**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess for change in conditions related to skin and constipation, follow hospice and physician orders, and obtain and report labs for 7 of 8 residents (Residents 83, 79, 12, 5, 4, 30, and 68) reviewed for quality of care. These failures placed all residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Resident 83 experienced harm when they obtained a facility acquired pressure injury (PI, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices). Additionally, Resident 79 experienced harm when they continued to have seizures when they did not receive medications indicated for seizures in a timely manner. Findings included . Review of a policy titled Skin Integrity dated 08/2018, showed staff would monitor the resident's skin and be alert to potential changes. The policy showed the changes would be reported and treatment interventions would be implemented and monitored to prevent worsening. <Skin> <Resident 83> Review of the medical record showed the resident admitted with diagnoses of a right hip fracture and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). The 08/06/2024 comprehensive assessment showed Resident 83 had moderately impaired cognition, required one to two staff assistance for dressing, grooming, bed mobility, and transfers. An observation on 10/15/2024 at 9:56 AM, Resident 83 was overheard from the hallway yelling out help me. The state investigator followed Staff N, Medication Assistant Certified, into the room and Resident 83 was observed lying on a bare mattress, there were no sheets or blankets on or around the bed, and the resident was stating they were freezing. Resident 83 had dried, white crusted areas of skin under their right and left eye, above the left eye lid, the right-side bridge of their nose, and to both ears. Staff N left and got a blanket and covered up Resident 83 but left them lying on the bare blue mattress. Staff N did not ensure the resident had their call light within reach when exiting the room, which was observed underneath the resident's bed on the floor. An observation and concurrent interview on 10/16/2024 at 11:35 AM, showed Resident 83 was observed lying in their bed, no pants on, partially covered with a sheet with only their feet exposed, both ears had white/brownish crusted areas to the entire outer and inner portion of the ears with dried red blood. The right eye had dried, crusted white areas surrounding the eye. An empty, soiled, urinal was on the floor in between the bed and the window, and the call light was under the bed on the floor. Resident 83's left eye was reddened with yellow/green drainage in the inner corner of the eye. The outer left great toe had thickened, dried red blood clumped at the corner of the outer nail bed and underneath the remaining four toes, there was dried red blood on the skin. Resident 83 stated when they required help, they would yell out help to get it. An observation and concurrent interview on 10/17/2024 at 2:39 PM, showed Resident 83 lying in bed, moaning out and repeating help me, help me and the call light was underneath the bedside table on the floor. Resident 83 stated their right leg was very painful and was holding their right knee up towards their chest. Resident 83 was covered by a sheet and the Surveyor could not visualize their right leg. An observation on 10/17/2024 at 2:59 PM, showed Resident 83 was grasping their right leg and moaning ooh, aww when Staff CC, Nursing Assistant (NA), Staff DD, NA, and Staff RR, Registered Nurse, all walked by and did not stop to ask the resident what was wrong. Review of the October 2024 Treatment Administration Records (TARs), showed an order on 06/27/2024 for weekly skin checks to be completed on Thursdays with a Yes/No for new skin issues. If new skin issues were found there was to be a progress note, notification to the provider, obtain new orders for treatment, and placed on alert charting (the assessment on 10/10/2024 and 10/17/2024 showed a yes for new skin issues observed). The record showed no treatments or monitoring for the ears, eye, left toes, and the pain to the right leg. Review of Nursing progress notes showed on 10/10/2024 at 10:46 PM, Resident 83 had redness to both ears and their right eye with edema (swelling) to the outer and inner ears and open areas behind the ears with pus [typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during infections] drainage, and drainage to the right eye and S&S [signs and symptoms] of infection. Review of a note on 10/12/2024 at 9:09 am, showed the on-call provider was notified of the ears and right eye and gave new orders for Doxycycline (a brand of medication used to treat fungal infections) to be started. There were no orders documented to continue cleaning or monitoring the ears and the eye. There