During an observation on 09/06/2024 at 8:28 AM, Staff H, Licensed Practical Nurse (LPN), exited room [ROOM NUMBER] after administering medications to a resident without performing hand hygiene. Staff H returned to the medication cart and began to document in the computer. Staff H proceeded to unplug the computer power cord from the wall and moved the medication cart down the hall. Staff H plugged the power cord back into the wall and resumed documenting in the computer. Once Staff H completed their documentation, they obtained a new medication cup and dispensed medications for another resident into the medication cup. These medications were then placed into a small pouch, crushed, and mixed with applesauce. Staff H walked down the hall with the medication mixture, entered room [ROOM NUMBER], and administered the medications to the resident with a spoon. They obtained the resident's drink on their bedside table and assisted them with a drink. Staff H then performed hand hygiene prior to exiting the resident's room. During an interview on 09/06/2024 at 11:15 AM, when asked their process for hand hygiene when exiting a contact enteric precaution room, Staff O, Housekeeper, stated they would use hand sanitizer and not perform hand washing. During an interview on 09/06/2024 at 1:03 PM, Staff B, Director of Nursing Services (DNS), stated they expected staff to follow TBP guidelines that were placed on the contact enteric precaution room door and when exiting the room to perform the required hand washings. <TBP> <Resident 33> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including Multidrug-resistant Organism (MDRO-bacteria that is resistant to multiple antibiotics) right hip surgical wound that required a Peripherally Inserted Central Catheter [(PICC) - a thin, soft tube that is inserted into a vein in the arm, leg, or neck for long-term administration of antibiotics, medication, nutrition, and blood draws] for antibiotic therapy. The 08/01/2024 comprehensive assessment showed the resident required substantial/maximum assistance of one to two staff members with activities of daily living (ADLs) and had an intact cognition. Resident 33 was on Contact precautions. <Resident 34> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of stroke and obstructive uropathy (urine cannot drain from the urinary tract) with an indwelling catheter (a flexible tube that drains urine from the bladder into a drainage bag). The 08/02/2024 comprehensive assessment showed the resident required moderate assistance of one staff member for eating and had a moderately impaired cognition. Resident 34 was on EBP. An observation and interview on 09/05/2024 at 8:24 AM, showed Staff M, Nursing Assistant (NA), in a resident room that was designated as Contact Precautions and Enhanced Barrier Precautions (EBP) for two separate residents (Resident 33 and 34). Staff M sat bedside Resident 34 assisting them with their breakfast. Staff M provided the resident's fluid cup to drink and wiped their face after they coughed and cleared their throat. Staff M was not wearing personal protective equipment (PPE). Staff M stated they were supervising and assisting Resident 34 with their meal. Staff M stated the yellow sign (Contact Precautions) was for Resident 34 and the orange sign (EBP) was for Resident 33. Staff M stated they were required to wear a gown when providing catheter care, peri-care, and transfers for both residents. During and observation on 09/06/2024 at 8:18 AM, Staff N, Director of Rehabilitation, was sitting at Resident 34's bedside, assisting with their meal. Staff N was not wearing the required PPE for the room that was designated as Contact precautions and EBP. A concurrent observation and interview on 09/09/2024 at 5:16 AM, showed the signage posted on the entrance to the resident's room as Contact precautions and EBP. Staff L, LPN, entered the resident's room with gloves and no gown and administered medication to Resident 33. Staff L stated they were following the instructions for both signs, as they had not been informed of which precaution sign to follow. <Environmental Cleaning and Disinfection> <Furniture> An observation on 09/05/2024 at 8:57 AM, showed three chairs located in the hall across from the dining room, that had stains on the seat cushions. One chair had multiple dark stains, varying in size on the seat cushion and a two inch (unit of measure) black/brown smear down the right arm of the chair. A second chair had an eight-inch by seven-inch dark stain on the seat cushion and the third chair had four one-inch stains that were dark in color and contained a white crusty substance. During a follow up observation on 09/09/2024 at 5:32 AM, the three chairs continued to show the same stains and black/brown smear. During an interview on 09/09/2024 at 6:32 AM, Staff K, Housekeeper, stated they were responsible for cleaning breakrooms, offices, therapy rooms and hallways. Staff K stated they did not clean furniture, and the evening housekeeping staff were responsible for cleaning furniture. During an interview on 09/09/2024 at 7:07 AM, Staff G, stated Staff K was responsible for cleaning breakrooms, offices, therapy and hallways. Staff G stated Staff K should clean the furniture in the hallways at least once per week and as needed. An observation on 09/09/2024 at 11:58 AM, showed a black, smooth surfaced sofa located in the television area on the Team 1 Hallway, that had peeling and cracked arm rests with exposed white fabric. The seam of the right arm rest had a six-inch by two-inch tear with peeled edges that exposed the white fabric with worn fibers. The right arm rest showed two two-inch by three-inch areas with peeling black sofa material and exposed white fabric. During an interview on 09/10/2024 at 8:43 AM, Staff G stated the stained chairs did not look clean and had not attempted to remove the stains. Staff G stated they were unaware of the worn black sofa, and it did not look professional for the facility. Staff G stated the exposed white fabric was not cleanable and was unable to be disinfected. During an interview on 09/10/2024 at 9:14 AM, Staff B, DNS, stated there were stains on the chairs and if they were unable to be cleaned, they would need replaced. The fabric on the sofa was worn and was now an uncleanable surface. The sofa should be replaced with furniture that was cleanable. <Resident Equipment> In an observation on 09/04/2024 at 10:03 AM, a white colored sit-to-stand machine (a device that helps people get from a seated position to a standing position) had a pleather (an imitation of leather) knee pad with splits in the pleather that exposed the fabric of the inside of the knee pad and the pleather had worn out areas of discoloration. On top of the sit-to-stand machine there was a visibly stained, worn-out white sling with Velcro that had old hair and dirt woven throughout it. Further observation of another sit-to-stand machine with a blue footrest which had dark brown debris and white substance all over the footrest, on top of the sit-to-stand machine there was an unsanitary blue and red sling lying across it. An observation on 09/05/2024 at 10:24 AM, a blue colored sit-to-stand with blue footrest was visibly soiled with dark brown debris and white substance, an unkempt, worn-out blue and red sling was lying on top of the machine. The white colored sit-to-stand continued to have the visibly soiled and worn-out white sling lying over it. An observation on 09/09/2024 at 5:07 AM, the white colored sit-to-stand with the white sling that had Velcro on it was observed in the same soiled condition as noted on 09/04/2024. An observation on 09/09/2024 at 6:42 AM, showed Staff J, NA, push a sit-to-stand with a sling into a resident's room that was designated as EBP. After use of the sit-to-stand lift, Staff J placed the sit-to-stand lift into a lift device holding area in the Team 1 hall. Staff J placed the used sling on top of the lift device and walked away without cleaning the lift device. The lift device foot plate (an area for resident's feet during transfers) was visibly soiled with dirt, debris and thick food particles. The white sling had multiple areas of discoloration and shredded fabric. The 10-inch by eight-inch Velcro securement area was filled with hair, black, brown, and yellow debris. During an interview on 09/09/2024 at 8:28 AM, Staff J stated they placed the lift device back into the holding area for other staff to use. Staff J stated they did not clean the lift device after each use. During an interview on 09/10/2024 at 9:14 AM, Staff B stated the sit-to-stand lift should be cleaned and slings changed and laundered in between use of residents. Staff B stated when the sling was unable to be cleaned or was in disrepair, then it would need to be replaced. <General/Isolation Precaution Resident Rooms> During an interview on 09/03/2024 at 3:16 PM, Staff G, stated that all housekeeping staff utilized a Multi-Surface Peroxide (tables, dressers, nightstands, bedside tables and other surfaces) and a Floor Rejuvenator chemical when cleaning/disinfecting all resident rooms and throughout the facility. During an observation on 09/03/2024 at 3:37 PM, in facility's housekeeping closet, showed the Multi-Surface Peroxide nor the Floor Rejuvenator were labeled as an EPA registered disinfectant. Review of EPA registered chemicals titled, List K: EPA's Registered Antimicrobial Products Effective against Clostridium difficile Spores, dated 06/15/2016, showed the Multi-Surface Peroxide nor the Floor Rejuvenator were registered disinfectants nor were they effective against C. diff. During a concurrent observation and interview on 09/03/2024 at 3:44 PM, showed Staff P, cleaning a contact enteric precaution room without an EPA registered disinfectant. Staff P and Staff G both stated they used the Multi-Surface Peroxide and Floor Rejuvenator for cleaning/disinfecting all resident rooms, including the TBP rooms, like the C. diff positive resident room. During an interview on 09/06/2024 at 11:15 AM, Staff O, stated they used Multi-Surface Peroxide and Floor Rejuvenator for cleaning/disinfecting all resident rooms, including all the TBP rooms (including C. diff positive rooms), and throughout the whole facility. During an interview on 09/06/2024 at 1:03 PM, Staff B, and Staff C, Infection Preventionist Nurse, stated they were unfamiliar with the chemicals, utilized by housekeeping staff, to clean and disinfect resident rooms. Staff B stated they would expect housekeeping staff to have used the correct EPA registered disinfectant when cleaning/disinfecting rooms on TBP's and throughout the whole facility they should be disinfecting everywhere. Staff B stated they were unsure if the Muli-Surface Peroxide and Floor Rejuvenator were EPA registered disinfectants. During an interview on 09/10/2024 at 1:29 PM, Staff B stated the Muli-Surface Peroxide and Floor Rejuvenator chemicals utilized by housekeeping were not registered disinfectants. Reference: WAC 388-97-1320 (1)(a)(c)(2)(b)(3)(5)(d)(e) 45642 46722

Based on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 3 residents (Residents 7 and 9) reviewed for hospital transfers. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed and any monetary charges associated with the bed hold while in the hospital. Findings included . Review of the policy titled, Bed Hold Policy Notification 2024, updated 01/11/2024, showed residents were able to retain their bed when they were discharged to the hospital or on a therapeutic leave. The resident and/or their representative must sign and return the Bed Hold Policy Notification 2024 form to the business office within 24 hours of receipt of the form if they chose to retain their bed. <Resident 7> Review of the medical record showed Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory disease and depression. The 07/01/2024 comprehensive assessment showed Resident 7 required substantial assist of two staff members for activities of daily living (ADLs) and was cognitively intact. Further review of the medical record showed Resident 7 was transferred to the hospital on 08/02/2024. There was no notice of a bed hold in the medical record. During an interview on 09/10/2024 at 10:52 AM, Resident 7 stated the facility did not give them a bed hold policy to review when they transferred to the hospital to sign. <Resident 9> Review of the medical record showed Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including a stroke, respiratory disease and heart disease. The 06/15/2024 comprehensive assessment showed Resident 9 required substantial assist of one to two staff members for ADLs and had difficulty making decisions regarding daily care needs. Review of the medical record showed Resident 9 was transferred to the hospital on 06/05/2024 and the resident's power of attorney was notified of the transfer though there was no notice of a bed hold in the medical record. During an interview on 09/09/2024 at 10:11 AM, Staff B, Director of Nursing Services, stated that if residents were transferred emergently a bed hold wasn't always completed, though one should have been completed by the resident or sent to a resident's representative within 24 hours of the transfer. Reference: WAC 388-97-0120(4)

