**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review, the facility failed to accurately assess and develop/implement a care plan (CP) for the management of chronic heart problems and failed to timely identify/assess/implement interventions for a related change in condition for 1 of 3 sampled Residents (Resident 51) reviewed for hospitalization. The facility also failed to consistently monitor and document bowel movements (BMs) and implement the bowel program when needed for 2 of 3 sampled residents (Residents 16 and 66) reviewed for bowel management. Resident 51 experienced harm when they had a significant fluid volume overload (too much fluid in the body causing difficulty breathing, increased weight and swelling/edema) and a delay in respiratory interventions resulting in an emergency transfer to the hospital for respiratory failure. The failure placed residents at risk for further decline in their conditions, discomfort, and a diminished quality of life/quality of care. Findings included . Review of the facility's Weight Assessment and Intervention policy, revised March 2022, residents were weighted on admission and at intervals established by the Interdisciplinary Team (IDT). Weights would be documented in the clinical record. Any weight change of 5% or more since the last weight measurement would be retaken the next day for confirmation and if verified, nursing would immediately notify the dietician in writing. Unless notified of a significant weight change, the dietician would review all the resident's weight record monthly to follow individual weight trends over time. Undesirable weight changes would be reviewed by the IDT team to determine level of significance, review status to identify potential contributing factors for the weight change. The resident's individualized CPs would be reviewed and updated to include the identified change in status, identified causes, goals/benchmarks for improvement, and timeframe/parameters for monitoring and reassessment. Review of the facility's Heart Failure-Clinical Protocol policy, revised November 2018, showed the physician would help to identify individuals with a history/diagnosis of heart failure (HF) and clarify as much as possible their severity and underlying cause. The physician would help identify individuals at risk for cardiac decompensation (acute decline / change in condition)- (for example because of a heart rhythm problem or chronic lung disorders). The physician would make recommendations for the nursing plan of care including symptoms monitoring, edema and weight measurement frequency, lab monitoring, and provide parameters for when to report findings, consistent with relevant protocols and professional standards: such as those from the American Heart Association and the American Medical Directors Association. Review of the American Heart Association (Vol.8, No.3) Heart Failure Management in Skilled Nursing Facilities, published 04/08/2015, recommended for residents who were higher risk for decompensation (and with the admission goal to rehabilitate and discharge home or was uncertain), the nursing care plan should adhere to daily weight monitoring (same time of day-preferably first thing in the morning after the first toileting) and fluid volume evaluations. A weight gain of three to five pounds over three to five days should alert licensed staff to perform an advanced assessment of volume status, vital signs, and oxygen saturation, then promptly notify the physician with the findings. Routine daily symptom monitoring should occur for any degree of edema, abnormal lung sounds, cough (especially when lying down), JVD (jugular vein distention-a bulging of major veins in the neck and a key symptom of HF) symptom of too much water in the blood system ), difficulty breathing at rest, when lying flat, and/or at night along with routine weights at the same time every day helped determine exacerbations in HF. <Fluid Volume Overload: Weights and Edema> <Resident 51> In an interview on 04/10/2024 at 11:14 PM, Resident 51 stated they were not weighed routinely and had problems with edema. Resident 51 stated they recently returned from a hospital stay because they had too much fluid on their body. Resident 51 stated they had heart failure and a chronic lung disease, and experienced daily difficulty breathing while lying flat. They required a non-invasive mechanical ventilator via bilevel or continuous positive airway pressure (BiPAP/CPAP: machines that assists with breathing) for their lung problems at night, but they wore it all the time, and only removed it to eat or when they got up in the wheelchair. Review of the Annual Minimum Data Set (MDS), an assessment tool, dated 02/02/2024, showed Resident 51's diagnoses included respiratory failure, diabetes, high blood pressure, fluid volume overload, and swelling to both lower legs. The MDS did not include Resident 51's diagnosis of HF and assessed them as not having a problem with breathing when laying flat. Resident 51 was assessed to require Bipap/Cpap and did not receive oxygen therapy. Resident 51 was assessed to weigh 475 pounds but was not assessed to have a significant weight gain. Review of Resident 51's respiratory CP, dated 01/23/2023, showed they had obstructive sleep apnea (repeatedly stop and start breathing while asleep), COPD (chronic obstructive lung disease), respiratory failure, and the goal was to decrease episodes of respiratory distress with nursing interventions. The CP showed interventions dated 1/23/2023: Bipap/Cpap per physician orders (not personalized with prescription or parameters), oxygen as ordered (not personalized with prescription), and weight per facility protocol- Notify physician of significant weight fluctuations. Review of Resident 51's electric health record (EHR) showed no provider order for routine weight monitoring or frequency. Review of Resident 51's nutritional CP, revised 01/08/2024, showed they were at nutritional risk due to fluid overload and edema including a 01/30/2023 intervention that directed nursing staff to monitor and evaluate for signs or symptoms of significant weight changes or trends and obtain weights as ordered or directed by the licensed nurse. An additional intervention, dated 03/28/2024, read weights and did not specify further. Review of Resident 51's weight record showed they were not weighted consistently since their initial admission on [DATE]. Resident 51's recorded weights were: 08/31/2023-415 pounds, 10/17/2023-440 pounds, and 01/25/2024-474 pounds (an 8% weight gain in three months and a 14% weight gain in four months). There were no weights recorded for September 2023, November 2023, or December 2023. Review of the corresponding Progress Notes showed no identification of the significant weight change. Review of the Vascular Specialist consult note, dated 02/19/2024, showed the provider ordered medical grade lower extremity compression therapy (Unna boot) and elevation therapy for the management of chronic lower extremity edema and recurrent venous stasis ulcers (chronic and recurrent wounds of the lower legs, a result of venous insufficiency- the condition of poor blood circulation from the legs back to the heart). Review of the February 2024, March 2024, and April 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no order for weight monitoring frequency or parameters for physician notification, no edema monitoring (except for two days, 03/11/2024 and 03/12/2024), and no medical grade compression therapy was never initiated. In an interview on 04/12/2024 at 1:15 PM, Staff S, Licensed Practical Nurse, stated when residents go to their specialist appointments, they made a point to try to review the consult orders and/or ensure they were reviewed by the provider and expected the orders provided by the specialists to be implemented. Staff S was unable provide documentation to show medical grade compression therapy was started for Resident 51. Staff S stated residents were expected to be weighed monthly unless otherwise specified in their orders or care plans. Staff S stated if a resident had heart failure and problems with edema, their edema should be monitored routinely (daily or weekly) which would include frequent and routine weight monitoring (typically daily, or two to three times per week, depending on the resident's condition), and have parameters for physician notification. Staff S could not provide documentation to show how often Resident 51 should have been weighed to monitor their fluid volume status or how often their edema should have been monitored. <Change in Condition: Respiratory Failure> Review of provider order, dated 01/19/2024, showed oxygen via nasal canula was ordered for 2 liters per minute (lpm) as needed to maintain oxygen saturations above 89%. Review of a Provider Progress Note (PPN), dated 03/01/2024, showed Resident 51's weight was 475 pounds (using the weight from 01/25/2024) with a warning triggered for significant increase in weight. The PPN showed Resident 51's room air oxygen saturation was 89% which triggered for being below 90%. The PPN showed Resident 51 had mild edema on both lower legs. The provider documented Resident 51's COPD was stable and their oxygen sats were greater than or equal to 90%. The documentation showed no adjustments were made to the resident's medical plan. Review of a Nurse Progress Note (NPN), dated 03/11/2024 at 9:53 PM, showed Resident 51's oxygen saturation was around 80% at PM (almost six hours prior to the writing of the NPN). Staff L, Registered Nurse, documented they gave an emergent puff of their inhaler and called the on-call doctor. Staff L did not document a respiratory assessment or an assessment of fluid volume status. Staff L documented Resident 51 did not want the oxygen on [they] wanted to wear their BiPap. Staff L documented the on-call physician requested Resident 51's primary care provider adjust their BiPap prescription to maintain oxygen saturation greater than 90%. Staff L documented Resident 51 reported breathing difficulty earlier in the morning, but now complained of difficult breathing and chest tight. Staff L documented Resident 51's oxygen saturation was between 78% and 86%. The NPN did not document the provider was contacted to report the previous interventions were ineffective at keeping Resident 51's oxygen saturation greater than 90% and that the oxygen saturations were decreasing. Staff L documented Continue to monitor and endorse accordingly. Review of the electronic health record (EHR) showed Resident 51 was not sent to the emergency room at this time (03/11/2024) for evaluation of their low oxygen levels, new onset of increase demand for oxygen, or chest pain. In an interview on 04/12/2024 at 2:15 PM, Staff B, Director of Nursing, stated the facility had a system to help identify and monitor for a change of condition that included the SBAR form (SBAR stands for Situation, Background, Assessment, and Recommendation) for non-emergent concerns. If the concerns were more emergent the nurses were expected to evaluate the resident's condition and call the provider (or on-call) to report their findings. Staff B stated the provider should have been called after there was no improvement in Resident 51's respiratory status on 03/11/2024 