were no nursing progress notes for the skin check completed on 10/17/2024 even though there was documentation that showed new skin issues were found. An observation and concurrent interview on 10/18/2024 at 8:35 AM, showed Resident 83 was observed lying in their bed, no pants on, uncovered, the call light was under the bed on the floor, and their right leg from mid-calf to their ankle was bright red. Resident 83 had the same dried red blood to the outer left great toenail and on the skin, underneath the remaining four toes. Resident 83 stated they had intolerable pain, pointing to their right leg, from their ankle to their knee. Resident 83 was moaning and yelling out ooh, aww repeatedly and stated they yelled because it was their expression so people will know and help me. Staff FF, Housekeeping, and Staff I, Admissions Coordinator, both walked by Resident 83's room, stopped in front of the door, and Staff FF stated to Staff I, oh, that's just [Resident 83], they always yell like that and both walked away without asking the resident what they needed. During an interview on 10/21/2024 at 10:27 AM, Staff N, stated they would never hear Resident 83 moaning/crying out in pain, they only heard the resident when they would sing. Staff N further stated it was against their scope of practice to complete the skin checks and that the nurse unit managers completed them. During an interview on 10/22/2024 at 9:23 AM, Staff N stated when residents were found with new skin issues or had a change in their condition, the NAs were to report it to them and they, along with a nurse, would go and assess the resident. Staff N stated no one had reported Resident 83's redness to their right leg/ankle, the dried red blood to the toes, or the dried red blood to the ears. Staff N then retrieved Staff B, Director of Nursing Services, to assess Resident 83. Staff B assessed the resident and the provider, who was in the facility, were called to the room to further assess Resident 83. Review of the Provider's note on 10/22/2024 at 11:27 AM, showed during the physical exam the resident complained of pain when the right leg was moved and had restricted range of motion (the extent or limit to which a part of the body can be moved around a joint or a fixed point) to the knee, hip, and ankle. The examination showed redness from below the toes to above the ankle with slight fluctuance (alternate pressure by palpating fingers so as to suggest that the area being felt contains fluid) to the heel and was purple in color. Review of the Physician Orders for 10/22/2024 showed a new treatment order for a suspected deep tissue injury (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often come before skin color changes) to the right heel. During an interview on 10/22/2024 at 4:34 PM, Staff B stated Staff K, Licensed Practical Nurse (LPN)/Unit Manager (UM, an Licensed Nurse (LN) that provided oversight and management of the nursing staff and residents within their units), completed the weekly skin check on 10/17/2024 and documented new skin issues were found. Staff B stated Staff K got busy and forgot to complete the process for the new skin issues found during that assessment and did not follow the correct process. <Constipation> Review of the undated facility policy Bowel Protocol and Bowel Tracking, showed residents who went without a regular bowel movement (BM) greater than three days would be physically assessed by nursing and the bowel protocol would be implemented. The policy showed the physician would be notified if no bowel movement results after implementing the bowel protocols, and the assessment and physician notification would be documented. <Resident 12> Review of the medical record showed the resident admitted with diagnoses to include heart failure and emphysema (lung condition that causes shortness of breath). The 08/04/2024 comprehensive assessment showed Resident 12 required one to two staff assistance with transfers and bed mobility, was incontinent of their bowels and their cognition was intact. During an interview on 10/16/2024 at 3:30 PM, Resident 12 stated they experienced constipation (a problem with passing stool, such as having fewer than three stools a week or hard, dry or lumpy stools) often and did not receive routine medication for them. Resident 12 stated they received a medication that caused constipation. Review of Resident 12's bowel record showed as follows: from 09/17/2024 night shift through 09/25/2024 evening shift, the resident went seven days and two additional shifts with no BM (seven shifts showed no documentation); 09/26/2024 day shift through 09/30/2024 day shift, four days and one additional shift without a BM (nine shifts showed no documentation); from 10/01/2024 day shift through 10/08/2024 evening shift, seven days and two additional