Based on observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care, related to assessing for trauma and identifying trigger-specific (a psychological stimulus that prompts recall of a previous traumatic event) interventions for residents with a history of trauma for 1 of 3 residents (Resident 14) reviewed for trauma informed care. This failed practice placed the resident at risk for unidentified triggers, re-traumatization and psychological harm. Findings included . Review of the facility's undated policy titled Trauma Informed Care Purpose, showed that social services staff were trained on screening, trauma assessment and how to identify triggers associated with re-traumatization. <Resident 14> Review of Resident 14's medical record showed the resident was admitted to the facility on [DATE] with diagnoses including insomnia (trouble sleeping) and Post Traumatic Stress Disorder [(PTSD) a mental health condition that's triggered by a terrifying event-either experiencing it or witnessing it]. The comprehensive assessment, dated 06/09/2024, showed the resident had a severely impaired cognition and required extensive assistance of two staff members for activities of daily living (ADLs). Review of Resident 14's care plan, dated 05/08/2024, showed that the resident was at risk of depression PTSD, their goal was to be free of depression. The care plan did not show trigger-specific interventions or identify Resident 14's triggers. Review of Resident 14's trauma screenings dated 02/09/2024 and 09/05/2024, showed no documented discussion of the resident's diagnosis of PTSD nor their person-centered triggers that would cause them re-traumatization. During an interview on 09/10/2024 at 9:49 AM, the Resident Representative, (RR), stated Resident 14's PTSD had resulted from their military service in the Vietnam War and the resident suffered from nightmares, night terrors, and had a lot of anger. Resident 14's physician had started medicating them with an antidepressant, which helped for a while. The RR stated as the resident aged, they had those recall moments which were horrifying for them. During an interview on 09/10/2024 at 9:19 AM, Staff E, Social Services Director, stated the trauma screening was completed on admission, quarterly, changes in condition, and on discharge. Staff E stated their process for trauma screening included interviewing or completing an assessment using trauma related questions. When residents did not open up, Staff E would reapproach in a week or more to complete the screening. Staff E stated Resident 14 said they did not have trauma or tell me anything about their trauma. During an interview on 09/10/2024 at 9:32 AM, Staff B, Director of Nursing Services, stated the expectation was for staff to ensure the trauma screenings were completed timely and followed up on as needed. Reference: WAC 388-97-1060(3)(e)

Based on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 6 residents (Residents 21 and 43) observed during 25 medication administration opportunities that resulted in an error rate of 12%. The failed practice had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . Review of the policy titled, Medication and Flexible Pass Time, dated 10/2023, showed nurses would follow the general guidelines for safe and accurate medication administration. Review of the Instructions for use (IFU) by the U.S. Food and Drug Administration (USFDA) revised 07/2023, stated to prime the insulin pen (a pre-filled disposable device containing insulin) with a new needle prior to each injection administration. To prime the insulin pen was to turn the dose knob to two units, hold pen and needle upright, tap pen slightly to remove air bubbles and push the dose knob until stopped and 0 was seen in the dose window. Priming was meant to remove air from the needle and the cartridge that may collect during usages. In addition, the IFU stated to insert the needle into the skin, press plunger all the way down, and continue to hold the plunger and slowly count to six prior to removing the needle. These steps were to ensure the insulin pen worked correctly and the proper dosage of medication was administered. <Resident 21> Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses including diabetes and dementia (a progressive disease that destroys memory and other important mental functions). The comprehensive assessment, dated 08/02/2024, showed Resident 21 required substantial/maximal assistance of one to two staff for activities of daily living (ADLs) and had a moderately impaired cognition. Review of Resident 21's physician orders, dated 04/11/2024, showed the resident's insulin was to be administered on a sliding scale based on the resident's current blood glucose result. The sliding scale showed based on a blood glucose of 251-300 mg/dl the resident was to have eight units of insulin. Resident 21's blood glucose was 262 milligrams/deciliter (mg/dl, unit of measure). An observation on 09/06/2024 at 10:57 AM, showed Staff I, Licensed Practical Nurse (LPN), administered eight units of insulin with the insulin pen to Resident 21. Staff I held the needle into the resident's lower abdomen for three seconds. <Resident 43> Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), heart disease and depression. The comprehensive assessment, dated 06/23/2024, showed Resident 43 required supervision of one staff member for ADLs and had an intact cognition. Review of Resident 43's physician orders, dated 05/21/2024, showed the resident's insulin was to be administered on a sliding scale based on the resident's current blood glucose (sugar) result. The sliding scale showed based on a blood glucose of 150-199 mg/dl, (a normal blood glucose level is between 70 and 100 mg/dl) the resident was to have two units of insulin. Resident 43's blood glucose was 187 mg/dl. An observation and interview on 09/06/2024 at 11:44 AM, showed Staff H, LPN, prepared the insulin pen by attaching the disposable needle to administer the insulin. Staff H dialed the insulin pen to two units and proceeded to Resident 43's room. Staff H inserted the needle into the resident's left lower abdomen, pressed the plunger and removed the needle at three seconds. Staff H did not prime the needle of the insulin pen prior to the administration. Staff H stated the process for using an insulin pen was to dial the dose needed, administer to the resident and hold the needle in the skin for 10 seconds. Staff H further stated they were unaware of the requirement to prime the insulin needle prior to each use, and they did not count how long they held the needle into the resident's skin. An interview on 09/09/2024 at 1:05 PM, Staff B, Director of Nursing Services, stated the nurses should be priming the insulin pen for each use and leaving the needle in the resident's tissue for the required length of time to ensure the resident received the accurate dose. Reference: WAC 388-97-1060(3)(k)(ii)

Based on interview and record review, the facility failed to develop and implement an effective discharge planning process that addressed the resident's goals and needs, that involved the resident and the interdisciplinary team [(IDT) a group of healthcare professionals from different disciplines to help residents receive the care they need] for 1 of 3 residents (Resident 5) reviewed for discharge planning process. The failure to develop and implement a plan consistent with the resident's needs and expressed discharge goals, placed the resident at risk for decreased self-worth and dissatisfaction with their living situation. Findings included . <Resident 5> Review of the medical record showed Resident 5 was admitted to the facility with diagnoses including a stroke, diabetes (a group of diseases that result in too much sugar in the blood), and anxiety. The 05/14/2024 comprehensive assessment showed Resident 5 required moderate/maximum assistance of one staff member for activities of daily living. The assessment also showed Resident 5 had a moderately impaired cognition. During an interview on 08/13/2024 at 9:57 AM, Resident 5 stated their plan was to return to their home. They stated their representative had everything set up for them to return to their home in June 2024, including two caregivers, but the discharge had fallen through. Resident 5 stated they had no additional discharge planning with Staff B, Social Services Director (SSD), since June 2024. Staff 5 stated I just want to be able to go home and feel independent. During an interview on 08/13/2024 at 3:43 PM, Staff B stated they were responsible for the discharge process. They stated their process included care planning the resident's goals for discharge. Staff B stated when Resident 5 first admitted to the facility, their goal was to return home. They stated a month or two ago, they had planned for Resident 5 to discharge to their home. Staff B stated the Resident's Representative was hesitant about Resident 5 discharging to their own home and/or discharging to the RR's home, despite having caregiver support in place. At that time, Resident 5 did not have a safe place to discharge to as there were legal issues with their home. Review of Resident 5's 08/03/2024 comprehensive care plan, showed no documentation of a discharge care plan. Review of Resident 5's medical record showed no documentation identifying the resident needs for discharge, re-evaluation of those needs, and updates to the care plan. Review of the 05/14/2024 comprehensive assessment showed Resident 5 had active discharge planning already occurring for the resident to return to the community and a referral had not been made to the local contact agency (an organization that helps nursing home residents learn about community support options, including alternative living situations). During an interview on 08/14/2024 at 1:55 PM, Staff A, Administrator, stated they were aware that Resident 5 was going to discharge home, but there had been issues with the discharge. They stated Staff B had been working with the Resident Representative (RR) and had been cleared by therapy to return home. Staff A stated Resident 5 was now staying in the facility long term, a decision made by the RR/Power of Attorney (POA - a person that can make decisions on your behalf in the event you no longer have the capacity to make decisions), despite Resident 5 stating they wanted to return home. Staff A stated Staff B had been working with the RR on discharge planning and the discharge planning should have been documented in the resident's medical record. Reference: WAC 388-97-0080(1)(2)(a)(b)(d)(e)(4)(5)(6)

Based on interview and record review, the facility failed to send a copy of a notice of transfer/discharge to the representative of the Office of the State Long Term Care (LTC) Ombudsman (a person that advocates for residents in nursing homes) for 3 of 3 residents (Residents 2, 3, and 4) reviewed for notice of transfer/discharge. This failed practice placed the residents at risk for lack of access to an advocate that could inform them of their options and rights, and to ensure the resident advocacy agency was aware of the facility practices and activities related to a transfer or discharge. Findings included . Review of a policy titled, Admission, Transfer and Discharge - Facility Initiated Transfers and Discharges, undated, showed the facility would send a copy of the notice of transfers or discharges to a representative of the Office of the State Long-Term Care Ombudsman. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease [(COPD) a group of lung diseases that block airflow and make it difficult to breathe], respiratory failure, and anxiety. Review of the 07/01/2024 comprehensive assessment showed Resident 2 was cognitively intact. Review of the medical record showed Resident 2 was transferred to an emergency room for evaluation and treatment on 08/02/2024. There was no documentation that the facility had notified the LTC Ombudsman of the transfer. <Resident 3> Review of the medical record showed Resident 3 was admitted to the facility with diagnoses of COPD, high blood pressure, and emphysema (a type of lung disease that causes breathlessness). The 07/04/2024 comprehensive assessment showed Resident 3 was cognitively intact. Review of Resident 3's medical record showed they were transferred to an acute care hospital for evaluation and treatment on 07/15/2024. There was no documentation in the record that the LTC Ombudsman was notified of the facility-initiated transfer. <Resident 4> Review of the medical record showed Resident 4 was admitted to the facility with diagnoses including COPD and diabetes (a group of diseases that result in too much sugar in the blood). The 05/27/2024 comprehensive assessment showed Resident 4 had a moderately impaired cognition. Review of Resident 4's medical record showed they were transferred to an acute care hospital emergency roiagnom on [DATE]. There was no documentation that the LTC Ombudsman was notified of the transfer. During an interview on 08/13/2024 at 1:49 PM, the Regional LTC Ombudsman stated they had not received any notices of transfers/discharges from the facility for quite some time. During an interview on 08/13/2024 at 3:43 PM, Staff B, Social Services Director, stated they were responsible for providing notification of transfer/discharge to the LTC Ombudsman. They stated they had been doing that every Friday but had not been providing the notifications consistently. During an interview on 08/14/2024 at 12:57 PM, Staff A, Administrator, stated when there was a facility-initiated transfer/discharge, the notice of transfer/discharge should be transmitted to the LTC Ombudsman on a weekly basis, per the facility protocol. Reference: WAC 388-97-0120(5)