and their oxygen saturation persisted below 90% with interventions. Review of a NPN, dated 03/11/2024 at 11:23 PM showed the nurse wrote an SBAR to the provider for the adjustment of the level of the BiPap. Review of new verbal provider order, dated 03/12/2024, written by nursing, showed oxygen two to three lpm to maintain oxygen saturations above 92%. Review of the NPN, dated 03/12/2024 at 1:47 PM showed Resident 51 was on 3 lpm of continuous oxygen with a mask. The nurse documented the Provider would see Resident 51 today. Review of the NPN, dated 03/12/2024 at 11:16 PM showed Resident 51's oxygen saturation was 90% on 3 lpm of oxygen, sometime that evening. After dinner, Resident 51 reported they felt like they could not get enough air and requested to switch to their BiPap. The nurse documented they put both the nasal canula (with oxygen set at 3 lpm) and the BiPap together and their oxygen saturation was 84%-88%. They would continue to monitor and endorse accordingly. There was no documented respiratory evaluation or assessment of fluid volume status. There was no documentation to show they contacted the provider to report the abnormal oxygen saturations readings that were below the ordered parameters. Review of Resident 51's Progress notes did not show a provider note for 03/11/2024 or 03/12/2024, or any new order changes were made. Review of the NPN, dated 03/13/2024 at 6:00 AM showed Resident 51 was sent to the ED at 3:45 AM in respiratory distress and their oxygen saturation was between 84% and 88% that was below the ordered parameters. Review of the hospital Emergency Department (ED) Encounter note, dated 03/13/2024 at 4:38 AM, showed Emergency Medical Services reported to the provider Resident 51's oxygen saturation was 69% at the facility on 4 lpm of oxygen (although the order was for two to three lpm). Resident 51 reported they were short of breath for several days, had worsened lower extremity edema, and chest pain/tightness which would come and go. Review of the SBAR, dated 03/11/2024, regarding Resident 51's situation showed He would like to see a provider for increased coughing and congestion for a few days now. The nurse documented an assessment: no fever, no increased sputum production, wheezing on and off. The nurse made the recommendation to please see the patient today. Next to the Orders section of the SBAR, the Physician wrote patient sent to hospital and signed and dated 03/13/2024 (two days later). Review of the Advanced Heart Failure Consultation note, dated 03/19/2024, showed Resident 51 weight readings from their previous encounters were: 1/17/2023- 466 pounds and 3/16/2024- 493 pounds. The cardiologist consult showed Resident 51 had acute on chronic heart failure with fluid volume overload, removed a total of 15 liters of fluid over the course of six days, started an additional diuretic medication, and increased a blood pressure medication. Review of the hospital Discharge summary, dated [DATE], showed Resident 51's weight on 3/28/24 was 454 pounds, a decrease of 39 pounds since 03/13/2024 (expected weight loss from the removal of excess fluid). <Fluid Volume Overload: Post Change in Condition> Review of the quarterly MDS, dated [DATE], showed Resident 51 re-admitted to the facility on [DATE] after a hospitalization. Resident 51's diagnoses included pneumonia (a lung infection), respiratory failure, and oxygen dependence. The MDS did not include the diagnosis of HF. Resident 51 was assessed to require non-invasive mechanical ventilation but did not receive oxygen therapy. Resident 51 was assessed to weigh 433 pounds and inaccurately documented Resident 51 did not have a recent significant weight increase. Review of Resident 51's comprehensive CP on 04/08/2024 did not show a CP was developed for cardiac or edema problems after readmitting from the hospital visit. Review of Resident 51's current weight record showed no weight documented for the date of readmission, no daily weights monitoring. The only weight on record showed Resident 51 weighed 469 pounds on 04/03/2024, an increase of 15 pounds in six days based on the hospital discharge weight of 454 pounds on 03/28/2024. In an interview on 04/09/2024 at 10:13 AM, Resident 51 stated they were not weighted routinely, and their edema was less that it had been because they just got out of the hospital after having a bunch of fluid removed from their body. Resident 51 stated before the hospitalization, they kept telling the staff they could not breathe but no one would listen. Resident 51 stated they did have wounds on their lower legs that come and go and get worse when their edema flares. Resident 51 stated they felt like they were starting to have more swelling. Resident 51 stated their lower legs were not routinely wrapped with compression dressings to help manage their edema and vascular problems. Resident 51 stated before the hospitalization they did not routinely use oxygen, only when they needed it connected to their BiPap at night. During the interview, Resident 51 lower legs were observed to not have medical grade compression. Resident 51 was wearing their BiPap with no oxygen connected, and the oxygen concentrator and tubing was sitting under the sink, not in use. <BOWEL MONITORING> POLICY Review of the facility's Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol policy, dated September 2021, showed the staff and provider would identify individuals with gastrointestinal problems, which included alterations in bowel movements. [BM]. The licensed nurse (LN) would assess and document/report the presence of stool impaction and the onset, duration, frequency, and severity of signs and symptoms. The facility would monitor the individual's response to interventions, including frequency and consistency of bowel movements. The provider would adjust based on identification of causes and the resident's response to treatment. <Resident 16> During an interview on 04/08/2024 at 2:14 PM, Resident 16 stated they experienced constipation (inability to have a bowel movement naturally) that sometimes lasted longer than three days, throughout their stay at the facility. Review of Resident 16's electronic health record (EHR) BM report showed staff documented no BM on the following dates: 03/12/2024, 03/13/2024, 03/14/2024 with a BM documented on 3/15/2024 at 9:17 PM. Additional dates included 04/06/2024, 04/07/2024 with a BM on 04/08/2024 at 8:53 PM. Review of Resident 16's EHR showed several bowel management provider orders dated 02/24/2024 within the resident's March and April 2024 medication administration records (MAR). The BM protocol showed that the LNs were to administer the following orders, as needed, for the resident without a BM: Dulcolax (a laxative that stimulates bowel movements/used to treat constipation), on the evening of the 3rd day, Milk of Magnesia suspension (a laxative) on the morning of the 4th and Dulcolax suppository (in the evening of the 4th day for no BM. The MAR also showed in the evening of the 4th day that the LN had an order for a Fleet enema (a laxative) to be administered to the resident without a BM. The MARs showed an order for Polyethylene Glycol (a medication used in the management and treatment of constipation) to be administered as necessary for constipation. The March and April 2024 MARs showed no documentation that any of the providers orders were administered or documented. Review of Resident 16's care plan dated 02/24/2024 showed resident was ordered a psychotropic (a medication used to affect the brain and causes changes in mood, awareness, thoughts, feelings, and behavior), related to a disease process daily. Interventions included LNs to monitor and document side effects to include constipation. <Resident 66> During an interview on 04/08/2024 at 2:14 PM, Resident 16 stated they had constipation at times during their time at the facility. Review of Resident 66's electronic health record (EHR) showed documentation within the point of care (POC) task section whereas staff had documented longer than three days Resident 16 was without a BM. The staff documented lack of a BM on the following dates: 03/15/2024, 03/16/2024, 03/17/2024, 03/18/2024, 03/19/2024, 03/20/2024 and with a BM not documented until 03/21/2024 at 07:00 PM. Additional dates included 03/22/2024, 03/23/2024, 03/24/2024 03/25/2024, with a BM documented on 03/26/2024 at 07:01 PM. On 03/27/2024 to 03/31/2024 no BM was documented until 04/01/2024. Review of Resident 66's EHR showed several bowel management provider orders dated 02/24/2024 within the resident's March and April 2024 medication administration records (MAR). The BM protocol showed that the LNs were to administer the following orders, as needed, for the resident without a BM: Dulcolax (a laxative that stimulates bowel movements/used to treat constipation), on the evening of the 3rd day, Milk of Magnesia suspension (a laxative) on the morning of the 4th and Dulcolax suppository (in the evening of the 4th day for no BM. The MAR showed in the evening of the 4th day that the LN had an order for a Fleet enema (a laxative) to be administered to the resident without a BM. During an interview on 04/10/2024 at 10:04 AM, Staff R, Registered Nurse/Residential Care Manager (RN/RCM) stated that it was their expectation that the staff start the bowel protocol as ordered by the provider for residents who had constipation for greater than 3 days. During an interview on 4/10/2024 at 10:08 AM, Staff Q, Assistant Director of Nursing (ADON) stated that it would be their expectation that the LNs administer the bowel protocol as ordered for the resident's constipation. Reference WAC 388-97-1060(1)(2)(3)(b)(c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview, and record review the facility failed to ensure an environment free of avoidable accidents/hazards for 1 of 7 residents (Resident 1) reviewed for mechanical lift transfers. The failure to assess and develop a safe care plan for the use of a mechanical lift device, ensure staff training and competency in the use of the Named Mechanical Lift system, utilize the mechanical lift according to the manufacturers recommendations, and conduct post-fall resident assessment and investigation procedures resulted in harm to Resident 1 when they were dropped to the floor during an improper mechanical lift transfer, sustained cuts and bruising to their head and body, experienced pain, and created intense sense of fear for Resident 1 surrounding further use of the mechanical lifts. The facility staff's lack of training, failure to observe posted WARNINGS, and improper use of the mechanical lifts as recommended by the manufacturer placed residents at risk for feelings of fear, further hazards, and potential for serious injury/death. Findings included . Review of the facility's Safe Lifting and Movement of Residents policy, revised 2017, showed the facility would assess the resident's individual needs for transfer assistance and document those needs in the care plan, including: preferences for assistance, degree of dependency, weight-bearing ability, and resident's size. Only staff with documented training on the safe use and care of the equipment used would be allowed to lift/move residents. Staff would be observed for competency in using mechanical