shifts without a BM (three shifts showed no documentation); and from 10/09/2024 day shift through 10/16/2024 day shift, seven days and two additional shifts without a BM (six shifts showed no documentation) (in the past 30 days Resident 12 had four bowel movements). Review of the September and October 2024 Medication Administration Records (MAR) showed the resident had six PRN (as needed) bowel medications that could be used when experiencing constipation. The medications were to be used when the resident did not have a BM in three days and continued until there were results. The September 2024 and October 2024 MARs showed no documentation that any of the PRN medications were administered. During an interview on 10/29/2024 at 8:33 AM, Staff Y, NA, stated they were alerted when charting if a resident needed to have a BM. Staff Y stated they would document every shift whether the resident had a BM or not and they would additionally document after each BM the resident had during their shift. Staff Y stated they would notify the nurses if the resident had a BM. During an interview on 10/29/2024 at 9:01 AM, Staff N stated they checked their alerts prior to the start of their shift for residents who had not had a BM in three days. Staff N stated after the third day they would start their bowel protocol by using the PRN bowel medications and document after each one was given. Staff N stated the nurses would complete bowel assessments, document them in the progress notes, and notify the provider if additional medications were needed or the current medications did not result in a BM. During an interview on 10/29/2024 at 9:08 AM, Staff BB, NA, stated when they documented, an alert would let them know that a resident had gone three days without a BM. Staff BB stated the nurses also would get the same alerts and let them know during their daily report if someone needed to be monitored. Staff BB stated they would monitor the resident and inform the nurses if the resident did or did not have a BM during their shift. Staff BB stated the process was to document each shift and after each BM. Review of the 09/17/2024 through 10/16/2024 nursing progress showed no documentation of bowel assessments, medications administered due to no BMs, or notification to the physician that Resident 12 experienced constipation and was not having regular bowel movements. During an interview on 10/21/2024 at 3:16 PM, Staff B stated the nurses should have been monitoring bowels when a resident was not having regular BMs, document their bowel assessment, notify the physician, and obtain new orders if what the resident currently had was not working. <Hospice Services> <Resident 79> Review of the medical record showed the resident admitted to the facility with diagnoses to include schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania). The 07/15/2024 comprehensive assessment showed Resident 79's cognition was severely impaired. Further review of the medical record showed the resident was admitted to Hospice (a service for people with serious illnesses who choose not to get (or continue) treatment to cure or control their illness) services on 10/04/2024. Review of a provider note on 10/01/2024 showed Resident 79 was observed to be having several seizures (s a sudden change in behavior, movement, and/or consciousness due to abnormal electrical activity in the brain) and provider diagnosed the resident with epilepsy (a disorder that causes seizures or unusual sensations and behaviors) and the plan was to start a nasal spray, Midazolam (a drug that helps prevent or stop seizures). Review of the October 2024 MAR showed an order on 10/01/2024 for Midazolam Nasal Spray, one spray in the nostril when actively having seizures, and could repeat the dose once (no uses of this medication had been documented and after a search, the medication could not be found in the facility). Review of Nursing progress notes showed on 10/07/2024 at 2:33 PM, Staff LL, LPN, documented the Hospice Nurse (HN) gave new orders for Ativan (a brand of medication used to treat trouble sleeping, severe agitation, active seizures, and anxiety [a feeling of worry, nervousness, or unease]) two milligrams (mg) four times daily and an additional order of Ativan four mg to be given now due to the continuance of seizures. Staff LL documented the HN reported almost 50 seizures while they were in the room with the resident. A follow-up note at 3:16 PM showed Staff LL documented, Resident 83 was having seizures majority of shift. Review of Hospice orders dated 10/04/2024, electronically signed by the provider, showed as follows; 1)Haldol (used to treat nervous, emotional, and mental conditions) two mg, two tablets by mouth every six hours for hallucinations; 2) Ativan one mg, one tablet by mouth every four hours PRN