Based on observation, interview, and record review, the facility failed to ensure a resident's smoking location was away from a high traffic thoroughfare, dry grassy area, and had a receptacle for disposing of lit cigarettes and ashes for 1 of 1 sampled resident (Resident 30) reviewed for smoking This failure placed all residents a risk for avoidable accidents, injuries, and the potential risk of fire. On 07/17/2023 At 2:10 PM, the facility was notified of an immediate jeopardy (IJ) at CFR 483.25 (d)(1)(2) F689, related to the facility's failure to ensure the resident had a safe smoking environment, and all residents remained free of fire risks. The facility removed the immediacy on 07/18/2023, with onsite verification from investigators, by providing a safe smoking location on the facility property and a cigarette receptacle for the resident to dispose of cigarettes and ashes. Additionally, the facility provided education to the resident and all staff of the location and the safe disposal practice. Findings included . Record review of the facility's policy titled, Smoking Policy - Residents, revised on 02/24/2023, showed the following: 1. The facility was a smoke-free campus and that included outside patios and parking lots. 2. That smoking offsite posed risks to residents and included weather related illnesses, accidents and injuries. 3. The facility did not consider admitting any resident who smoked. 4. Residents considered for admission must agree in writing, to not smoke at the facility, either on or off campus. 5. Residents were not permitted to store smoking material with them or in their rooms. Those items were to be removed from or turned over to the facility until the resident was discharged . 6. Residents would be assessed for safe smoking upon admission to the facility. This assessment included: a resident's ability to smoke independently and safely, and the ability to safely mobilize off-campus. Review of the National Weather Service report for 07/17/2023, showed there were Red Flag (warm temperatures, very low humidities, and stronger winds combined to produce an increased risk of fire danger) critical fire and wind warnings for Eastern [NAME]. <Resident 30> Review of Resident 30's Electronic Health Record (EHR), showed the resident admitted to the facility on [DATE] with diagnoses to include a history of seizures, and long-term smoker. Resident 30's comprehensive assessment, dated 05/03/2023, showed the resident had no cognitive deficits. There was no signed copy of the expectations related to this facility's nonsmoking policy for Resident 30. Record review of Resident 30's care plan, dated 05/19/2023, showed Resident 30 smoked cigarettes and that the facility was a non-smoking facility. The care plan showed Resident 30 was to retrieve and return their smoking supplies each time they left the premises. Resident 30's Smoking Safety Evaluation, dated 06/21/2023, was conducted 57 days after admission to the facility. Review of the facility's progress notes, dated 04/29/2023, showed Resident 30 smoked four cigarettes a day, and showed that Resident 30 used tobacco. Record review of the progress notes, dated 05/06/2023, showed Resident 30's cigarettes were in the medication cart. The note further showed Resident 30 knew they had to do the following: get cigarette supplies from medication cart, sign out, go off property, and return smoking supplies to the nurse upon return. Record review of the facility's progress notes, dated 05/24/2023 and 06/01/2023, showed Resident 30 smoked cigarettes and continued to smoke. Observation and interview on 07/17/2023 at 10:12 AM, showed a cigarette carton was located on Resident 30's bedside table and contained cigarette butts. Resident 30 stated that they smoked off grounds in front of the facility. Resident 30 said their smoking supplies were kept in the nurse's cart. Observation and interview on 07/17/2023 at 11:20 AM, showed Resident 30 sat on their walker on the sidewalk parallel to a busy street near an intersection, with the rear wheels of their walker on dry grass. The roadway was busy with traffic in both directions. There were 30 plus cigarette butts in the area, about the size of 10 feet by 10 feet, on the dry grass behind where Resident 30 sat. Across the driveway there was another place that was a low, grassy and dry, leafy area about 3 feet by 3 feet in size and contained about 8 cigarette butts. Resident 30 stated that they sat there because there was no place on the property for them to smoke. Resident 30 said they flicked their ashes as they smoked, put the cigarette butts out on the metal of their walker and put the cigarette butts in an empty cigarette package. Resident 30 said they took the package of cigarette butts into the facility. Resident 30 further stated that they did not know this was a nonsmoking facility prior to being admitted . During an interview on 07/17/2023 at 1:13 PM, Staff P, Licensed Practical Nurse, said Resident 30 signed themselves out when they wanted to smoke and obtained their supplies from the nurse. Staff P showed the surveyor Resident 30's smoking supplies which were on the cart, and they matched the cigarette butts found outside. During an interview on 07/20/2023 at 12:51 PM, Resident 30 stated that they began to smoke cigarettes four to five days after they were admitted to the facility. Resident 30 said their smoking supplies were kept in the nurse's cart and that they were not allowed to keep those items in their room. Resident 30 stated that when they wanted to smoke, they got their supplies from the nurse, signed out, went out to smoke, signed in, and turned their supplies into the nurse. Resident 30 stated that they were not allowed to smoke in the employee smoking area and was told by facility staff they had to go off the property. Resident 30 further said staff told them that the sidewalk was considered off grounds. During an interview on 07/18/2023 at 4:22 PM, Staff A, Administrator, stated that they were aware Resident 30 was signing out and going to the edge of the sidewalk near the street to smoke. Staff A further stated that there were limited places for the residents who smoked to leave the property as the facility was a non-smoking facility. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to ensure the food was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 residents (Residents 5, 38, 54, 32, 55, 46, and 27) interviewed about meal satisfaction during the Resident Council meeting, and 2 of 4 residents (Residents 49 and 30) reviewed for meal palatability. Additionally, Resident 49 was served eggs for breakfast routinely even though eggs were listed as a dislike. This failure placed the residents at risk for weight change, less than adequate nutritional intake, and dissatisfaction with meals. Findings included . Record review of the facility's policy titled, Food and Nutrition Services, dated 07/2023, showed that food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. <Meal Satisfaction> Record review of Resident Council Meeting Minutes, dated 02/01/2023, showed the representatives had a concern about the meals. The Resident Council Meeting Minutes showed that there were no salt and pepper shaker on the dining room tables and not enough seasoning on the food. They submitted this concern to the facility and the corrective action response from the facility showed residents had to request individual packets of salt and pepper. During an interview on 07/18/2023 at 9:09 AM, the Representatives of the Resident Council meeting stated that there was a lot of sauce on the food; the food that was supposed to be hot was not hot all the time; the milk was always warm; and the did not seem to have spices, salt, or pepper. During an interview on 07/20/2023 at 11:45 AM, Staff BB, Food Manager, stated that residents could request individual packets of salt and pepper. <Meal Palatablilty> Resident 49. Electronic Health Record (EHR) review showed the resident was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Review of the 06/23/2023 comprehensive assessment showed the resident had moderate cognitive impairment and required supervision and set up for meals. During an interview on 07/17/2023 at 8:50 AM, Resident 49 was sitting in their bed with the overbed tray in front of them. When asked how breakfast was today, they stated they did not like it. Resident 49 stated the food was cool, and the juice and milk were warm and there was scrambled eggs and I do not like eggs. During an observation on 07/18/23 at 11:38 AM, Resident 49 was eating their lunch. There was a meat patty, green beans, and watermelon. There was a glass of juice and milk. They stated this meal tasted good today, but it was cool when it arrived and the drinks were warm. During an interview on 07/19/23 10:00 AM, Resident 49 stated breakfast was good and warm today; however, I got eggs again and I don't like eggs and I did not eat them. Review of a 04/18/2023 progress noted from Staff BB, Food Manager, showed Resident 49 disliked eggs and did not want them for breakfast. Resident 30. EHR review of Resident 30's Diet Order, dated 04/26/2023, showed Resident 30 had a regular diet with thin liquids with no added salt. During an interview on 07/17/2023 at 10:17 AM, Residient 30 stated that the food looked almost edible but that they would never serve it to anyone. They stated that they only had a choice between two meals and there was no substitue meal if they did not like it. Resident 30 stated that foods that were supposed to be hot were not hot and that the facility did not reheat the food. Resident 30 stated that the weekend meals ran about an hour to an hour and a half late and the food might be warm when they received it. Resident 30 stated that the food was bland and that they had their own spices. A concurrent observation and interview on 07/18/2023 at 11:48 AM, showed Resident 30 ate their meal. Resident 30 stated that they had peas, onions, squash, and a leather pork chop that was too hard to chew. Resident 30 stated that the food was warm but not hot and that it all tasted the same. Observation of the half cut up pork chop showed it looked dry on the plate. <Test Tray> During observation of kitchen lunch serve out on 07/20/23 at 11:20 AM showed a double sided insulated cart set next to the stove/grill with the hot food in pans and plated by Staff HH, Cook. The meal plate was then set in a plate insulator and covered with insulated cover. Then the plate was placed on the pre-setup tray that included glasses of milk, juice, ice cream cup, and flat wear. A tray was set up for Resident 30 at 11:25 AM and a duplicate tray was set up at that time for testing. The cart had 10 trays, was closed and staff were notified the lunch cart was ready for the 100 hall. The cart was picked up by Staff DD, Nursing Assistant (NA) at 11:27 AM. Resident 30's tray delivered at 11:29 AM and the test tray was delivered at the same time to the surveyor conference room. The food temperatures were checked by Staff BB with a digital thermometer and while the surveyor was observing: baked beans- 135 degrees Fahrenheit (F) pork rib- 133 degrees F cold macaroni salad- 74.6 (served on hot plate) degrees F cranberry juice- 56.3 degrees F milk- 52.8 degrees F chocolate hi-calorie drink- 57 degrees F ice cream cup- 24 degrees F During an interview on 07/20/2023 at 11:41 AM, Staff BB stated the steam table in the dining room was broken and had not worked for one year or so, and that was why the food was plated from the stove. Staff BB stated they were waiting for approval for a mobile steam table that can go to the dining room for serving out. Staff BB stated the air conditioner had not worked properly in the kitchen for about one year. Staff BB stated they tested the ambient air temperature at the stove, next to the tray cart at 11:22 AM and the temperature of the air was 130 degrees F (too hot for frigerated items on trays nearby to maintain a cool temperature.) Observation on 07/20/2023 at 11:45 AM showed Resident 30 was served their lunch. At the same time, a test tray of the same meal was delivered to a surveyor. This meal consisted of beans, pork rib, macaroni salad, vanilla ice cream and white and chocolate milk. During an interview on 07/20/2023 at 11:45 AM, the surveyor that taste tested the test tray stated that the hot foods were warm, the macaroni salad was warm and bland, the milks were not cold enough and the ice cream was melting. Staff BB agreed with the surveyor as they tasted the food and liquids on the test tray. During an interview on 07/20/2023 at 12:48 PM, Resident 30 stated that the macaroni salad was bland, the hot food was warm, the milk was not cold enough and that the ice cream was melted a bit. During an interview on 07/20/2023 at 2:11 PM, Staff BB stated they were concerned about the milk temperature during the test tray, so they brought a 120 milliliter (ml) plastic cup of milk from the refrigerator and the milk temp was 34.2 degrees F and set it where the meal trays are set up for meals near the stove. Staff BB stated they retested the temperature of the milk after sitting for 15 minutes and the milk was 52.9 degrees F. Staff BB stated that was just not acceptable. During an interview on 07/21/2023 at 8:27 AM, Staff A, Administrator, stated they were aware there were cooling issues in the building and had the repair people out this week. Staff A stated they were also working on ordering a new steam table for the dining room. Staff A stated they were not aware of the resident's food complaints related too cool food and warm drinks. Reference: WAC 388-97-1100(1), (2) 39314