lifts and observed periodically for adherence to procedures regarding use of the equipment and safe lifting techniques. Review of the facility's Accidents and Incidents-Investigating and Reporting policy, revised 2017, showed all accidents/incidents involving residents and employees would be promptly investigated, reported, and documented. The Incident/Accident Report (IR) would include date and time of the incident, nature of the injury, circumstances surrounding the event, where it took place, the names of witnesses, the resident's account of the event, time/date the physician, administration, and responsible party were notified, the condition of the resident after the incident, any corrective actions taken, and other pertinent data. Review of the Named Mechanical Lift User Manual, dated 2018, showed WARNING (potentially hazardous situation which, if not avoided, could result in death or serious injury): >DO NOT use this equipment without first completely reading and understanding these instructions and any additional instructional material. >Observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. >Slings and accessories designed by other manufacturers are not to be utilized with the Named Lift. >Adjustments for safety should be made before moving the patient. >When using the lifts, the adjustable lift base legs MUST be in a maximum Opened/Locked position before lifting the patient. >DO NOT lock the rear casters (wheels) of the lift when lifting an individual. Casters MUST be left unlocked to allow the lift to stabilize during the transfer. <Resident 1> Review of the quarterly Minimum Data Set (MDS), an assessment tool, dated 01/22/2024, showed Resident 1's diagnoses included diabetes, heart failure, and obesity. Resident 1 required full staff assistance for transfers, had no history of falls, and received a daily anticoagulant medication (a blood thinner). Review of Resident 1's comprehensive care plan, dated 03/23/2024, showed no plan or identified needs for assistance with transfers. The care plan did not direct staff on how Resident 1 was to be transferred from one surface to another. Review of Resident 1's Visual/Bedside [NAME] Report (a focused care plan for direct care staff), dated 03/27/2024, showed they required assistance with transferring and mobility but did not indicate the type/level of assist or use of mechanical devices. Review of the facility's IR, initiated 03/25/2024, showed the root cause of the fall was improper use of the mechanical lift by staff. The IR showed the staff did not follow the manufacturer's instructions and warnings to ensure the base legs were always wide open and improperly turned the resident around which created the instability of the lift. The IR showed only Staff F, Certified Nursing Assistant (CNA), was evaluated for competency with the use of mechanical lifts, but the evaluation did not indicate which lift system (the facility utilized two different lift systems). The IR also showed Staff D, Licensed Practical Nurse (LPN), who was the nurse on duty at the time of the fall, did not evaluate Resident 1 for injuries, provide first aid, initiate an investigation, or notify the physician and responsible party of the fall with injury. Review of Resident 1's progress notes showed no documentation for 03/23/2024 or 03/24/2024, including documentation regarding the fall. Review of Resident 1's March 2024 Medication Administration Record (MAR) showed between 03/01/2024 and 03/23/2024, they only required one administration of mild pain reliever for mild knee pain and received opioid pain medication four times. The MAR showed after 03/23/2024, Resident 1 had increased pain levels that required opioid pain medication on 03/23/2024 at 11:14 PM for pain 8/10 (a numerical scale from 0 to 10. 0 means you have no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) and on 03/25/2024 at 1:32 PM for pain 3/10. Resident 1 also received mild pain-relieving medication on 03/24/2024 at 2:46 AM for knee pain 6/10, on 03/25/2024 at 4:06 PM for abdominal side pain 3/10, and on 03/26/2024 at 8:58 AM for pain 4/10 (undocumented location). An observation of the Named Mechanical lift on 03/27/2024 at 10:30 AM showed the lift had product labeling WARNING stickers that said: WARNING-BEFORE using the Patient lift, READ and UNDERSTAND the Owner's Manual for proper operation and safety procedures. DO NOT lock the casters of the Patient lift when lifting an individual. Casters MUST be left unlocked to allow Patient LIFT to stabilize during lifting procedures. USE ONLY Named Lift slings and lift accessories. In an interview on 04/01/2024 at 3:45 PM, Staff E, CNA, stated they had never read the Named Mechanical Lift User's Manual and did not know about the specific WARNINGs for use. Staff E could not verify they were specifically trained to use the Named Mechanical Lift, was not aware that only Named Mechanical lift system slings could be used with the Named Mechanical Lift and could not verify the type/size of sling Resident 1 was in during the fall. An observation, on 3/27/2024 at 11:27 AM, showed Resident 1 sitting on a blue mesh (size large) mechanical lift sling manufactured by a different company than the Named Mechanical Lift, in their wheelchair. Resident 1 had a 3.5 centimeter (cm) linear cut on their forehead, a small green bruise, and a hematoma goose egg on the top of their scalp. The hair covering the hematoma was matted and adherent to the scalp. In an interview on 03/27/2024 at 11:29 AM, Resident 1 stated the facility staff used the Named Mechanical lift with each transfer. Resident 1 was unsure what size sling they required and stated the staff used a different type of sling every day. Resident 1 stated that on 03/23/2024, after their shower, they were taken back to their room to transfer back to bed. Resident 1 stated the staff had them positioned backwards on the left side of their bed; their feet were toward the head of their bed, and their head was at the foot of the bed. Resident 1 stated the staff did not correct their position prior to starting the transfer with the mechanical lift. Resident 1 stated Staff E, Certified Nursing Assistant, lifted them up off the wheelchair and once they were suspended, Staff E began to turn them around while Staff F was standing on the other side (right side) of the bed (not within arm's length), and that was when the lift tipped over. Resident 1 stated they hit their head on the lift's bar which cut their head, something hit the top of their head which caused a painful goose egg which they believed some drainage occurred because it was making their hair stick to their head, and they hurt the left side of their lower back/hip area. Resident 1 stated after they fell, several other staff, which included Staff D, came in to help them get off the floor, and then they all left the room. Resident 1 said no one ever took their vital signs or provided first aid for their injuries to their head. Resident 1 stated they were concerned because they were diabetic and took a blood thinner. Resident 1 stated the nurse that arrived on evening shift didn't know anything about the fall. Resident 1 became tearful and stated since the fall, they have experienced increased pain because of their injuries. Resident 1 stated they were already scared of riding in the mechanical lift, but now they are terrified of it. In an interview on 03/27/2024 at 10:50 AM, Staff B, Director of Nursing, stated they were not made aware of the incident until 03/25/2024, but should have been notified the day of the fall, since they were at the facility around the time of the event and conversed with Staff D. Staff B stated Staff D should have assessed Resident 1 for injuries and evaluate their neurological status immediately after the fall, contacted the physician and responsible party as soon as possible after the fall, placed the resident on Alert Status (increased frequency of nurse monitoring), and initiate a facility IR before the end of shift on 03/23/2024 but did not. Staff B stated they had Staff E and Staff F re-enact the transfer with the Named Mechanical lift and determined they did not correct Resident 1's position prior to starting the transfer and should have had the base legs wide open and the rear casters unlocked but did not. Staff B stated the CNAs should have been trained on the specific Named Lift but were not able to validate which lift system or lift information was used in the training, and could not locate training validation for Staff E. REFERENCE WAC: 388-97-1060 (1)(3)(e)(g)- 0320 (1)(a). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for 1 of 1 Residents (Resident 20) reviewed for re-hospitalization. The facility's failure to: recognize and assess risk factors that placed the resident at risk for decline or complications,; develop a person-centered care plan with interventions that met their specific care needs related to arterial ulcers (a wound developed from prolonged inadequate blood flow) caused by Peripheral Artery Disease (PAD-narrowing or blockage of the blood vessels that carry blood from the heart to the legs),; implement physician orders timely,; recognize, and report a change of condition to the vascular surgeon caused harm to Resident 20 who developed wet gangrene (death of body tissue due to lack of blood flow or bacterial infection) and a serious bone/systemic infection that resulted in amputation of part of their foot. Findings included . According to the American Heart Association/American College of Cardiology Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary, dated March 21, 2017 (Volume 135, Issue 12), a comprehensive treatment plan to achieve intact skin and a functional foot included coordinated efforts with vascular medical specialists. To minimize further tissue loss, prompt recognition of foot infection through daily inspections was necessary especially for patients who had diabetes and peripheral neuropathy. Foot infections were to be suspected in patients with pain or tenderness to the area, redness or swelling around the wound, any drainage, foul odor, or white blood cell count greater than 12. <Resident 20> Review of the hospital Discharge summary, dated [DATE], showed Resident 20 was in the hospital for five months prior to admission to the facility. The resident's history included partial amputation of half of the left foot due to a serious bone infection and gangrene. In August of 2023, Resident 20 had a right great toe amputation due to bone infection and ischemia (inadequate blood supply to an area due to blockage of the blood vessels that carry oxygenated blood from the heart to rest of the body). Resident 20 underwent vascular surgery in the middle of October 2023 to improve the blood flow to right leg. Vascular studies conducted after the surgery showed they had moderate arterial insufficiency (any condition that slows or stops the blood flow through the arteries that carry oxygen rich blood to the body). Resident 20 discharged from the hospital to the facility with two arterial ulcers: on the right heel and at the base of the right fifth toe. The discharge summary showed directives to continue wound care as directed by the vascular surgeon by scrubbing the heel with saline and apply a dry dressing