for anxiety, agitation, restlessness, or seizures (not processed until 10/09/2024, five days after ordered) 3) Haldol two mg, give one tablet by mouth every six hours PRN for nausea, agitation, or hallucinations (processed and discontinued on 10/09/2024, five days after ordered); 4) Ativan one mg, one tablet by mouth four times daily for anxiety (this order was a continued order from 04/08/2024); and reordered, 5) Midazolam nasal solution PRN for seizures. Again, on 10/07/2024 an order for Ativan two mg, give two tablets by mouth for a one time dose for seizure activity; Ativan one mg, give four tablets for a one time dose for seizures (order not processed); Ativan one mg, give two tablets by mouth every four hours PRN for seizures, restlessness, or agitation (not processed until 10/09/2024, two days after order given); and an order to discontinue Ativan one mg, give one tablet every four hours PRN (not discontinued until 10/9/2024). During an interview on 10/22/2024 at 9:16 AM, Staff N stated they worked the day shift on 10/07/2024 and observed Resident 79 actively seizing and had also been alerted by the Hospice Social Worker (HSW) that had been there. Staff N stated the HSW informed the HN of Resident 79's seizure activity, and the HN gave directions for the PRN Ativan to be administered, but Staff N did not have that order on Resident 79's current October 2024 MAR so could not administer it. When Staff N was asked about using the Midazolam nasal spray, which there was an order for, Staff N stated they were unaware that medication was on the MAR. During an interview on 10/22/2024 at 10:39 AM, a Collateral Contact from the consulting pharmacy, stated they had not received an order for the Midazolam Spray on or after 10/01/2024, therefore they did not fill it. During an interview on 10/22/2024 at 10:43 AM, Staff K stated when they processed an order it automatically transmitted to the pharmacy. Staff K stated they then had a report that they could use to track that the medication was delivered. Staff K then clarified through the report that the medication had never arrived from the pharmacy. Staff K stated there could have been a problem with obtaining that medication but would have received a fax from the pharmacy. Staff K could not produce a fax and stated they did not usually keep the faxes from the pharmacy because they had the reports in the computer to access. During an interview on 10/22/2024 at 11:05 AM, Staff RR, Medical Director, stated they had not been aware of Resident 79's seizure activity on 10/07/2024 and had no idea they had been seizing for that long. Staff RR stated Resident 79 probably should have been sent to the hospital since the medications/orders weren't working or available to at least keep them comfortable. During an interview on 10/24/2024 at 1:10 PM, Staff LL stated they had observed Resident 83 having seizures one after another. Staff LL stated the HN gave them additional orders, but they did not see them in Resident 79's MAR, so they were unable to administer them. Staff LL stated the HN was able to show them the orders they had given, and Staff LL was able to verify the orders, but when they attempted to process those orders, they ran into issues with the provider's prescribing number not being in their system. During an interview on 10/24/2024 at 12:06 PM, the HSW stated Resident 12 had been admitted to Hospice services on 10/04/2024 and at that time the facility had been given admission orders. The HSW stated they arrived at the facility shortly after 7:00 AM on 10/07/2024 and observed the resident having seizure type behaviors. The HSW stated the resident's head was hanging over the side of the bed and there was a puddle of vomit on the floor beside them. The HSW stated when they called the HN to inform them of the seizure activity, they were told to inform the facility to use the orders they were given on 10/04/2024, when they admitted Resident 79 to hospice services, but when the HSW communicated that to Staff N, they were told there were no orders in their EMAR to give other than the routine Ativan. The HSW further stated the HN arrived at the facility and took over the medication issue with the facility and the SW left the facility at nearly 11:00 AM and Resident 79 was still having seizures. Review of Hospice admission orders, dated 10/04/2024, showed the orders were signed and acknowledged by Staff J, LPN/UM, and Staff Q, RN. The orders showed they were the same as the electronic, physician signed orders as listed above. During an interview on 10/29/2024 at 10:06 AM, Staff B stated they were not aware of Resident 79's on-going seizure activity or the issues that took place with inputting or obtaining hospice ordered medications. Staff B stated if the nurses were having issues processing orders under