Based on observation, interview and record review, the facility failed to ensure current state survey results were available for 7 of 7 sampled residents (Residents 5, 27, 32, 38, 46, 54, and 55) to examine. This failure prevented residents, family members, and visitors from exercising their rights to examine these documents. Findings included . Record review of the facility's undated policy titled, Admission Agreement - appendix D [facility name] Resident Rights, showed residents had the right to examine the most recent results of the facility's state survey or inspections. During an interview on 07/18/2023 at 9:09 AM, Resident Council Representatives (Residents 5, 27, 32, 38, 46, 54, and 55), stated that they did not know where state survey results were available to them to read. Observation on 07/19/2023 at 11:16 AM, showed a hard covered three-ring binder located outside of the business office. The most recent copy of state survey results in this binder was dated 03/30/2023. There were other state survey investigations, dated 05/18/2023 and 06/02/2023, that were not included in the book. During an interview on 07/19/2023 at 11:35 AM, Staff A, Administrator, stated that state survey results were printed and put into a book near the business office. Staff A confirmed the most recent state survey results in the book was dated 03/30/2023. Reference: WAC 388-97-0480

Based on interview and record review, the facility failed to document, periodically review, and revise Advanced Directives related to residents' wishes for 9 of 9 sampled residents (Residents 1, 7, 8, 21, 26, 30, 31, 44 and 213), reviewed for Advanced Directives. This failure prevented residents from having their health care decisions and preferences known in advance, and when they were unable to communicate this information. Findings included . Record review of the facility's undated policy titled, Advance directives (legal documents that provide instructions for medical care when a person is unable to communicate their own wishes) will be respected in accordance with state law and facility policy, showed: 1. A copy of residents' Advance Directives would be placed in their medical record. 2. The residents' decision to accept or decline an Advance Directives would be documented in the medical records. 3. The Interdisciplinary Team would conduct an annually review, with the resident, their Advance Directives. Record review of the 9 sampled residents' Electronic Health Records on 07/18/2023, showed, no documentation related to Advance Directives or residents' decisions to accept or decline this document. During an interview on 07/18/2023 at 12:54 PM and at 1:38 PM, Staff E, Social Services Director, stated that the process for Advanced Directives was that they received a copy of residents' Advanced Directives when a resident was admitted , and that the documents were kept in their health records. Additionally, they were unable to locate Advanced Directives for the 9 sampled residents. Staff E stated they were unaware of the process for conducting reviews of Advanced Directives with residents and did not conduct those reviews, nor document residents' Advanced Directives on their decisions to accept or decline this document. Further stated a nurse would look for the Advanced Directives documents when needed. During an interview on 07/18/2023 at 2:10 PM, Staff K, Licensed Practical Nurse (LPN) Care Manager, stated they provided and went over a form titled Advanced directive and Physician Order for Life Sustaining Treatment (POLST) and residents signed this form. Also, a resident's signature on this form indicated they went over the Planning Ahead packet and the POLST form with them. Staff K stated they did not document when a resident did not have an Advanced Directives document and that they communicated this information verbally at their stand-up meeting, that there was no paper process. Further, they did not know how often Advanced Directives were reviewed. During an interview on 07/19/2023 at 2:13 PM, Staff B, Director of Nursing, stated the Resident Case Manager provided an Admission packet and residents signed they received the information. Staff B said they did not know if this was documented. Staff B stated the Advanced Directives should be scanned into the residents' charts and if residents had Advanced Directives, it would be in their Care Plan. Further, if residents did not have Advanced Directives it would not be in their Care Plan. Reference 388-97-0300 (1)(b), (3)(a-c)

Based on interview and record review, the facility failed to periodically review resident rights with residents during their stay at the facility for 7 of 7 sampled residents (Residents 5, 27, 32, 38, 46, 54, and 55). This failure placed residents at risk of not understanding their rights and a reduced ability to self-advocate. Findings included . Record review of the facility's undated policy titled, Admission Agreement - appendix D [facility name] Resident Rights, showed this policy did not address the review of resident rights. During an interview on 07/18/2023 at 9:09 AM, Representatives of the Resident Council (Residents 5, 27, 32, 38, 46, 54, and 55), stated that they were not aware of staff reviewing resident rights. During an interview on 07/19/2023 at 11:15 AM, Staff D, Activity Director, stated that they did not review resident rights at the Resident Council meetings. During an interview on 07/19/2023 at 11:35 AM, Staff A, Administrator, stated that the Social Services Director reviewed resident rights with residents. During an interview on 07/19/2023 at 11:44 AM, Staff E, Social Services Director, stated that they did not go over resident rights during care conferences. Staff E further stated that there was no documentation to show resident rights were periodically reviewed. Reference: WAC 388-97-0300 (1)(a), (7)(b)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer development for 1 of 2 residents (1) reviewed for facility acquired pressure ulcers. The facility failed to complete a thorough admission assessment of Resident 1's skin, re-assess on a weekly basis per the resident's care plan, and act to treat and prevent further development after first identified on 05/19/2022. This failure caused harm to Resident 1 when they developed a preventable Stage 3 pressure ulcer that required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, Pressure Ulcer Definition and Stages: A Pressure Ulcer is localized damage to the skin and 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 (a combination of downward pressure and friction). A Stage 3 Pressure Ulcer is full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue (reddish connective tissue that forms on the surface of a wound when the wound is healing) and epibole (rolled wound edges) are often present. Resident 1. Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/29/2022 skin assessment showed the resident had some scattered bruising on their arms and legs and some cuts in-between their toes. No other areas of skin impairment was identified. Review of a 05/05/2022 comprehensive assessment showed the resident had moderately impaired cognition, required extensive assistance from staff to reposition in bed and had no pressure ulcers. Review of a 05/05/2022 Care Area Assessment showed the resident was at risk for pressure ulcers due to their mobility impairment and with a plan that a licensed nurse would assesses skin as scheduled and put proper interventions in place to prevent skin breakdown. Review of the 05/05/2022 Discharge Plan showed [Resident 1] plans to discharge to [named] Assisted Living once [they have] completed [their] therapy goals and is well enough to transfer. Review of the May 2022 Treatment Administration Record (TAR) showed a 05/05/2022 order for skin assessments weekly with Thursdays as the assigned assessment date. Review of the TAR showed 05/12/2022, 05/19/2022 and 05/26/2022 were blank. During an interview on 07/13/2022 at 2:45 PM, Resident 1's Representative (RR1) stated the resident developed a deep wound on [their] right heel, that was not found by the facility, but the Podiatrist. This has caused [Resident 1] discomfort and prevented [their] discharge to an assisted living facility (senior living option for those with minimal needs for assistance with daily living and care.) RR1 stated I am so angry, this should not have happened! During an interview and observation on 07/15/2022 at 9:38 AM, Resident 1 was sitting in their wheelchair, in their room, with a blue pad fastened to their right foot. They stated they did not know how the heel wound started and did not recall ever floating their heels when in bed. They stated that the area did not hurt much now, but the wound was very painful when they stood and put pressure on the area. During an interview on 07/15/2022 at 10:30 AM Staff C, Licensed Practical Nurse (LPN) and Resident Care Manager (RCM), stated that when she looked at Resident 1's admission record, the status of the skin on the heels was not documented. She stated the heel wound was first found by the podiatrist. If [Resident 1] was admitted with it (heel wound), we missed it and not found until after progressing to a Stage 3. Staff C was informed there were no skin checks documented for the resident in May 2022 after the initial 05/05/2022 assessment. Staff C stated they have not had a full time treatment nurse and those checks should not have been missed. Review of the podiatry consult note, dated 05/19/2022, showed Resident 1 had an ulceration right posterior plantar (back sole of foot) heel with sanguineous (containing blood) drainage approximately 2.5 centimeters (cm) by 2.0 cm and .2 cm deep. Review of a 05/23/2022 progress note by Staff D, Advanced Registered Nurse Practitioner (ARNP), showed the resident was being seen for [CONDITION(S)] (nerve damage) pain . Patient states [they] have occasional R (right) sided heel pain. The physical exam of the skin showed no [CONDITION(S)] or rashes to visible skin. The plan was to order Tylenol as needed for pain. Review of a 05/24/2022 progress note (five days after Podiatrist exam) by Staff B, Director of Nursing, showed Resident appears to have an open Stage 3 ulcer to [their] right heel that measures approx[imately] 5.0 cm by 3.0 cm, open area forming a crater with full thickness loss of skin, granulated tissue and epibole is present. The resident states he has minimal pain. (Measurements about doubled in five days). Review of a 05/27/2022 progress note by Staff D showed, Patient is being seen today for a Stage 3 pressure ulcer of [their] right heel. Patient saw [podiatrist] several weeks ago and this was documented at that time. Today on evaluation it does look slightly infected. There appears to be some redness on the left side of the wound that is extending into [their] dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings). There is yellow pus, scant amount of drainage. There is no odor. Patient states there is pain on palpation (to examine by touch). Wound culture was obtained today for sensitivity. Antibiotics were ordered and started. Review of a 05/31/2022 wound culture report showed the right heel wound was infected with two different bacteria and an additional antibiotic was ordered. Review of a 05/31/2022 progress note by Staff C showed, the Resident [was] provided with pressure relief heel protectors to have on all day except when soiled, showering, or skin checks. (11 days after wound first identified by Podiatrist). Review of a 06/02/2022 progress note by Staff D showed, Patient is being seen today for evaluation of R[ight] heel wound . appears to be healing well. Patient has an apartment waiting for [them] when [they] discharge R[ight] heel ulcer needs to be stabilized before they discharge. Plan will be moving forward to bare weight as tolerated Review of a 06/23/2022 wound evaluation showed Resident 1's right heel wound measured 1.45 cm by 2.18 cm with no signs of infection. Review of progress notes showed wound assessments completed on 07/07/2022 and 07/14/2022 without measurements. The assessment on 07/14/2022 showed wound appears stable and healing. During a telephone interview on 07/18/2022 at 10:00 AM, RR1 stated they were having Resident 1 transferred to another facility due to the unsatisfactory care at the facility and angry that this wound was preventable and has prevented [their] discharge to a lesser level of care. Record review showed on 07/19/2022, Resident 1 was discharged with return not anticipated. On 07/25/2022 at 3:00 PM, Staff A, Administrator, was informed of the failed practice regarding Resident 1's pressure ulcer that caused harm. Staff A stated she understood. Reference: WAC 388-97-1060 (3)(b) This is a repeat deficiency from Statement of Deficiency dated 05/12/2022.