daily. Review of the 10/30/2023 admission Minimum Data Set (MDS-an assessment tool), showed Resident 20 had no cognitive problems and diagnoses included diabetes, cardiovascular disease (occlusions of the blood vessels of the heart), Peripheral Vascular Disease (PVD - any condition that slowed the return of blood back to the heart)/Peripheral Artery Disease (PAD), and end-stage kidney failure. Resident 20 was assessed to have two vascular ulcers and no infection of the foot. Review of the alteration in skin integrity care plan, dated 10/24/2023, directed staff to conduct diagnostics and lab tests as ordered by the physician and refer to the Wound Care Specialist (WCS-a wound care group contracted by the facility to provide wound care evaluation and assist with development and implementation of the care plan). The care plan did not show PAD as a risk factor for skin problems and there were no interventions consistent with the nursing care and treatment of PAD ulcers. In an interview on 12/13/2023 at 12:44 pm, Staff C, Assistant Director of Nursing (ADON), stated they conducted the admission evaluation of Resident 20's arterial ulcer at the base of the right fifth toe which was dry, black, intact eschar (dry gangrene) that measured 2.0 cm (centimeters) x 2.0 cm. Staff C stated Resident 20 also had a small arterial ulcer on the top of the fourth toe which healed shortly after admission. Staff C stated the care plan should have included PAD as a risk factor with interventions that would have included: daily monitoring of the foot to ensure the wounds remained clean and dry, protect from injury, assess and treat for pain, and include the name and contact information of the vascular surgeon with directives to report any change in condition of the resident or wound status (any drainage, signs of infection, or new wounds). Staff C stated they did not know if anyone contacted the vascular surgeon to clarify orders and ensure a follow-up appointment was established but should have. In an interview on 12/11/2023 at 10:22 am, Resident 20 stated they went to this facility for wound care of the right foot because they were unable to see or perform their own self-care. Resident 20 stated the facility changed the dressings of their right foot three days a week but was concerned it was not enough. Resident 20 stated while at the facility they asked to see the vascular surgeon twice, but the facility never followed through. Resident 20 stated the day they left the facility, their anxiety was intolerable from the severe pain, and fear they were going to lose their foot. The odor was so bad they asked to see their right foot. Resident 20 stated they were shocked to see the right fifth toe was black and a large, infected wound along the side of their right foot, so they called the vascular surgeon on their own phone. The vascular surgeon told Resident 20 to get to the emergency room (ER) as soon as possible. The facility told Resident 20 they were not able to arrange transportation and offered to establish care with a vascular surgeon locally. Resident 20 called a family member who transported them to the ER on [DATE]. Resident 20 stated they were not informed of their condition including: when the wound began to drain, lab results, when the wound began to get larger, and when their toe turned black. Resident 20 stated if they had stayed at the facility any longer, they would have lost more than part of their foot because the facility didn't see their situation as an emergency. Review of Resident 20's October Physician Orders (PO) showed a PO dated 10/24/2023 for wound care treatment to the right foot, to cleanse with wound cleanser, apply a dry dressing, secure with a gauze wrap, and change three times a week. Review of the facility physician history and physical note dated 10/25/2023, Staff G, Physician, documented Resident 20 expressed concerns regarding the frequency of wound care but did not change the treatment orders. Staff G documented the right foot wound was covered with a dry dressing but did not document an evaluation of the right foot arterial ulcers. Review of the Skin Alteration Weekly Review (SAWR) nursing evaluation, dated 11/01/2023, showed the arterial wound on the base of the fifth toe had a small amount of drainage (a change in condition of the wound). The documentation did not show the resident, physician, or vascular surgeon were notified of the change in condition and no changes were made to the treatment plan or the wound care orders. In an interview on 12/13/2023 at 11:29 am, Staff F, Licensed Practical Nurse (LPN), stated when stable, dry, arterial ulcer starts to drain it becomes wet gangrene and must be debrided (removal of dead tissue from the wound bed) as soon as possible and then monitored closely to prevent further tissue damage, bone infection, or risk of amputation. Staff F stated the vascular surgeon must be notified to determine if there are problems with blood flow to the area. Staff F was not able to find documentation in the clinical record to show the resident, physician, and/or vascular surgeon were notified the wound was draining. Staff F stated new wound care orders should have been obtained so the wound could be monitored daily, using the right kind of dressing to protect the wound from excess drainage but was not. A physician note dated 11/2/2023, by Staff G, did not show documentation to support they were notified of the change of condition of the wound. The documentation did not show an evaluation of the right foot wound or a change the treatment plan. Review of a WCS note, dated 11/06/2023, Staff I, Advanced Registered Nurse Practitioner (ARNP), documented Resident 20's right fifth toe wound measured 2.0 centimeters (cm) x 2.0 cm., was followed closely by their vascular surgeon, and was at high risk for complications. The note did not show documentation to support Staff I was notified the wound was draining. Review of a WCS note, dated 11/13/2023, Staff I documented the right fifth toe wound had a moderate amount of drainage and half of the wound was covered with dead tissue which they removed. The wound measured 1.5 cm x 2.1 cm x 0.3 cm deep. Staff I documented the skin around the wound was macerated (softening and damage of skin due to prolonged exposure to moisture). The documentation did not show the vascular surgeon was notified or the treatment plan and wound care treatment orders were changed. Review of the physician note dated 11/14/2023, showed Resident 20 had very high blood sugars (which can be an indication of infection in diabetics), complained about painful muscle spasms, and increased severe pain to their right foot. The documentation did not show an evaluation of the wounds or that the vascular surgeon was made aware of the change of condition. Review of the WCS note, dated 11/21/2023 at 3:38 pm, showed Resident 20 was concerned their right foot wound was infected due to odor during dressing changes that week. The documentation showed the wound size increased to 5.0 cm x 4.0 cm x 0.2 cm, there was redness and maceration around the wound edges, and had deteriorated. The documentation did not show a consultation with the vascular surgeon. Staff I ordered to change the wound treatments to daily dressing changes, collect a culture of the wound, start an antibiotic, obtain x-rays of the right foot and ankle, and draw labs. Review of the November 2023 Medication Administration Record (MAR) showed the first dose of antibiotic was administered on 11/22/23 at 8:00 am, (a delay of 16 hours from the time it was ordered by the WCS ARNP). In an interview on 12/13/2023 at 12:57 pm, Staff C stated antibiotics should be started within four hours of the order. Staff C did not know why there was a delay in starting the antibiotic but Resident 20 should have received their first dose that same day. Review of a nurse progress note (NPN) dated 11/22/2023 at 11:06 am showed the mobile x-ray company was called to order the x-ray (19 hours after it was ordered by the WCS ARNP). The clinical record did not show documentation to support when mobile x-ray arrived to take the x-ray, when the results were received, what the results were, or who was notified of the results. The clinical record did not provide x-ray results for the right foot while at the facility. Review of a lab report, dated 11/23/2023 at 8:28 am, showed Resident 20's blood was not collected until 11/22/2023 at 9:17 am, a delay of 18 hours from the time the WCS ARNP wrote the order. The lab result was flagged as Critical and showed an elevated WBC count of 17.0 (normal is 3.8-10.1), indicating infection. Review of the clinical record did not show documentation to support that the resident, the ARNP, or the vascular surgeon were notified of the abnormal lab results. The lab showed it was not reviewed by a provider until 11/27/2023 at 11:48 am. Review of the November 2023 Treatment Administration Record (TAR) showed the order to change the wound dressings to daily was not started until 11/23/2023, a delay of two days from the date the WCS ARNP changed the treatment order. The TAR showed no signature for a dressing change on 11/22/2023. Review of a PO dated 11/23/2023 at 10:40 am directed staff to obtain STAT (a directive to medical personnel during an emergent situation which means instantly or immediately). Review of a lab report dated 11/25/2023 at 3:17 pm showed the blood for the STAT lab (ordered on 11/23/2023 at 10:40 am) was not collected until 11/25/2023 at 1:15 pm, 51 hours after the order was written for STAT labs. The STAT labs results were sent to the facility on [DATE] at 2:45 pm and showed the WBC was now 18.7 (higher than the last result). In an interview on 12/13/2023 at 12:55 pm, Staff C stated STAT means as soon as possible. Staff C stated the STAT labs were not done timely and should have been done within four hours of the order. Review of a wound culture lab report dated 11/28/2023 at 12:24 pm, the day after Resident 20 transferred to the hospital, showed the specimen was collected on 11/23/2023 at 8:00 am, 40 hours after it was ordered by the WCS ARNP and 24 hours after Resident 20 started the antibiotic. In an interview on 12/13/2023 at 12:15 pm, Staff F, stated they were unable to collect the wound culture specimen on 11/21/2023 during wound rounds because they were out of culture swabs and had to wait until the lab sent them more. Staff F stated the wound culture was not collected timely or before the antibiotic was started but should have been. Review of an SBAR (Situation, Background, Assessment, Response-a universal reporting tool used to report and document changes in resident status) dated 11/23/2023 showed Resident 20 had elevated blood sugars, was sleeping most the day, asked for an increase in pain medication, and to be referred to their vascular surgeon. The SBAR was signed reviewed by Staff K, ARNP, four days later, on 11/27/2023. In an interview on 12/13/2023 at 1:00 pm, Staff K stated due to the nature of the concerns that were written on the SBAR, the staff member should have called the provider that same shift, as soon as possible, to prevent delay in treatment. Review of the NPNs between 11/24/2023 and 11/26/2023 showed no documentation to support staff closely monitored Resident 20's change