another provider's number, then the medical director should have been contacted and asked if they could have orders until the issue was resolved. Staff B also stated they would expect the unit managers to be monitoring and checking off that medications ordered were being delivered and accessible. <Hospitalization> <Resident 5> Review of the medical record showed the resident was admitted with diagnoses to include diabetes (a condition where there is too much sugar in the blood) and kidney failure. The 08/09/2024 comprehensive assessment showed Resident 5's cognition was intact and required one to two person staff assistance with dressing and personal hygiene. During an interview on 10/15/2024 at 11:02 AM, Resident 5 stated they had just returned from a hospital stay for an infection to their breast. Resident 5 stated they had a yeast infection that worsened and the powder the nurses used didn't help, it only made it worse so they refused to let them use it. Review of the Provider's note on 09/25/2024 showed Resident 5 was observed to have blood blisters and open sores with pus (thick, milky fluid) and bloody drainage to their left breast and open sores to their stomach pannus (when excess skin and fat hang from the abdomen). The note showed orders as follows: 1) Cephalexin (a brand of antibiotic medication that kills bacteria) 500 mg every six hours for five days and then send an acute visit to reassess in one week on Tuesday 10/01/2024; 2) apply Caldesene (used to treat and prevent diaper rash and other minor skin irritations) powder underneath the pannus every shift for seven days and then PRN, prior to applying the powder, Betadine (a topical medication used on the skin to treat or prevent skin infection in minor cuts, scrapes, or burns) was to be applied to the open sores, and then covered with gauze and tape, and then apply interdry (moisture-wicking antimicrobial fabric dressing). Additionally, the powder was to be applied under both breasts folds every shift PRN for fungal infection. The provider's note also showed the resident did not want Nystatin (a brand of antifungal powder) used because they were allergic and made the yeast worse. Review of the nursing progress notes showed as follows: on 09/26/2024 at 10:30 PM, Resident 5 requested to be sent to the hospital due to worsening of their breast. Resident 5 was sent back from the hospital at 2:17 AM on 09/27/2024 with new orders for Fluconazole (an antifungal medication that may be used to treat serious fungal or yeast infections) twice daily for 14 days; on 10/10/2024 at 4:05 PM, Resident 5 was observed to have redden and blistered areas under breast with the left breast painful, very red and hard to the touch. The note showed the provider was notified and gave orders for the resident to be sent to the hospital; a note on 10/14/2024 at 3:18 PM, showed Resident 5's hospital admission diagnosis was left breast cellulitis [a bacterial skin infection that causes swelling, pain, warmth and redness]; Review of Resident 5's September 2024 and October 2024 MAR showed the Fluconazole order had not been processed until 09/30/2024 (four days [eight doses] were missed before first dose was received) with the last dose of the course to be completed on 10/10/2024 on the evening shift. The 09/25/2024 Cephalexin order had three doses not documented as given, and the betadine treatment showed no documentation it had been completed because when the order was processed, there wasn't a schedule added to the order so did not show as needing to be done. Additionally, the Caldesene powder showed no documentation it had been administered under the breasts even though the resident had symptoms of a fungal infection. Review of the discharge hospital summary on 10/14/2024 showed the resident was treated for left breast cellulitis and a fungal skin infection. The summary showed Resident 5 had worsening of their left breast swelling, redness, and pain and a severe fungal infection. During an interview on 10/29/2024 at 10:08 AM, Staff B stated the UMs would review the provider notes and process orders they received on that day. Staff B stated all nurses should be reviewing notes and documentation when a resident returns from the hospital and should process orders they reviewed and not leave them for the UMs to process. <Laboratory/Diagnostic services> Review of the facility's policy dated 11/2017, titled Laboratory and Diagnostics Services, showed the facility provides or obtains laboratory and other diagnostic services to meet the needs of the resident and were responsible for the quality and timelines of the services. <Resident 4> Review of Resident 4's medical record showed they were admitted to the facility on [DATE] with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal activities of daily living), insomnia (trouble sleeping at night, staying asleep or both), and kidney failure. The comprehensive assessment dated [DATE] showed the resident required substantial assistance with activities of daily living (ADL's) and transfers. The assessment showed the resident's cognition was severely impaired. Review of the physician visit notes showed on 08/08/2024 orders for a complete blood count (CBC, used to look at overall health and find a wide range of conditions, including anemia, infection) and a comprehensive metabolic panel (CMP, a blood test that gives doctors information on how well the kidneys and liver are working). Review of the medical record showed no test results. Review of the physician visits on 08/13/2024 showed current laboratory orders of a CBC and CMP, further review on 10/29/2024 showed there were no results in the resident's medical record. In an interview on 10/21/2024 at 10:20 AM, A Collateral Contact (CC) stated the facility's order process had been a problem since February 2024. The CC stated that they had requested lab orders on Resident 4 since August that had not been obtained, there were a few residents here that we had requested labs for and had not received results, so we keep ordering them. <Resident 30> Record review showed the resident was admitted with diagnoses to include Alzheimer's Disease (a common form of dementia, believed to be caused by changes in the brain, usually beginning in late middle age, characterized by memory lapses, confusion, emotional instability, and progressive loss of mental ability), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and End Stage Renal Disease (ESRD, when the kidneys can no longer function on their own). Review of the resident's 07/18/2024 comprehensive assessment showed they had severely impaired cognition and received medications including a diuretic (medication designed to increase the amount of water and salt expelled from the body as urine), an antianxiety (medication to relieve symptoms of anxiety), and an antipsychotic (medication treats symptoms of psychosis). Record review of a 03/25/2024 provider visit showed a Basic Metabolic Panel (BMP, a blood test that checks the levels of different substances involved in metabolism and kidney function) lab test drawn to monitor Resident 30's kidney function. Record review of a 09/03/2024 visit note from Resident 68's behavioral health specialist showed the most current labs for review in the resident's medical record were from 10/18/2023. The specialist requested blood drawn for a CBC. CMP and a lipid profile (a blood test that measures the amount of certain fat molecules in the blood). Record review of a 10/02/2024 provider visit note showed they ordered labs to be drawn that included a CBC, CMP, lipid profile, Vitamin D level, Vitamin B 12 level and iron studies on the next facility lab draw. Record review of Resident 30's medical record on 10/22/2024 at 10:05 AM showed no laboratory results for the tests that were ordered on 03/25/2024, 09/03/2024 and 10/02/2024. Record review of the laboratory reports for Resident 30 sent to the facility on [DATE], after the DNS requested the results, showed blood samples ordered on 10/02/2024 were sent to the lab on 10/08/2024 and reported to the facility on [DATE]. <Resident 68> Record review showed the resident was admitted to the facility with diagnoses to include dementia, anxiety disorder and failure to thrive (a progressive functional deterioration of a physical and cognitive nature). Review of the 08/23/2024 quarterly Minimum Data Set (MDS, a required assessment and care planning tool) showed that the resident had medications prescribed for dementia with behavioral disturbance and anxiety. Medical record review showed an order dated 04/03/2024 for a BMP and lipid panel on next facility [blood] draw day. Record review of a 05/03/2024 provider visit note, showed Resident 68's last laboratory results in their record were from 08/22/2023. The provider ordered a complete lipid panel and a BMP lab test to be completed. The provider also requested a referral be made to [a neurologist] for consultation on dementia. Record review of a 07/09/2024 provider visit note showed no recent labs were found in the medical record and the provider ordered a BMP blood test be completed. Record review of a 09/10/2024 provider visit note showed that they ordered a BMP to be drawn in one week. Record review of Resident 68's medical record on 10/22/2024 at 10:00 AM showed no laboratory results for the tests that were ordered on 04/03/2024, 05/03/2024, 07/09/2024, and 09/10/2024. Also, there was no documentation of a referral made to a neurologist from the 05/03/2024 order. During an interview on 10/22/2024 at 10:58 AM, Staff B stated that the night nurse was responsible to draw the resident's blood. Staff B