Based on interview, and record review, the facility failed to ensure residents with falls were thoroughly investigated to determine the circumstances of resident accidents and failed to find root cause analysis to minimize injury, avoid reoccurrence of falls, and to develop and implement measures to prevent further falls with injury, for two of three Residents (4 and 5) reviewed for multiple falls. Failure to thoroughly investigate falls and determine the root cause of falls, and re-evaluate fall risks and interventions, resulted in a fall with a large bruised lump to Resident 4's head and a new compression fracture to Resident 4's back, and a fall for Resident 5 resulted in a fracture of the left hip and required surgical intervention. Findings included . A review of the 10/10/2019 Fall Assessment and Management policy showed that the staff were to .look for evidence of a possible link between the onset of falling .or an increase in falling episodes .to work with the attending physician to evaluate functional and psychological factors that may increase fall risk .and to identify and address modifiable risk factors and interventions. If a resident continues to fall, .staff are to re-evaluate the situation whether to continue or change interventions. Resident 4. Review of the resident's medical record showed she was admitted on [DATE] and discharged on [DATE]. Diagnoses included dementia, [CONDITION(S)] (brittle bones), dislocation of recent right hip replacement, a urinary tract infection (UTI), and [CONDITION(S)] with a recent heart valve replacement. During a telephone interview on 02/19/2021 at 9:14 AM, the resident's representative stated the resident fell many times and sustained a lump on her head and a compression back fracture due to falls. The representative stated he told the facility that since the resident had multiple falls and a change in behavior that it usually meant that the resident had a UTI that needed to be treated. The resident's representative stated that after the 02/15/2021 fall he wanted the resident discharged to another facility, but then before that happened the resident fell again and was sent to the hospital emergency room with injuries and was admitted to the hospital. Review of the 01/23/2021 comprehensive assessment showed that the resident was cognitively impaired, exhibited behaviors such as yelling at staff, and required extensive assistance with transfers, eating, toileting, bed mobility and bathing. The 01/16/2021 Fall Risk Evaluation showed the resident had intermittent confusion, had three or more falls in the last three months, was incontinent of bowel and bladder, and used a walker due to recent hip surgery. Review of the 01/16/2021 fall care plan showed the resident was a high risk for falls with, a history of multiple falls with fracture and surgical repair prior to admission to the facility. Interventions for 01/16/2021 included to Keep needed items such as water, cell phone, call light within reach. The resident should wear appropriate footwear such as shoes or non-skid socks while ambulating or mobilizing in a wheelchair and a fall mat on the right side of the bed. Make sure bed is in the low position at night for the resident. Interventions added to the fall care plan on 02/04/2021 was to ensure fall mat is in place at all times for fall safety in bed and wheelchair and offer assistance to the bathroom. Hourly checks while in observation unit. An additional intervention added to the fall care plan on 02/09/2021 was, a manual bed for safety. Review of the January and February 2021 progress notes and Fall Investigative Reports showed the following fall incidents: · 01/20/2021- unwitnessed, non-injury fall from the bed to the floor; no new interventions · 01/22/2021- unwitnessed, non-injury fall from wheelchair to the bed; no new interventions, floor mat added to care plan · 01/27/2021- unwitnessed, non-injury fall from wheelchair to the bed; no new interventions · 02/04/2021- unwitnessed fall with injuries; large knot on the back of the resident's head and the resident complained of back pain, resident used a walker to get out of bed and fell . The resident was on a blood thinner and sent to the hospital and was diagnosed with a new compression fracture related to the fall; personal alarm added to the resident to alert staff if she attempted to get out of bed or the wheelchair 02/11/2021- witnessed, non-injury fall from the wheelchair; staff who witnessed stated, The resident took off her alarm and self-transferred and I told the resident to not remove the alarm. No new interventions. · 02/15/2021- unwitnessed, non-injury fall, resident screaming and found on the floor, alarm did not sound, the resident self-transferred and fell ; no new interventions · 02/16/2021- unwitnessed fall with injuries; the resident was on the floor in front of lift recliner chair that was fully elevated. The resident was sent to the hospital and admitted for a UTI and change in heart status, (a new diagnosis of a heart block - when the electrical impulse from the upper chamber of the heart fails to connect with the bottom chamber of the heart that controls your regular heart beat is blocked). During an interview on 02/26/2021 at 1:00 PM with Staff A, Director of Nursing Services, (DNS), she stated she had accepted the DNS position about a month ago. She stated she was not familiar with root cause analysis and thoroughly investigating cause and patterns of behavior. Review of the 01/16/2021 care plan showed the resident was to have the call light in reach and needed assistance of one with toileting but no indication of how often to assist Resident 4 with toileting. Staff were to use a four wheeled walker for transfers but there was no direction for staff on supervision of the resident. If the resident was not able to use the call light there were no interventions or instruction to the staff to ensure safety of the resident. The 01/16/2021 and 02/12/2021 post fall assessments did not address and further instruct staff to suspervise the resident for transfers and safety. Resident 5. Review of the resident's medical record showed she was admitted on [DATE] with a recent left hip fracture with surgical repair, [CONDITION(S)] (brittle bones), dementia, frequent falls, [CONDITION(S)] Disease (chronic [CONDITION(S)] bowel disease) and [CONDITION(S)]. Review of the 01/27/2021 Advanced Registered Nurse Practioner (ARNP) progress notes showed the resident had previously fallen multiple times and had broken both hips in the last three months, which were surgically repaired. Review of the 02/24/2021 comprehensive assessment showed the resident was cognitively impaired with short term memory loss and required extensive assistance with toileting, transfers, bed mobility, bathing and supervision with eating. The resident was incontinent of bowel. During an interview on 02/26/2021 at 2:40 PM, Resident 5 stated that she fell because she needed to go to the bathroom and no one came when she used her call light. The resident also stated she lost her balance, fell , and had to scream for someone to help. During an observation on 02/26/2021 at 2:50 PM of Resident 5's room, there was a large bed mattress laying parallel on the floor on the right side of the resident's bed. The height of the mattress (12 inches in height) was a potential environmental hazard for the resident. There were no assessments of the risk and benefits for using the mattress at the resident's bedside. Review of the 01/27/2021 fall care plan showed the resident was at moderate risk for falls even though the resident had a history of multiple falls. Interventions for the 01/27/2021 care plan showed, Anticipate and meet the resident's needs, call light in reach as well as cell phone and water, and ensure resident is wearing appropriate foot wear. There were no directions on how the staff were to supervise the resident. Additional interventions added to the fall care plan on 02/26/2021 included, place mattress on the floor and leave door open at all times. On 03/02/2021 interventions added to the fall care plan were to add a clip alarm to the resident to alert staff of position changes. A review of the fall investigative reports and progress notes from 01/27/2021 through 02/24/2021 showed the following fall incidents: · 02/11/2021 - Unwitnessed fall with injuries - resident was trying to go to the bathroom and fell , floor was wet by bedside commode and stool was noted in her brief. There was no documentation by staff of when the resident was last toileted. The resident was in pain and transported to the hospital with a left upper leg fracture. · 02/22/2021 - Unwitnessed fall without injuries, resident had transferred from recliner and fell to the floor. The resident was last visualized at 4:15 PM in the recliner. The resident's call light had been on and when staff answered the call light at 4:40 PM, the resident was on the floor. The resident stated she was transferring to her wheelchair and fell . · 02/24/2021 - Unwitnessed fall without injuries, resident was screaming for help. The resident was attempting to change her brief and fell on the mattress by her bed. The resident had frequent bowel movement and needed to be changed frequently there was no indication of last bowel movement or change. The resident was last seen in bed at 6:55 PM and fell at 7:40 PM. The resident did not use the call light. Review of the 02/11/2021 post fall evaluation showed the resident fell and sustained an upper leg fracture and the resident was incontinent and hospitalized for surgery to repair the fracture. There were no assessments of the resident's room environment or use of other devices used such as clip alarm or mattress at bedside. Review of the 02/24/2021 Post Fall Evaluation did not provide additional information, and repeated the fall investigative report. There was no assessment of why or what potentially caused the fall. During an interview on 03/04/2021 at noon with the resident's representative concerning the resident's fall history, the representative stated that the resident had many falls at home and started to decline in November 2020. The representative stated that the resident had [CONDITION(S)] Disease all her life and wore a brief because she didn't know when she would have a bowel movement and she would change her brief immediately because it was very uncomfortable. During an interview on 03/02/2021 with Staff A, DNS, she stated she completed all incident report investigations. Staff A was unaware that an assessment was to be completed when added interventions such as a clip alarm or a mattress on floor at bedside was added to ensure that environmental safety and hazard preventions were evaluated. Additionally, Staff A did not consider the pattern and time of resident falls or why she wanted to transfer to go to the bathroom. There was no re-evaluation of added interventions to show whether the preventions were appropriate or not. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure one of three sampled residents (1) reviewed for medication errors, was free from a significant medication error. Failure to ensure the correct narcotic [MEDICATION(S)] (Tramadol - a narcotic [MEDICATION(S)]) was administered to the right resident (Resident 1), resulted in harm to Resident 1, who was given the wrong narcotic [MEDICATION(S)] medication ([MEDICATION(S)] - an opioid pain medication) that required the administration of [MEDICATION(S)] (a nasal spray used for known or suspected signs and symptoms of narcotic overdose). Findings included . Review of the January 2016 Medication Pass Policy, showed in the general guidelines for medication administration that the nurse was to .Double check the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . The five rights to medication administration included the nurse ensuring medications given were for the right patient/resident, right drug, right dose, right route and given at the right time. Resident 1. Review of the resident's medical record showed s/he was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to Resident 1's 12/21/2020 comprehensive assessment, the resident had cognitive impairment and short term memory loss. The resident required extensive assistance with all activities of daily living and did not walk, and used a wheelchair. During an interview on 03/09/2021 at 9:00 A.M., Resident 1 stated she did not remember the incident of not receiving the correct medication, but stated she had pain in her back and legs. Review of the 03/01/2021 progress notes showed, a medication error occurred when the resident received the wrong narcotic medication at 6:30 AM and, the resident was more sleepy than usual. The Advanced Registered Nurse Practioner (ARNP) ordered [MEDICATION(S)] nasal spray to be given and to monitor the resident for adverse side effects to include changes in breathing. During an interview on 03/09/2021 at 9:30 A.M., Staff A, Director of Nursing Services (DNS), stated that Resident 1 was more drowsy than usual after the [MEDICATION(S)] (opioid pain medication) was given in error by Staff H, Registered Nurse (RN), and she was concerned and alerted the ARNP. Staff A also stated the [MEDICATION(S)] worked, and the resident returned to her baseline. Review of the 03/01/2021 investigative report showed that, Staff H was placed on administrative leave pending investigation for administration of the wrong narcotic medication. During a telephone interview on 03/16/2021 at 9:46 A.M. with Staff H, she stated she pulled the wrong narcotic card for Resident 1 and gave the medication. Staff H stated she realized she gave the wrong medication and reported the medication error. Staff H stated the resident became very sleepy and hard to wake up and [MEDICATION(S)] was ordered and given to the resident to ensure the resident didn't overdose. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview and record review the facility failed to A) ensure all pertinent medical information related to medication allergies [REDACTED].#98) reviewed for medication allergies [REDACTED]. The failed practice was identified for 1 of 3 sampled residents (#2) reviewed for positioning. Findings include: Resident #98. admitted on [DATE] with [DIAGNOSES REDACTED]. Upon admission, [MEDICATION NAME] was the only medication noted on the list of allergies [REDACTED].>On 07/08/15 at approximately 11:00 a.m. Resident #98 lay on her bed. A pair of dark glasses lay on the bedside table. The resident's eyes were reddened around the upper and lower edges/perimeter. She said her eyes felt better than they had been. She used the dark glasses when her eyes bothered her. Record review revealed the resident saw her eye physician on 05/01/15. Subsequently, the evening charge nurse requested the physician's notes for the office visit which arrived at the facility on 05/07/15. The notes included a list of medication allergies [REDACTED]. On 07/09/15 at approximately 10:00 a.m., Staff Member F, Resident #98's RN case manager, reported the resident's admission [DIAGNOSES REDACTED]. The RN case manager said the resident's eyes bothered her recently. The RN stated, When (resident's primary physician - PCP) made rounds (on 06/11/15), he saw the resident's eyes were not good. They were beet-red. The resident complained her eyes were causing her more anxiety because they weren't getting better. So (the PCP) ordered a [MEDICATION NAME] ribbon (antibiotic ointment to eye lids). On 07/09/15 the RN case manager was questioned about why the resident's PCP ordered an eye ointment on 06/11/15 when that medication ([MEDICATION NAME]) was listed as a medication allergy in the eye physician's notes of 05/01/15. The RN responded that after (resident) saw (eye physician) on 05/01/15, the evening charge nurse called the office for the chart notes which arrived on 05/07/15. She (charge nurse) reviewed the document and didn't see any new orders, so she filed (the report). The RN case manager said the charge nurse didn't see the list of allergies [REDACTED]. So when the resident's PCP made rounds on 06/11/15 and (resident's) eyes were red and still bothering her, (PCP) ordered the [MEDICATION NAME]. On 07/09/15 the RN said the resident had seen her mental health provider on 06/26/15 for increased anxiety. A telephone interview conducted on 07/09/15 with mental health clinic staff revealed when staff saw Resident #98 on the 06/26/15, they found her eyes were very red, goopy, and the lids were swollen. Clinic staff also stated the resident complained of her eyes hurting and burning, itching, and she could not see as well because her vision was blurred. They said they called the facility that day to inform them of their concern. They reported they thought the resident's eyes were bad enough that they wanted the resident to see her eye physician that day or go to the local emergency room so she wouldn't have to suffer over the weekend. On 07/09/15 the RN case manager said the resident's mental health provider did call the facility on 06/26/15 and spoke with the social services director (SSD), Staff Member C. The RN said clinic staff wanted someone to pick up the resident because she was complaining of severe eye pain. A progress note by Staff Member C dated 06/26/15 at approximately 11:22 a.m. included, (Staff at local mental health clinic) contacted this author regarding (resident) needing to be picked up regarding severe pain issues. This author could hear (resident) on the phone screaming out in pain and (clinic staff) trying to console her . A progress note dated 06/26/15 at approximately 3:00 p.m., written by Staff Member O, the day RN charge nurse, included, Patient was seen at (local mental health clinic) today. I received a call from (SSD's) office to report that (clinic staff) wanted patient seen by (eye physician's) office today and if that was not possible, to send her to the emergency room . Sclera and conjunctiva tissues red (whites of the eyes, inside of eyelids, and around the edges of the eyes) .Patient complained of itching. Update to (eye physician's) clinic. (Eye physician's) allergy list reviewed and it is noted that patient has an allergy to [MEDICATION NAME] ointment that was ordered earlier this month by her PCP. New orders received to stop [MEDICATION NAME] now .OK to have patient seen in office on Monday (06/29/15). Transport has been arranged . Physician notes for the 06/29/15 office visit revealed a [DIAGNOSES REDACTED]. The physician ordered two types of eye drops to be started and documented he wanted to see the resident again for a follow-up visit in one week. On 07/02/15 a progress note included, Resident's eyes are much clearer than yesterday .Resident states that eyes are still itchy . A progress note dated 07/06/15 revealed, .Resident states that eyes still feel like they have grit in them but are no longer itchy or dry. On 07/13/15 at 9:45 a.m. the resident sat on her bed and removed a wash cloth from her face. She said putting a cold cloth against her eyes helped them feel better. The resident reported, They (eyes) feel much better now. I had some problems with them before (redness, itching, burning). I still have a little blurred vision at times and it still feels like I have some sand in my eyes. On 07/13/15 at 12:25 p.m. in a telephone conversation with the facility's pharmacist, he stated, [MEDICATION NAME] and [MEDICATION NAME] are in the same class of drugs. He said this was the reason Resident #98's eyes reacted severely to the [MEDICATION NAME] eye ointment. The pharmacist stated, That should have been looked at. The pharmacist also remarked that the only medication allergy listed for this resident in their files was [MEDICATION NAME] and this was why the order for the [MEDICATION NAME] was filled without question from the pharmacist on 06/11/15. On 07/14/15 at 1:15 p.m. the day charge nurse stated, The telephone call (on 06/26/15 about Resident #98's eyes and complaints of pain and discomfort) came from a mental health provider. I called (eye physician's) office and told them what was happening. They made the appointment for Monday 06/29/15. That's when we (charge nurse and eye physician's staff) reviewed the resident's allergy list and found that their list had more medications on it than ours. We found that (resident) was on the wrong medication ([MEDICATION NAME] ointment) and we stopped it immediately. The charge nurse said 06/26/15 was the day she updated the allergy list in the resident's computer file with the additional allergic medications including [MEDICATION NAME] and [MEDICATION NAME] (both antibiotics). Although documentation about additional medications to which the resident was allergic was received in the facility on 05/07/15, over one month before the [MEDICATION NAME] was prescribed, no facility staff was aware the resident was allergic to [MEDICATION NAME] until a comparison of the eye clinic medication allergy list and the facility's list of medication allergies [REDACTED]. Resident #2. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. On 07/06/15 at approximately 4:30 p.m., the resident was observed sitting in her wheelchair. Her back was not against the back of the seat. The resident's legs and feet were in a hyperextended position, with her feet pointed and her toes resting on the floor. Approximately a half hour later, Staff Member S, a Licensed Nurse (LN), entered the resident's room to administer a medication. She noted the resident did not have the lower leg braces in place. She proceeded to search for the lower leg braces. While she was searching, Staff Member T, a Nursing Assistant (NA), walked into the room and commented, You caught me (referring to not having placed the leg braces on the resident). On 07/06/15 at approximately 5:05 p.m., Staff member H, a LN, stated the resident is to have her lower leg braces on at all times while she is in her chair. He added the resident's chair was to be positioned in an upright position when the resident was eating, and the chair was to be reclined to 20 degrees at other times. He further noted when the resident was in bed, she was to have a blue wedge at the foot of the bed to protect her feet. On 07/07/15 at approximately 12:30 p.m., the resident was observed in the dining room sitting in her wheelchair. The back of her chair was tilted back at approximately 20 degrees during the entire meal. On 07/09/15 at approximately 9:30 a.m., Resident #2 was observed in bed. She was positioned so the back of her head was against the headboard, tilted forward, with her chin touching her chest. She coughed several times. Her lower legs and feet did not have support pillows in place. On 07/09/15 at approximately 9:45 a.m., both Staff Members M and U, NAs, stated they did not know the degree the resident's chair was to be tilted to. Both NAs added the wheelchair did not have any markings to help them determine the correct degree of tilting. Staff Member U stated I put the resident back in bed this morning after breakfast. I know she is supposed to have a pillow between her legs for positioning but I am not sure about a pillow for her feet. She added the reason I did not place the pillow between her legs is because I did not have a pillowcase for the pillow. Both NAs commented they were aware of resident's required positioning assistance. The resident's most recent comprehensive assessment, dated 04/04/15, documented the resident was severely cognitively impaired. She required extensive assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required total assistance from staff for locomotion in and out of her room. Record review revealed both the resident's care plan and the in-room care plan included specific instructions; .place pillows under the mattress at the head and middle of the bed to prevent the resident from rolling herself onto the floor. Keep blue wedge at the foot of the bed. The care plan included additional intervention for proper positioning; including: Podus boots (a foam boot) when she is up in her wheelchair, and she is to be tilted to 20 degrees while up in her wheelchair except during meals when she is to be seated upright. In spite of facility staff being aware of the resident's required positioning needs, identified on her care plan, the staff failed to consistently implement the positioning interventions. The reclined positioning during meals put the resident at risk for aspiration, and not consistently placing her assistive devices; such as Podus boots and pillows between her legs, put her at risk for development of skin issues.