of condition, that the resident was notified of their abnormal lab and diagnostic results, or that the change of condition was reported to the vascular surgeon. Review of a physician note dated 11/27/2023 at 8:27 pm, Staff K documented Resident 20 notified the vascular surgeon of their change of condition and was directed to go to the ER. Staff K documented Resident 20 reported their right fifth toe turned black and was painful. Staff K documented Resident 20 reported not feeling well and continued to have elevated blood sugars. In an interview on 12/13/2023 at 1:18 pm, Staff L, Physician, indicated wet gangrene was a medical emergency and 27 days of wet gangrene on a diabetic foot with PAD was too long to wait before evaluation and intervention by a vascular and/or infectious disease specialist. Review of hospital history and physical dated 11/27/2023 at 1:23 pm, showed Resident 20 was admitted to the hospital for an infected gangrenous right fifth toe and sepsis (systemic blood infection). Resident 20 was started on intravenous antibiotics for the severe infection and had arterial diagnostic studies that determined acute bone infection and ischemia (lack of oxygenated blood flow) to the right foot. In an interview on 12/11/2023 at 10:48 am, Resident 20 stated the vascular surgeon met them in the ER, scheduled them for immediate surgery to correct the blood flow to their right leg, got started on intravenous antibiotics, but was too late and had to have two toes and part of the right foot amputated. Resident 20 stated if they would have got to the vascular surgeon in time, the most likely would have avoided the amputation. (Refer to F580 and F658) Reference WAC 388-97-1060 (1)(2)(3)(b)(4). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit 1 of 6 residents (Resident 1) reviewed for hospitalization to return to the facility after a facility-initiated transfer to the emergency room (ER). The facility's failure to provide bed hold information in writing upon transfer to the hospital, provide appropriate discharge/transfer notice and rights to an appeal prior to the facility-initiated transfer and discharge, and failure to permit Resident 1 to return to the facility and resume residence after the ER visit caused physical and psychological harm to Resident 1 who experienced unnecessary pain, anxiety, fear, humiliation, and re-traumatization. Findings included . <Policy> Review of the facility's policy, Transfer or Discharge Documentation, revised December 2016, showed each resident would be permitted to remain in the facility and not be discharged or transferred unless it was necessary for the resident's welfare and their needs could not be met in the facility; transfer/discharge was appropriate because their health had improved and they no longer required the level of care the facility provided; the health and/or safety of individuals in the facility was endangered due to clinical or behavioral status of the resident; if the resident failed to meet their financial obligations after reasonable and appropriate notice; or if the facility ceased to operate. A resident who chose to exercise their right to appeal a transfer/discharge notice would not be transferred/discharged during the appeal process unless the failure to do so would endanger the health or safety of the resident or other individuals. When a resident was transferred or discharged the facility would document in the medical record: the basis for the discharge; that appropriate notice was provided to the resident and/or representative; the date and time of the transfer/discharge; the new location of the resident; mode of transportation; a summary of the resident's overall status. If they were transferred/discharged because their care needs could not be met, the resident's attending physician would document the specific needs that could not be met, the facility's attempt to meet those needs, and the receiving facility's service(s) that were available to meet those needs, that the facility could not. <Resident 1> Review of the 08/25/2023 Annual Comprehensive Minimum Data Set (MDS-an assessment tool), Resident 1 had no cognitive problems, made consistent and reasonable decisions regarding tasks of daily life, and had no behaviors or rejection of care. Resident 1 had no indicators of a mood problem. Resident 1's diagnoses included stroke (a brain injury caused by loss of blood supply), loss of movement of some parts of their body, anxiety, depression, and chronic pain syndrome. Resident 1 required extensive assistance for activities of daily living (ADLs). Resident 1 was assessed to have pain and received scheduled and PRN (as needed) medication. Review of Resident 1's 08/25/2022 Trauma Informed Care screen showed three indicators of past trauma. Review of the 08/25/2023 Trauma Informed Care screen showed more than 10 indicators of past trauma and Resident 1 did not feel safe. Review of Resident 1's 11/23/2022 Trauma care plan showed they had trauma in their past and would be free of trauma while at the facility. A 02/23/2023 trauma care plan intervention showed Resident 1 received treatment from Behavioral Health Service (BHS). Review of a Physician Order (PO) dated 02/01/2023 at 4:23 PM by Staff D, Medical Director, showed they accepted to oversee Resident 1's medical care and were listed as primary Physician. Review of a PPN dated 08/21/2023 by Staff E, Physician, showed they tapered down Resident 1's pain medication without involving Resident 1 in the pain management plan. Resident 1 told Staff E they wanted a different provider. Review of POs for Resident 1's pain medication prescriptions from September and October 2023 showed they were ordered by Staff D. In an interview on 10/24/2023 at 3:35 PM, Resident 1 stated their pain was not managed well by Staff E and they no longer had trust in them. Resident 1 stated they told Staff E they wanted a different provider, but one was never provided so they assumed Staff E was still their provider. Resident 1 stated they were transferred to the hospital on [DATE] because the facility was out of their prescribed scheduled pain medication and the physician refused to re-new their prescription. Resident 1 stated they were treated for chronic pain for many years and was not asking for more pain medication. Resident 1 felt they were on a tolerable lowest effective dose. Resident 1 stated they told the nurse they were in horrible pain and the nurse came into their room and told them they would need go to the hospital ER for pain medication. Resident 1 stated they initially did not want to go to the ER because they knew they would have a long wait time and they did not need anything from the ER that the facility couldn't already provide. Resident 1 stated a staff member called 9-1-1. Resident 1 stated they felt pressured to go to the ER and they were in excruciating pain, so they went with the paramedics. Resident 1 stated they were assessed in the ER and provided with the same dose of pain medication they were previously prescribed at the facility. Resident 1 stated they had not experienced a change of condition or acute illness. Resident 1 stated they were notified by a social worker in the ER that the facility refused to allow them to return. Resident 1 stated they were surprised, humiliated, and felt retaliated against. Resident 1 stated they immediately experienced increase fear and worsened anxiety because they did not know what they were going to do about their living situation because the hospital had no reason to admit them. Resident 1 stated they felt traumatized because they were forced to live in an observation holding room of the ER, where everything was covered in plastic, for six days. Resident 1 stated the first two days were spent lying on an uncomfortable transport stretcher, then the ER staff brought them an actual bed for the remaining four days. Resident 1 stated they felt almost suicidal because they did not want to go to another skilled nursing facility and start over. Resident 1 stated they were not provided a bed-hold notice upon transfer to the hospital, they were not given a discharge notice prior to transfer to the hospital or after the facility-initiated discharge. Resident 1 stated they had never been told by facility staff the facility could not meet their care needs. Resident 1 stated they had no change in their care requirements. Review of Resident 1's clinical record showed no documentation to support the facility notified Resident 1, in writing, of their bed-hold rights upon transfer to the hospital or provided a written Notice of Transfer/Discharge and rights to appeal. There was no documentation to show the facility could not meet Resident 1's care needs as they had for the past year. Review of Resident 1's narcotic ledger (NL-an accounting mechanism used to track and document narcotic use) showed a quantity of 35-5 mg tablets (a four-day supply) was ordered by Staff D and filled on 10/06/2023 (the day Resident 1 was transferred to the ER for pain medication). The 35 unused tablets were destroyed on 10/13/2023. Review of the 10/06/2023 Discharge Return Anticipated MDS showed Resident 1 had an unplanned discharge. The MDS showed Resident 1 had no behaviors, no rejection of care, no change in ADL care needs, and no change in special treatments, procedures, or programs. Review of an ER Physician Progress Note (PPN) dated 10/07/2023 at 12:10 PM showed they tried to consult with Staff D, via phone at 8:23 AM. At 11:38 AM, they called Staff D's call center to request an on-call provider contact them for arrangements to return Resident 1 to the facility since Resident 1 had no acute medical concerns. At 12:10 PM, the on-call Provider called back after talking to the facility and reported the facility was adamant, they would not accept Resident 1 back to the facility because Resident 1 refused all care with exception of opiate pain medication. Review of the ER Physician Treatment Plan dated 10/07/2023 showed they were concerned for Resident 1 who was vulnerable, bedbound, and required skilled nursing care. The ER physician documented the facility transferred Resident 1 to the ER without emergent medical concerns or acute illness which they believed was an inappropriate use of emergent care resources. Review of Resident 1's 10/18/2023 admission MDS showed they transferred from the hospital to a new skilled nursing facility on 10/12/2023 (six days after the facility-initiated transfer and discharge). Resident 1's mood assessment score showed a significant increase in symptoms of depression. Resident 1 had no behaviors, no rejection of care, and did not require any new special treatments, care, or procedures. In an interview on 10/24/2023 at 4:00 PM, Staff G, Physician Assistant at the new skilled nursing facility, stated Resident 1's care was as basic as it gets for nursing home care with no special care requirements. Review of a PPN dated 10/20/2023 by Staff D (14 days after Resident 1 discharged ), showed Resident 1 was not suitable for re-admission to the facility because their needs for medical management and residential care exceeded the facility's abilities because they had no physician who was credentialed to oversee Resident 1's medical care needs, Resident 1 was a threat to