stated they were aware we were behind on completing lab draws. Staff B stated they would call the lab and request any results for Resident 68 and Resident 30 since April 2024. Record review of the laboratory reports for Resident 68 sent on 10/22/2024 after the DNS requested the results showed blood samples were obtained: - on 04/08/2024 the report was sent to the facility on [DATE] that included the tests ordered on 04/03/2024. There was no record these results were reviewed by the physician. - on 07/15/2024 the report was sent to the facility on [DATE] that included the test ordered on 07/09/2024. There was no evidence in the record that the test results were reviewed by the physician. During an interview on 10/22/2024 at 11:05 AM, Staff B stated that orders for lab work or referrals that were included with medical visit notes, as their plan, was the same as a physician order that should be followed up on by the nursing unit manager. Staff B stated that they were not aware Resident 68 had an order to be referred to a specialist that was not completed. During an interview on 10/22/2024 at 1:58 PM, Staff K for Resident 68 stated that they were not aware there was an order for Resident 68 to receive a consultation by a specialist for their dementia. During an interview on 10/22/2024 at 5:34 PM, Staff B stated after lab work was drawn it would be sent to the laboratory. The results were reported through a fax and the nurses were supposed to monitor for the results. Staff B stated should there be a critical lab value, the laboratory would call the facility. The results were reviewed by the nurse, placed in a file for the physician to review during rounds. The physician then dates, signs and would include any follow up orders. After the reports are reviewed by the physician, the nurse would put the results in a box labeled to scan at the nurse's station. Medical records would then scan the results into the resident's medical record. During an interview on 10/24/2024 at 1:48 PM, Staff J stated when the physician's ordered labs, the UMs processed the orders and co[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 5 residents (Resident 54) reviewed for hospitalization. Resident 54 experienced harm when they received an antipsychotic medication (a class of drugs used to treat symptoms of psychosis and other mental health disorders) that caused acute toxic encephalopathy (indicates brain dysfunction caused by toxic exposure in the absence of primary structural brain disease) and increased sleepiness that resulted in a four-day hospitalization. Findings included . Review of Lippincott's Guide to Preventing Medication Errors dated 11/15/2002, showed the five rights of nursing drug administration are the right patient, the right drug, the right dose, the right route, and the right time. <Resident 54> Review of the medical record showed the resident admitted with diagnoses to include dementia (the loss of cognitive functioning that interferes with daily life and activities). The 08/07/2024 comprehensive assessment showed Resident 54's cognition was severely impaired and required one to two person staff assistance with activities of daily living. During an interview on 10/16/2024 at 2:16 PM, the Resident's Representative (RR) stated Resident 54 had received the wrong medications and ended up in the hospital and was real sick. Review of a hospital discharge summary on 10/14/2024 showed Resident 54 admitted to the hospital on [DATE] for receiving another resident's medication. The summary showed the resident received an antipsychotic (a collection of symptoms that affect your ability to tell what's real and what isn't) medication (Seroquel, a medication used for managing symptoms including delusions, hallucinations, paranoia or disordered thoughts). The summary showed the resident had a low blood pressure at 66/24 millimeters of mercury ([mmHg, a unit of measure], where the normal range for an adult is 120/80 mmHg) and required the administration of intravenous (through the vein) fluids. Resident 54 was diagnosed with acute toxic encephalopathy from receiving an antipsychotic medication in error. Review of a facility incident investigation on 10/10/2024 at 12:00 PM, showed Staff VV, Licensed Practical Nurse, had mixed up Resident 54's medications with their roommate's medications. Staff VV realized they had made the error and called the physician who gave orders to send the resident to the hospital. The investigation showed a follow-up note on 10/14/2024 that the resident had no negative outcome and would remain at the hospital for observation. The investigation showed Staff VV did not follow the five rights of medication administration, which are right resident, right drug, right dose, right route, and right time which should have been verified prior to