Based on observation, record review, and interview, the facility failed to provide: necessary skin risk assessments, preventative interventions, and/or prescribed care to prevent formation of pressure sores or promote healing for 4 of 5 sampled residents (#5,6,7,&8). Residents #5 and #8 experienced harm as a result of the lack of necessary care. Findings include: Resident #5: The resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission skin assessment, dated [DATE], noted the resident did not have any open ulcers. Labs values on [DATE] in the hospital noted the resident's [MEDICATION NAME] (a protein in the blood) was low at 2.2 (normal range was 3XXX,[DATE].0) and his total protein was also low at 5.2 (6XXX,[DATE].3). His plan of care identified he had difficulty performing his activities of daily living related to weakness, impaired mobility, and a cognitive deficit. Despite his multiple medical conditions and weakness, the facility failed to perform a skin risk assessment at the time of admission to determine the resident's risk of skin breakdown and to implement preventative interventions. Over the course of the next month the resident began to lose weight which placed him at increased risk for skin breakdown. See F325. According to a [DATE] nursing entry, the resident was noted to have a persistently red area on his right (lateral) shoulder. A skin assessment on that day, documented the red area was 4 centimeters (cm) in diameter (more than 1 ,[DATE] inches) but the skin had not broken. "(R)resident spends majority of time laying on right side. Have advised him to turn sided (sic) to side, implemented q (every) 2 hour turn schedule, and requested an overlay for him, will monitor site until resolved." The [DATE] nursing entry documented the resident had an "open area measuring 0.5 centimeters (cm) by 0.5 cm" (about ,[DATE] inch diameter) on his right shoulder. A specialized dressing was ordered with daily dressing changes on [DATE]. A [DATE] Wound Assessment documented the presence of a Stage II pressure sore (partial thickness loss of skin) but no measurements were documented related to the size. It was noted the dressing was not present but it was replaced. A [DATE] Wound Assessment form noted the continued presence of the Stage II pressure sore but no size was noted. A [DATE] Wound Assessment documented the ulcer site was now a Stage I (persistent redness of the skin) and the dressing was in place. Review of the plan of care revealed a plan for skin management that was dated [DATE], generated after the request for the plan. Staff Member C (Licensed Nurse) was interviewed on [DATE] at approximately 12:55 p.m. and 1:20 p.m. and stated Resident #5's shoulder skin was pink and intact and continued as a Stage I pressure sore. According to the Staff Member, the resident preferred to lie on his right side and staff had to remind him to turn. Resident observations on [DATE] at approximately 1:20 p.m. with Staff Member C revealed the resident was lying toward his right side. The Staff Member cued and assisted the resident to reposition off his right side. The resident had a protective dressing in place on his right shoulder. The resident was interviewed on [DATE] at approximately 1:30 p.m. He was positioned on his right side/shoulder. The resident stated his right shoulder was tender. Review of the plan of care revealed a plan for the skin dated [DATE], generated after the request for the plan. Staff Member D (Resident Care Manager) was interviewed on [DATE] at approximately 12:55 p.m. and stated the resident's skin risk assessment was not completed at the time of admission but was completed on [DATE] (when skin breakdown was identified, approximately one month after admission) and the skin management plan was not completed until [DATE]. Resident #8: Review of the medical record revealed the resident was admitted to the facility on [DATE] following a [MEDICAL CONDITION]. The [DATE] admission skin assessment documented a 0.5 cm by 1 cm blister (less than ,[DATE] inch by ,[DATE] inch, a Stage II pressure sore) on the resident's coccyx (over the tailbone) and a dark purple deep tissue injury 11 cm by 7 cm (approximately 4 ,[DATE] inches by 2 ,[DATE] inches) on the resident's right buttock. According to the care directives, the resident required staff asssitance with his activities of daily living including for repositioning every two hours. The resident was also noted to have some bladder incontinence and wore incontinent briefs. A [DATE] 6:41 a.m. nursing entry from Staff Member G noted the deep tissue injury to the coccyx "continues to evolve. black (sic) necrotic (dead tissue) area is now 7 cm by 8 cm (2 ,[DATE] inches by over 3 inches) on coccyx and right gluteus". The resident was on an air mattress for pressure reduction. The ,[DATE] treatment record noted the deep tissue injury on the right buttock and coccyx blister were to be monitored daily to evaluate and "re-evaluate for needed dressings when completed". No treatment orders were noted to protect the area from infection and irritation (from urine) and/or treat the blister area. A [DATE] skin assessment documented the coccyx deep tissue injury as 7.5 cm by 8 cm and was "unstageable". On [DATE] (9 days after admission) a Registered Dietitian made recommendations for wound healing supplements. According to the nursing entry on [DATE], a culture was sent from the coccyx wound. Additionally, there was an order for [REDACTED]. A [DATE] nursing entry documented the appearance of the coccyx area with [DIAGNOSES REDACTED] (redness), tactile fever (warm to the touch), and pain affecting the soft tissue with a suspected wound infection. Lab results revealed a high white blood cell count (21.5, an indicator of a bacterial infection), and the wound culture also revealed an infection. Daily injectable antibiotics were ordered. When interviewed on [DATE] at approximately 4:30 p.m. about the resident's treatment records, the Director of Nursing discussed facility wound protocols. She stated that treatment for [REDACTED]. Despite the presence of a blister (a Stage II pressure sore) at the time of admission, the facility failed to implement a timely protective dressing and treatment (in an area exposed to urine and feces). The area and adjacent injured tissue deteriorated and became infected requiring antibiotic treatment. The resident died from another cause on [DATE]. The autopsy report documented a bedsore, 10 cm (nearly 4 inches) in diameter on the right sacrum (area on the back above the lower tailbone area) and extending laterally into the right buttock area. Resident #7: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission skin assessment identified 2 large open ulcers on her coccyx, "unstageable and a Stage II open ulcer on her right gluteal fold (right buttocks area). A culture was obtained on the tunneling wound to the coccyx. Multiple interventions were implemented including care at the wound clinic, antibiotics for the wound infection, and treatment changes over time. Review of the ,[DATE] treatment record revealed an order for [REDACTED]. On [DATE] at approximately 3:30 p.m. Staff Member B was observed performing a dressing change on the resident's coccyx wound. The open area exposed the tailbone (a Stage IV, pressure ulcer, was approximately 6 cm long and 2 cm wide (2 ,[DATE] by nearly an inch wide) with deep tunneling present. There a noted odor to the wound and drainage was creamy/light green in color. The dressing was documented [DATE], two days earlier, despite documentation on the treatment record that it had been completed as scheduled by Staff Member B. When an inquiry was made about the discrepancy, Staff Member B stated she had not completed the dressing change the evening before and occasionally she skipped the dressing change. When interviewed (on [DATE] at approximately 3:00 p.m.) the cognitively alert resident stated Staff Member B had such a heavy workload and sometimes she came in at 10:00 p.m. to complete the dressing change. The resident could see how tired the Staff Member looked so she would tell her, "we can forget it tonight". The resident further stated it was helpful when there were students at the facility so Staff Member B could catch up. Resident #7 was also concerned about her wound healing and a possible ongoing wound infection. Review of the medical record revealed the resident had a culture of her coccyx ulcer on [DATE]. There was an infection with multiple organisms. She was treated with an antibiotic at that time. No further cultures were found. On [DATE] at approximately 11:20 a.m. Staff Member F (the Charge Nurse) stated she was unable to say without a follow-up culture if the she had an ongoing infection. Resident #6: admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Documentation stated on admission that it was anticipated the resident would "unavoidably expire" during her stay in the facility. It was noted the resident was on bedrest, disoriented to time, and had a poor appetite. Review of Progress Notes on [DATE] revealed a skin audit was not done on admission due to the resident's agitation with a stated plan to re-assess at a different time. Documentation on ,[DATE], ,[DATE] noted the resident was resting quietly with no evidence of agitation, however a skin assessment was not completed until [DATE] (ten days later). The assessment revealed the resident had two Stage II pressure ulcers (partial thickness loss of skin presenting as a shallow open ulcer) and one Stage I pressure ulcer (persistent area of redness) to the coccyx area with bloody, thin drainage noted. A [MEDICATION NAME] dressing (adhesive dressing used to provide a moist wound-healing environment) was placed over the area. Review of the resident's plan of care revealed a problem addressing the pressure ulcers to her coccyx and the potential for additional pressure ulcers to develop with planned interventions was not initiated until [DATE] (13 days following admission to the facility). Two days later on [DATE] documentation stated the area to the resident's coccyx which was present on admission had worsened. One area to the coccyx was noted to be black in color. The [MEDICATION NAME] dressing was discontinued and [MEDICATION NAME] (moisture barrier ointment) was applied to the area. A telephone interview on [DATE] at 11:05 a.m. with the resident's family member revealed she was very frail and thin and had resided in several heath care facilities between October- [DATE]. Despite the resident being at high risk for skin problems on admission (terminal diagnosis, bedrest with immobility, frail and thin, and weight loss secondary to poor appetite) there was no evidence that preventative measures were implemented until [DATE] (13 days following admission to the facility). In addition, documentation stated the resident had pressure ulcers to her coccyx on admission but treatments to the area were not implemented until [DATE] (10 days later).