staff due to aggressive and abusive behaviors, Resident 1 expressed intent to harm others, and Resident 1 rejected alternative treatments to include medications to manage their alleged pain. Staff D's PPN did not show documentation to support Resident 1 had a change in care needs, what specific care needs the facility could not provide Resident 1 (or any resident who required the same level of care and similar diagnoses), alternatives attempted to try to meet Resident 1's care needs, and what services the receiving facility would need to provide to Resident 1 that the facility could not. In an interview on 10/23/2023 at 4:18 PM, Staff D stated they were unsure if the facility had made any attempt to assist Resident 1 to find another provider after they fired Staff E. Staff D did not know if Staff E officially notified Resident 1, they would no longer provide their medical care. Staff D, primary Physician of record, stated it was their decision to not accept Resident 1 back based on what they were told by the facility administration, consultation with Staff E, and limited historical chart review. Staff D stated they did not consider Resident 1's status on 10/06/2023 at the ER to make their decision to not accept Resident 1 back to the facility. Staff D stated their knowledge of Resident 1's care was limited to clinical chart review and interviews with facility staff and Staff E. In an interview on 10/20/2023 at 4:30 PM, Staff A, Administrator, stated they sent Resident 1 to the ER because they threatened to harm themselves by self-medicating for pain and refused to relinquish any medication they may have had. Staff A stated they were unsure if Resident 1 had any medication in their belongings. Staff A stated they were unsure if the facility had provided Resident 1 with bed-hold information upon transfer to the hospital. Staff A stated they had not provided Resident 1 with a Notice of Transfer/Discharge with the required information that the facility could not meet Resident 1's care needs and what those needs were, what alternatives were attempted to try to meet those care needs, and what special services the receiving facility would need to provide Resident 1 that the facility could not. (Refer to F-625 and F-697) Reference WAC 388-97-0120 (1)(b)(2) (a-e) (3)(a)(c). .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents received effective pain management consistent with professional standards of practice and according to residents' goals/preferences for 7 of 11 residents (Residents 1, 2, 3, 4, 5, 6, & 7) reviewed for pain. The facility's failure to re-evaluate Resident 1's pain after medication change and ensure they had an adequate supply of medication to administer their scheduled and PRN (as needed) pain medication caused harm when Resident 1 experienced unnecessary extreme pain and was transferred the emergency room (ER) for pain medication administration. The facilities failure to properly assess resident's pain, involve residents in development and modification of a person-centered pain care plan, notify residents of changes to their pain management plan, re-evaluate the effectiveness of changes made, identify and utilize person centered non-pharmacological interventions, consider adjunctive pain modalities, provide referrals to pain management specialists, and administer pain medications as ordered placed residents at risk for poorly managed pain, decline in mood, decline in activities of daily living (ADL's), and diminished quality of life/quality of care. Findings included . <Policy> Review of the facility's policy Pain Assessment and Management, revised [DATE], showed the facility would commit to ensuring each resident was comfortable and their pain management regime would result in a reduction of their pain to a level that was acceptable to them based on their clinical condition and goals for treatment. The Interdisciplinary Team (IDT) would implement their facility process to assess pain, effectively recognize the presence of pain, address underlying causes, develop, and implement a pain management care plan, monitor effectiveness, and modify the plan as needed. <Resident 1> Review of the [DATE] Annual Comprehensive Minimum Data Set (MDS-an assessment tool) showed Resident 1 had no cognitive problems, made consistent and reasonable decisions regarding tasks of daily life, and had no rejection of care. Resident 1's diagnoses included stroke (a brain injury caused by loss of blood supply), mobility problems of the legs, spinal problems, anxiety, depression, and chronic pain syndrome. Resident 1 required extensive assistance for ADL's and was unable to walk. Resident 1 received both scheduled and PRN pain medication, and a Pain Assessment Interview should have been conducted but was not. Review of Resident 1's [DATE] pain care plan showed Resident 1's goals for pain management were to limit interruptions in normal daily activities and require fewer pain medications to achieve pain relief. The pain care plan interventions dated [DATE] directed staff to: evaluate the effectiveness of Resident 1's pain management plan quarterly and as needed; assess for pain every shift; implement non-pharmacological interventions and evaluate effectiveness prior to administration of PRN medications; and showed Resident 1 was able to reliably communicate their need for pain medication. A pain care plan intervention dated [DATE] showed Resident 1 preferred to direct pain medication use and would request medication from the licensed nurse as needed. The care plan did not provide individualized person-centered approaches to pain management such as non-pharmacological interventions they used in the past to help with pain relief. Review of the [DATE] hospital Discharge Summary (DS) showed Resident 1 had abnormal labs that indicated rheumatoid arthritis (an autoimmune and inflammatory disease that causes painful swelling of the affected body parts) and was recommended to follow-up with a rheumatology specialist after discharge from the hospital. Resident 1 was also evaluated by a neurologist who noted the diagnostic images used to conduct the consult were poor quality due to interference from hardware placed during previous neck and spine surgeries. The provider documented Resident 1 used CBD topical ointment (cannabidiol- an active ingredient in medical marijuana some find effective in the treatment of chronic pain and other medical conditions but does cause a high impairment or addiction) daily for pain management at home and was ambulatory with the use of a walker or cane. In an interview on [DATE] at 4:00 PM, Staff E, Physician, stated they were not aware of the recommendation for rheumatology. Review of a [DATE] Physician Progress Note (PPN) by Staff E showed Resident 1 reported back pain 10/10 (a standardized pain assessment scale used to determine pain intensity- zero means no pain and 10 means worst possible pain) and muscle spasms due to a three-hour delay in pain medication administration. Staff E documented they reviewed the neurology consultation from the hospital prior to admission and added to Resident 1's plan to refer to a pain management specialist. Review of a [DATE] PPN by Staff E showed Resident 1 continued to complain about pain medications not administered timely or as scheduled. Staff E documented they discussed tapering off the opioid pain medication which Resident 1 disagreed with. Staff E documented Resident 1 stated they were in pain and the current dosing frequency-when given timely-lowered the intensity of their pain but did not make the pain go away. Staff E's plan showed they would continue pain management with no mention of a pain clinic and follow-up with neurology. Review of a [DATE] PPN by Staff E showed Resident 1 had a past medical history of chronic pain syndrome, neck and back pain, opioid dependence, and osteoarthritis (a painful swelling disorder of the joints). Staff E documented Resident 1 stated their pain continued to affect their mobility and they continued to receive their scheduled pain medications late, depending on the nurse who was on shift. Staff E and Resident 1 discussed and agreed on the pain management plan. Staff E documented to follow-up with neurology. Review of a Physician Order (PO), dated [DATE] at 7:00 AM, showed a referral for Resident 1 to go to neurology for ongoing weakness and deconditioning. Review of a [DATE] PPN by Staff E showed Resident 1 stated they were doing fine in general, but continued to experience dental pain and was waiting to see a dentist. Staff E ordered an oral gel for tooth pain, continued plan for pain management, and follow-up with neurology. A Review of Resident 1's [DATE] Medication Administration Record (MAR) showed Resident 1 was scheduled to receive their schedule II opioid pain medication two-5 milligrams (mg) tablets (10mg total) every six hours routinely, and one 5 mg tablet every 12 hours PRN for breakthrough pain. Resident 1 reported daily pain levels between 4-8/10 with the scheduled medication routine and requested a PRN dose twice (they used two of the 62 PRN doses available). Review of a [DATE] PO showed Resident 1's scheduled pain medication frequency was increased from every six hours to every eight hours and one tablet every 12 hours PRN for breakthrough pain. Review of the [DATE] PPN by Staff E showed a review of Resident 1's neurology findings from the prior year and documented to follow up with Neurology (for the fifth time since [DATE] when they first made the referral). Staff E documented Resident 1 was upset with the recent change in their pain medication frequency from every six hours to every eight hours because Staff E did not notify Resident 1 prior to making the change. Staff E documented Resident 1 said they were taking three times as much pain medication when they were treated at a previous clinic for pain, and now was talking less pain medication than what they were prescribed when they discharged from the hospital in August of 2022. Staff E notified Resident 1 they were referred to a pain clinic on [DATE] (five months after the first documented pain specialist referral). Staff E documented Resident 1 said they wanted a different physician to oversee their care. In an interview on [DATE] at 4:30 PM, Staff E stated they discussed with Resident 1 the goal to decrease their intake of opioid pain medication in May. Staff E stated they did not notify or discuss with Resident 1 regarding decreasing the frequency of pain medication on [DATE] but should have. Staff E stated they notified Staff D, Resident 1's Primary Physician of record and Medical Director, Resident 1 wanted a different provider. Staff E was unsure what steps the facility took to obtain a new provider to oversee Resident 1's care. Staff E stated they were not sure why their referrals for the pain clinic and neurology were not carried out and should have followed-up with the facility. Resident 1 was not seen by a neurologist for over a year. Review of Resident 1's August and [DATE] MARs showed they continued to experience pain daily and did not show any non-pharmacological interventions were attempted to help alleviate Resident 1's Pain. Resident 1 had orders for Tylenol, but it was never offered. Resident 1's PRN opioid pain medication usage