Based on record review and interview, the facility failed to provide necessary, timely care following an acute change of condition for 1 of 4 sampled residents reviewed (#7) with changes of condition. Resident #7 developed acute respiratory symptoms and was diagnosed with [REDACTED]. Findings include: Resident #7: Review of the medical record revealed the resident had been hospitalized following a stroke that impacted her ability to eat and move. Her condition necessitated the placement of a feeding tube into her stomach to allow for nutrition via tube feedings. The resident was admitted to the facility on [DATE] with Medicare A coverage. Her admission assessment noted a normal body temperature, lung sounds were diminished, and there was a superficial gurgle that cleared with suctioning. The resident was receiving oxygen at 2 liters per minute. The physician directed the resident's oxygen saturation level should remain above 90%. Oxygen saturation levels were to be checked every shift. The resident's POLST form (outlining her treatment wishes) identified she was to receive full treatment including cardio-pulmonary resuscitation (CPR). Review of the resident's admission plan of care noted she was dependent on her feeding tube for all of her nutrition and hydration. An identified goal was that she was to be free of any aspiration (entry of any fluids into her lungs). The head of the resident's bed was to be elevated 30 degrees at all times (to help prevent aspiration). The plan of care did not contain specific written directives about respiratory assessments or suctioning. On [DATE] at approximately 12:20 p.m. Licensed Nurse (LN) B, the charge nurse, stated when residents were on Medicare A the expectation was the resident would receive vital signs and assessments every shift. Review of an [DATE] nursing entry revealed the resident's lung sounds were clear and the oxygen saturation level was 93 % on 2.5 liters of oxygen. The following day, on [DATE] at 1:06 p.m., the resident appeared to have a rapid respiratory rate of 32. Oral suctioning yielded a thick creamy white substance. Her saturation level was low at 88% so the oxygen was turned up to 4 liters to reach a 92% saturation. The resident also had a body temperature elevation to 99.8 degrees Fahrenheit (axillary, approximately 100.8 if taken orally). The physician was contacted and ordered a chest x-ray. The x-ray revealed the resident had pneumonia. On [DATE] at 3:45 p.m. the physician ordered an antibiotic and the first dose was pulled from the facility emergency kit and given shortly thereafter. Review of the facility records revealed no further vital signs were taken for the remainder of the evening on [DATE] or the following night shift despite the resident's new [DIAGNOSES REDACTED]. The last oxygen saturation check was documented at 7:48 p.m. and was 98%. The night shift documentation did not contain any respiratory assessment, vital signs, or overall assessment of her condition. Documentation on [DATE] at 4:39 a.m. noted the resident received Tylenol for general discomfort and was suctioned for a moderate amount of phlegm. The nursing assessment, dated [DATE] at 8:52 a.m., documented the resident had a rapid respiratory rate of 38, was diaphoretic (cold and clammy), had increased lung congestion, and had a decreased level of consciousness. The physician and family were notified and the resident was transferred to the hospital. Review of the [DATE] emergency room records revealed the resident was sent to the Intensive Care Unit (ICU). The [DATE] physician's consultation report noted the resident had [MEDICAL CONDITION] (an infection involving her entire body) and pneumonia. On [DATE] at approximately 2:30 p.m., Nursing Assistant (NA) A stated she had provided care for Resident #7 during the night shift of [DATE] going into [DATE]. NA A stated that at about 3:45 a.m. she and NA B were providing care for the resident. The resident appeared to have "foam in her mouth" and her skin was "soaked, like a bucket". The NA stated she had reported her observations/concerns to LN A. On [DATE] at approximately 4:05 p.m., NA B stated she and NA A were caring for the resident the night before she went to the hospital. At about 4:30 a.m. she went in to check the resident. Licensed Nurse A was in the bathroom and had been doing something with the resident's feeding tube. The resident's bed was flat (instead of being elevated as care planned). The NA recalled the resident was very sweaty and she was "foaming at the mouth". When interviewed on [DATE] at approximately 7:50 p.m., LN A stated no vital signs were taken during the night shift (approximately 19 hours since the last vital signs at the time of the acute change of condition). Additionally, she had not completed a lung assessment. The resident was not responding to her but she stated the resident had not responded to her before. The LN reportedly had not identified that the resident had a change of condition; she stated her condition was as it had been reported to her by the evening shift staff. The LN failed to obtain objective data such as vital signs, oxygen saturation checks, and physical assessments to evaluate the resident's condition despite reports of concern by the NAs; and new [DIAGNOSES REDACTED]. The resident's condition continued to decline until the day shift arrived and facilitated a transport to the hospital where she was placed in the ICU due to her medically fragile condition.

Based on record review and interview, the facility failed to transcribe physician's orders correctly, thus 1 of 1 resident (#1) in the sample received an anticoagulating medication every day without appropriate laboratory testing of blood. In addition, the facility failed to recognize the absence of orders for critical blood tests and to seek additional orders from the phsyician. That failure resulted in actual harm for Resident #1 who had a [MEDICAL CONDITION] and required hospitalization . Findings include: Resident #1. admitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. The resident had multiple [DIAGNOSES REDACTED]. ([MEDICAL CONDITION] is a decrease in hemoglobin in the blood and may be caused by a decrease in red cell production or blood loss.) While in the hospital following surgery, and the day before admission to the nursing home, the resident received a blood transfusion. The physician orders from the hospital, dated 03/19/11, included "[MEDICATION NAME] 2 milligrams PO X1 tonight please." That order was for a one-time dose of the medication. The order was incorrectly transcribed by the admitting nurse to the MAR (Medication Administration Record) as "[MEDICATION NAME] 2 milligrams daily". There were no orders for testing of the INR, or International Normalized Ratio, which is a blood test used to determine blood coagulation abilities. (Dosages of [MEDICATION NAME] are highly individualized and are determined by the INR blood test.) Additional medication orders were for Aspirin (with antiplatelet functions) 81 milligrams daily and [MEDICATION NAME] (an antiplatelet medication made of 25 milligrams aspirin and 200 milligrams [MEDICATION NAME]) 25/200 milligrams daily. (Platelets are essential for the coagulation of blood, thus an antiplatelet medication would decrease the coagulation of blood.) The initial admitting orders for the resident were transcribed incorrectly to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. He also received the Aspirin and the [MEDICATION NAME] daily. The order was transcribed incorrectly to the MAR, which allowed for the resident to receive an excessive amount of the [MEDICATION NAME]. In addition, there were no orders for blood testing of the INR. Multiple nurses failed to recognize the daily [MEDICATION NAME] dose without any orders for INR. The risk of bleeding with [MEDICATION NAME]/[MEDICATION NAME] increases when INR values are prolonged and hemorrhage is the adverse effect of greatest concern with anticoagulant therapy. Dosing of medications, such as [MEDICATION NAME]/[MEDICATION NAME] are highly individualized and may have to be adjusted several times based on laboratory test results. On 04/05/11 at 8:45 a.m. nurses' notes documented the resident was nauseated (not a new symptom) and uncooperative with care. It was noted the resident's stool was black (an indication of bleeding) and a sample was collected to determine if blood was in the stool. The nursing entry at 1:50 p.m. noted the resident was not feeling well. His skin color was white/gray. His pulse rate was 59 and blood pressure was 86/51 (significantly lower than previous pressures). The resident was transported to the hospital at 3:19 p.m. Review of the autopsy report noted the resident had upper and lower [MEDICAL CONDITION] which caused hypovolemic shock (a condition of rapid fluid/blood loss). On 04/12/11 at approximately 4:30 p.m. the Director of Nursing stated the transcription error was discovered after the resident was sent to the hospital.

Based on record review and interview, the facility failed to ensure the medication regimen of 1 of 4 residents (#1) receiving anticoagulation therapy was free from unnecessary drugs as required in CFR 483.25(l)(1)(i)(ii)(ii). The resident was given multiple medications with blood-thinning capabilities without adequate monitoring of blood and for an excessive duration. Failure to monitor the resident's medications resulted in harm to Resident #1 who was hospitalized as a result of hemorrhage. Findings include: Resident #1. admitted to the facility on [DATE] following surgical repair of a [MEDICAL CONDITION]. The resident had received a blood transfusion while at the hospital and had a known [DIAGNOSES REDACTED]. Transfer orders from the hospital, dated [DATE], included an order which read "[MEDICATION NAME] PO (orally) daily, call (named clinic) for dose, please see script." Another physician's orders [REDACTED]. INR 2.19." The Licensed Nurse who transcribed the admission orders [REDACTED]. That medication was given every day between [DATE] and [DATE]. There was no monitoring of that drug, which would have included blood testing of the INR and then reported to the physician for further dosing orders. Additionally, the resident received Aspirin 81 milligrams daily and [MEDICATION NAME] ,[DATE] milligrams daily. Both of those medications have blood-thinning capabilities. Yet staff did not recognize the need for physician orders [REDACTED]. On [DATE] at 8:50 a.m. the resident was noted to have black, tarry stool and a sample was collected to determine if blood was in the stool. At 1:50 p.m. that day the resident's skin color was "white/gray" and his blood pressure was ,[DATE]. He was sent to the hospital where he expired at 3:19 p.m. A note in the facility's investigation of the medication error noted the resident's cause of death was hypovolemic shock, [MEDICAL CONDITION] and [MEDICAL CONDITION] hemorrhage.