increased; In August of 2023 they used 44 of their 62 available PRN doses and in September they used 41 of 60 available PRN doses. In an interview on [DATE] at 3:45 PM, Resident 1 stated they felt they were finally getting a hold on their pain management in July of 2023 and barely used their PRN's. Resident 1 stated their pain got worse after Staff E changed the frequency. Resident 1 stated they were not notified of the change which effected their trust in Staff E, so they requested a new provider. Resident 1 stated they didn't want more pain medication, they just wanted what they were ordered, administered as timely as possible, and to be consulted about their pain management before making any changes. Resident 1 stated some staff were already so delayed in administration of the medications; the frequency change made it worse. Resident 1 stated they did not feel they were taken seriously about their pain. Review of Resident 1's clinical record showed no documentation to support Resident 1's pain was adequately evaluated prior to or re-evaluated for effectiveness after the frequency change on [DATE]. The clinical records did not show the facility followed through after Staff E wrote repeated referrals for neurology and the pain management clinic. In an interview on [DATE] at 4:00 PM, Resident 1 stated they were not evaluated at a pain clinic or seen by a neurologist during their stay at the facility and believed it would have helped their pain. Review of a Nurse Progress Note (NPN), dated [DATE] at 4:54 PM, showed the nurse requested a re-fill of Resident 1's schedule II opioid pain medication from Staff D, the day before the supply exhausted. The nurse documented Staff D wanted to speak with the Staff B, Director of Nursing Services (DNS), before they would authorize a refill due to Resident 1's refusal of care from Staff E. Review of a NPN, dated [DATE] at 10:06 AM, showed Resident 1 requested their routine schedule II opioid pain medication and described their pain as extreme. The nurse informed Resident 1 their pain medication supply was out, and they had no valid prescription from Staff D. In an interview on [DATE] at 4:10 PM, Resident 1 stated their last pain medication at the facility was received on the evening of [DATE]. Resident 1 stated they did not get their [DATE] morning and afternoon dose and by the time they were sent to the ER, they were in excruciating pain. Resident 1 stated they told facility staff they would self-medicate (with their CBD cream) if their pain medication was not provided, and after that, they were pressured to go to the ER for pain medication. Review of Resident 1's Narcotic Ledger (NL-an accounting mechanism used to track and document narcotic usage) page 125 showed the last pill from their supply was administered on [DATE] at 9:10 PM. The remaining balance of the card showed zero. Review of Resident 1's [DATE] ER MAR showed they were administered pain medication at 5:07 PM (20 hours after their last pain medication). The pain medication was the same medication and dose they were scheduled to receive routinely at 8:00 AM and 2:00 PM from the facility but did not. Review of an ER PPN, dated [DATE], showed the provider spoke with Staff E, Assistant Director of Nursing (ADON), who reported Resident 1 was prescribed 120-10 mg tablets (the incorrect amount and dose according to the NL) of their opioid pain medication on [DATE] and 'already used most, and only had two tablets remaining' (inaccurate according to the NL). Staff E reported to the ER provider Resident 1 threatened to self-medicate for pain but did not say what they would use and refused to allow staff to search their belongings. Staff C also reported to the hospital provider that Resident 1 refused to go to the pain clinic because they requested stretcher transport. It was documented that Staff E told the provider the facility was not able to accept Resident 1 without them finding another physician with facility privileges. Review of Resident 1's NL pages 103,110,114,119,120,125, and 126 showed the pharmacy issued a total quantity of 210-5mg tablets between [DATE] and [DATE]. The first tablet was not administered until the evening of [DATE]. For the facility to have enough medication to administer Resident 1's routine pain medication as ordered (six tablets per day) and have two tablets on hand for PRN administration (for a total of eight tablets per day), from [DATE] to [DATE], the facility needed to have a quantity of 224-5 mg tablets. This showed Resident 1 did not request the second PRN pain medication they had available to receive 14 times during that time frame. As of [DATE] at 9:10 PM, Resident 1 had no more medication left. Review of Resident 1's NL Page 132 showed a card of 35-5mg tablets (a four-day supply), ordered by Staff D, filled by the pharmacy on [DATE] (the day Resident 1 was transferred to the ER), and logged into the NL [DATE] (three days later). The bottom of the NL page showed the 35 tablets were destroyed on [DATE]. Review of a PO, dated [DATE] at 4:23 PM, showed Staff D accepted to oversee Resident 1's medical care as their primary physician. Further review of Resident 1's POs did not show an order to direct staff to find a physician for Resident 1, to transfer care to another physician from Staff D, or that Resident 1 was provided with a notice they would no longer have a provider to oversee their care after a reasonable timeframe. In an interview on [DATE] at 4:30 PM, Staff D stated Resident 1 did not have a provider to oversee their medical care after they notified Staff E they no longer wanted them as their provider. Staff D stated on [DATE] they were asked to send in a new prescription for Resident 1's pain medication and requested to speak with the DNS first. Staff D stated they did not evaluate Resident 1's PRN pain medication usage to determine the effectiveness of their pain regime and did not conference with facility administration to problem solve the concern of Resident 1's request for a new provider. Staff D was unsure if the facility took any steps to obtain a provider for Resident 1 outside of the facility provider group. Staff D stated Resident 1's needs could not be met at the facility, and they were sent to the ER. Staff D stated Staff E did not refer Resident 1 to a pain clinic because their clinical judgement found it was not necessary. Staff D was asked about their role in the care of Resident 1 given they were the provider of record and Medical Director of the facility. Staff D stated Staff E was the facility Physician who conducted Resident 1's evaluation and managed their care. Staff D stated their knowledge of Resident 1's care was limited to clinical chart records, Staff E's interview, and facility staff interviews. Staff D stated they were not aware of the status of Resident 1 after they transferred to the ER on [DATE]. <Resident 4> Review of Resident 4's [DATE] admission MDS showed no problems with cognition, diagnoses included cirrhosis (liver failure), kidney failure, and diabetes. Resident 4 received scheduled pain medication, no PRN pain medication, and their Pain Assessment Interview was incomplete. Review of Resident 4's [DATE] pain care plan showed they took pain medication would be reviewed quarterly and as needed, staff were directed to assess the pain characteristics and assess effectiveness of routine medication and PRN medication within one hour of administration. The care plan directed staff to observe and report physical indicators of pain and Resident 4 was reliable to indicate their pain care needs. The care plan was not person-centered, did not include individualized non-pharmacological interventions Resident 4 found to be effective, other pain modalities, goals and preferences, or their expectation for acceptable pain relief. Review of a History & Physical note, dated [DATE] by Staff E, showed Resident 4 had a history of a fracture of their spine and complications from liver failure that included severe ascites (accumulation of fluid in the abdominal spaces that in severe cases can be painful) and required repeated procedures to drain the fluid. Staff E documented Resident 4 stated they had back pain 7/10. There was no documented evaluation of pain characteristics, length of time they had the pain, their acceptable level of pain, or how they managed the pain in the past. Staff E documented the hospitalist sent a referral for Resident 4 to follow up with hepatology (branch of medicine that deals with diseases of the liver). Review of a PPN, dated [DATE] by Staff E, showed Resident 4 had multiple trips to the ER for shortness of breath and pain. Staff E documented on [DATE], Resident 4 was seen in the ER for shortness of breath from excess fluid and was unable to complete their full dialysis session the day prior due to back pain. Resident 4's Representative (RR) expressed concern about Resident 4's pain management and asked if their pain medication could be increased. Staff E told the RR 10 mg every eight hours was a high dose for their condition and the main goal was to identify the cause of their pain and have appropriate interventions instead of increasing pain medication (although the main causes for Resident 4's pain were already identified to be from their end stage liver and kidney disease and previous fractured back). Staff E documented they suggested if the current pain regime was not effective Resident 4 would be referred to a pain clinic. Staff E also repeated the referral to follow up with hepatology. A Review on [DATE] of Resident 4's POs showed no order for referral to a pain clinic. Review of Resident 4's clinical record showed no documentation to support they were seen at the pain clinic or hepatology. Review of Resident 4's [DATE] MAR showed two PRN orders for Tylenol (not recommended for patients with cirrhosis) and a [DATE] PO for an schedule II opioid pain medication 10 mg every eight hours PRN for severe pain. The opioid pain medication was administered multiple times daily and Resident 4 consistently reported pain levels greater than 7/10. The MAR showed no non-pharmacological interventions were attempted prior to administration of the PRN medications. In an interview on [DATE] at 2:30 PM, Resident 4 stated they broke their back several years ago and they were in constant pain. Resident 4 stated Staff E changed their pain medication frequency from every six hours to every eight hours without their knowledge and refused to change it back. Resident 4 stated they told Staff E they were still in pain. Resident 4 stated over half of their day was spent at a pain level of 8-10/10. Resident 4 stated they were not offered other non-pharmacological interventions by staff and stated they spent most of their day in bed. Resident 4 stated they were not evaluated at a pain clinic and was unsure if they were seen by hepatology. In an interview on [DATE] at 4:14 PM, Staff E stated they thought they had talked about referral to a pain clinic with Resident 4. Staff E stated they needed to review Resident 4's record and they would re-evaluate their pain management plan and follow up on their referrals. <Resident 5> Review of the [DATE] Quarterly MDS showed Resident 5 had no problems with cognition and diagnoses included blood clots, heart failure, vascular disease, diabetes, and kidney failure. Resident 5 received scheduled and PRN pain medication and their Pain Assessment Interview was incomplete, but they reported their worst pain an 8/10 during that timeframe. Review of Resident 5's comfort care plan revised [DATE] showed they desired to remain comfortable through their end-of-life process and directed staff to assess their pain regime and coping strategies, coordinate with the physician to ensure they remained comfortable, to administer pain medication as ordered and notify the physician for breakthrough pain immediately. Review of a PPN, dated [DATE] and signed by Staff E [DATE] at 7:01 PM, Resident 5 refused to start dialysis due to kidney failure and signed new advance directives for end-of-life care, no cardiopulmonary resuscitation (CPR), and wanted to be on comfort measures only. Staff E did not document an assessment or plan for pain management. Review of a social services note, dated [DATE] at 2:46 PM, showed Resident 5 stated they called hospice because the pain in their kidneys was unbearable and their Schedule II opioid pain medication of 5 mg three times daily was not enough to make their pain tolerable. The writer documented Resident 5 stated the physician did not spend enough time with them to understand their concerns or why they requested their pain medication be increased. Review of a PPN, dated [DATE] and signed by Staff E on [DATE] at 7:59 PM, showed the medication list did not include updated pain medication orders, Resident 5 stated their pain level was 7/10, experienced a change of condition, and Staff E suggested they take pain medication one hour prior to their wound care to help with the pain. Staff E's PPN did not show documentation to support they thoroughly evaluated Resident 5's pain concerns with their kidney's or their other pain concerns. Review of a PO, dated [DATE], showed Resident 5's schedule II pain medication was tapered down from 5 mg every 10 hours PRN to 5 mg every eight hours PRN for pain, although Resident 5 continued to complain of moderate to severe pain. Review of a PPN, signed and dated [DATE] by Staff D, showed Resident 5 stated they had pain to their kidney and abdominal area, described as sharp, wrenching, constant, and 8/10. Staff D documented Resident 5 stated their pain medication provided some mild-moderate relief. Staff D documented their assessment and plan for abdominal pain would be to order an x-ray and follow up as needed. Review of a PO, dated [DATE], showed Resident 5's schedule II pain medication changed from 5 mg every eight hours PRN to every four hours PRN FOR FOUR DAYS THEN CHANGE TO ONE TAB EVERY SIX HOURS THEREAFTER. Review of Resident 5's September and [DATE] MARs showed a [DATE] PO for the schedule II pain medication 5 mg every six hours PRN pain FOR FOUR DAYS THEN CHANGE TO ONE TAB EVERY SIX HOURS THEREAFTER. The September MAR showed the medication was never scheduled for routine administration every six hours on [DATE] (as ordered) but remained PRN. Resident 5 requested the medication multiple times daily and consistently reported their pain 6-10/10. Non-pharmacological interventions (the same interventions ordered for Residents 1, 2, 3, & 4) were not attempted. Review of a PPN, dated [DATE] by Staff E, showed Resident 5 wanted to start dialysis treatment because of feeling tired and being in constant pain. Staff E's PPN did not provide documentation to support they thoroughly evaluated Resident 5's constant pain. In Staff E's assessment and plan, Resident 5 took the schedule II pain medication every six hours PRN for pain related to an amputation of their limb, and did not address Resident 5's abdominal and kidney pain. Review of a PO, dated [DATE], showed Staff E tapered down Resident 5's schedule II pain medication to 5 mg every eight hours PRN despite Resident 5's continued multiple daily complaints of moderate-severe uncontrolled pain. In an interview on [DATE] at 12:50 PM, Resident 5 stated their pain was not managed and they stated they got three pain pills a day, but they had to ask for them. Resident 5 stated their acceptable pain level was 6-7/10 which they considered moderate pain and rarely was less than a 6/10 throughout the day. Resident 5 stated if they could get their pain to a 7-8/10, they can grit their way through it. Resident 5 stated they were frustrated with how their pain was managed, the stigma of pain management, and fear of addiction. Resident 5 stated I depend on the medication for relief due to my medical conditions, I am not addicted to it. Resident 5 stated earlier in the week, they had a medical procedure to insert a catheter into a vein in their chest and asked if they could have one extra dose prior to the procedure, but the on-call provider the nurse contacted refused to authorize a one-time dose and told the nurse to apply ice to the area. Resident 5 stated the procedure was very uncomfortable. In an interview on [DATE] at 4:20 PM, Staff E stated they were unsure which provider was contacted regarding the additional dose for the procedure but would investigate it and they would re-evaluate Resident 5's pain regime. <Resident 7> Review of the [DATE] Annual Comprehensive MDS, Resident 7 had significant cognitive impairment, diagnoses of vascular disease, and dementia. Resident 7 received scheduled pain medication, no PRN medication, and a staff assessment for pain was not conducted. Review of Resident 7's [DATE] pain care plan showed they had indicators of pain that included facial expressions, other non-verbal signs of pain, and a pressure injury. The established goal for Resident 7 was they would verbalize adequate pain relief and ability to cope with unrelieved pain (except they had severe cognitive deficits due to dementia). The care plan showed three generic care plan interventions to observe for discomfort through either verbal or facial expression, assess characteristic of pain including location and severity on the 1-10 scale, and listed some non-verbal indicators to monitor for. The care plan was not individualized, had unrealistic goals which indicated they would have unrelieved pain, and did not include use of a pain scale appropriate for dementia care. Review of Resident 7's [DATE] revised behavior care plan showed they had behaviors that included: aggression toward staff, disrobing, self-transfers to the floor, and crawling on the floor. The care plan did not direct staff to identify their behaviors as potential indicators of pain. Observations on [DATE] at 11:45 AM and 4:40 PM showed Resident 7 crawling on the floor from their room to the hallway, pushing their wheelchair, and hollering. During both observations, staff were aware of Resident 7's actions, but no staff were observed to intervene with Resident 7 to evaluate if they were hurting or had some other unmet care need. Review of Resident 7's [DATE] MAR showed they received scheduled Tylenol 1,000 mg three times daily for chronic pain, a lidocaine patch daily, a schedule IV narcotic pain medication every morning, and staff consistently documented pain level 3-5/10 (via the verbal pain scale). A PO, dated [DATE], directed staff to attempt non-pharmacological interventions (which were the same interventions as Residents 1, 2, 3, 4, 5, & 6) prior to administration of PRN medications but none were documented. Review of Resident 7's schedule IV NL, Page 36, showed they did not receive the medication on [DATE], [DATE], [DATE], [DATE], and [DATE]. In an interview on [DATE] at 5:10 PM, Staff B stated they would investigate why Resident 7 was not administered the scheduled doses of pain medication. <Resident 3> Review of the [DATE] admission MDS showed Resident 3 had no problems with cognition, they received scheduled and PRN pain medication, and reported their worst pain an 8/10. Review of Resident 3's [DATE] MAR showed they had orders for: a schedule II extended-release opioid medication twice daily for back pain related to chronic pain syndrome, a schedule II opioid pain medication every six hours PRN for severe pain, a scheduled medication for neuropathy, a PRN medication for neuropathy, scheduled Tylenol 1,000 mg three times daily (for a total of 3,000 mg), and Tylenol 650 mg every six hours PRN -not to exceed the maximum daily dose of 3,000mg /24 hours from all Tylenol sources, and two different muscle relaxants PRN for muscle spasms. Review of Resident 3's October PRN opioid medication showed they requested the medication two to four times daily for pain levels of 6-8/10. No non-pharmacological interventions were documented as attempted prior to the administration of the PRN opioid pain medication. Despite multiple daily use of their PRN opioid pain medication, on [DATE], Staff E decreased their order from one tablet every six hours to one tablet every 22 hours for seven days and then discontinued completely. The clinical record provided no documentation to support the facility or Staff E assessed Resident 3's pain management regime to determine why they continued to have breakthrough pain when they were on an extended-release opioid medication or the consequences of discontinuation of their PRN pain medication while they continuously reported breakthrough pain. Review of Resident 3's NL page 13 showed a quantity of 26-10 mg schedule II extended-release opioid tablets to be administered twice daily. The prescription did not indicate how far apart the medication should be administered. The facility scheduled the medication for 8:00 AM and 8:00 PM. According to the NL Resident 3 was not provided their scheduled dose on [DATE] at 0800 AM. Review of Resident 3's NL page 12 showed a quantity of seven-5mg instant release schedule II opioid tablets for PRN administration which was discontinued on [DATE]. An entry on [DATE] at 0800 AM showed Resident 3 was administered one 5mg tablet of instant release pain medication (two days after Staff E discontinued the medication). This indicated a medication error occurred when the nurse gave a 5 mg instant release tablet instead of their scheduled extended-release medication. Review of Resident 3's [DATE] MAR showed they complained of pain 8/10 on [DATE] at 3:49 PM and was given 650 mg of Tylenol for 8/10 (severe) pain. At 8:00 PM they were administered their evening extended-release pain medication as scheduled and at 9:00 PM they were given 1,000 mg of Tylenol for pain 8/10 (for a total of 3,650 mg of Tylenol which exceeded the maximum daily dose). The failure to administer the correct medication for their morning dose likely contributed to their severe breakthrough pain and they no longer had an order for the opioid PRN medication to treat moderate-severe pain, and was administered Tylenol (used for general pain and fever) which exceeded the maximum daily limit. In an interview on [DATE] at 12:45 PM, Staff B, Director of Nursing stated they were not aware of the medication error and would investigate it. In an interview on [DATE] at 3:00 PM, Resident 3 stated their pain was not managed. Resident 3 stated their scheduled pain medication was usually administered late, they were not referred to a pain specialist or offered other treatments for pain management such as contracture management and splinting for their contra[TRUNCATED]