administering medications to any resident. During an interview on 10/29/2024 at 10:28 AM, Staff B, Director of Nursing Services, stated they followed up with the hospital and was informed the resident was at their baseline and there were no negative effects for Resident 54 receiving the wrong medications. Staff B stated they did not review the hospital records on readmission and should have. Staff B stated Staff VV did not follow the correct steps when administering medications. WAC Reference: 388-97-1060 (3)(k)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively implement and evaluate line-of-site supervision to prevent abuse or mistreatment for 4 of 7 residents (Resident 2, 3, 4, and 5) reviewed for sexual abuse. The failure to consistently implement supervision interventions to potentially prevent four sexual abuse incidents in a seven-day period resulted in Resident 4 experiencing psychological harm when the sexual abuse triggered post-traumatic stress suicide ideation, and Resident 5 experiencing psychological harm when applying the reasonable person approach. Additionally, this deficient practice placed all residents at risk for sexual and psychological abuse and a diminished quality of life. Findings included . Review of the facility's state reporting log showed four resident-to-resident altercations, dated 09/24/2023, 09/25/2023, 09/28/2023, and 09/30/2023, involving Resident 1 as an Alleged Perpetrator (AP) and Residents 2, 3, 4, and 5 as Alleged Victims (AV). <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses including dementia (loss of thinking, remembering, and reasoning that interferes with daily life) and heart disease. Review of the comprehensive assessment, dated 08/21/2023, showed the resident had severe cognitive impairment and required supervisory assistance with activities of daily living (ADLs), transfers, and ambulated using a walker (assistive device). Further review of the medical record showed a care plan, dated 05/15/2023, that included a focus of .sexual ideation and sexual behavior . This care plan listed an intervention, initiated on 05/16/2023, to keep the resident .in line of sight (supervision level where the resident was in the field of vision of at least one staff member when out of their room) . <Resident 2> Review of the medical record showed Resident 2 admitted to the facility on [DATE] with diagnoses including alcohol induced dementia (dementia caused by excessive consumption of alcohol) and diabetes (when the body cannot effectively process sugar in the blood). Review of the comprehensive assessment, dated 09/09/2023, showed the resident had moderately impaired cognition and required the extensive assistance of one person with ADLs, transfers and mobility using a wheelchair. Review of the facility's investigation, dated 09/28/2023, for the incident that occurred on 09/24/2023 at 5:58 PM showed Resident 2 reported to facility staff that Resident 1 had touched my boobs. The investigation summary showed interventions to prevent reoccurrence included a referral for alternate housing placement for Resident 1 and .staff to continue to monitor location, reinforced need to ensure they are within line of sight when out of their room. During an interview on 10/04/2023 at 2:15 PM, Resident 2 stated they felt embarrassed by the incident that occurred on 09/24/2023 with Resident 1 and felt unsafe when they were around. Due to feeling unsafe, Resident 2 further stated, the facility staff was assisting them to and from meals and activities. <Resident 3> Review of the medical record showed Resident 3 admitted to the facility on [DATE] with diagnoses including bipolar disorder (serious mental health condition that causes extreme shifts in mood) and alcohol induced psychotic disorder (the mental disorder that causes the hearing, seeing and believing things that are not real caused by excessive consumption of alcohol). Review of the comprehensive assessment, dated 08/26/2023, showed the resident had an intact cognition level and required the extensive assistance of one person with ADLs, transfers and mobility using a wheelchair. Review of the facility's investigation, dated 09/29/2023, for the incident that occurred on 09/25/2023 at 1:21 PM showed Resident 3 reported to facility staff that Resident 1 had touched them in a sexually inappropriate manner while they sat at the tables in the lobby. The investigation showed that Resident 3 stated Resident 1 had placed their hand on their leg and proceeded to move it up toward their genital area. The investigation summary showed no new interventions, and Resident 1's supervision level was .to keep resident in line of sight. During an interview on 10/04/2023 at 1:50 PM, Resident 3 stated the incident that occurred on 09/25/2023 with Resident 1 made them .angry that (Resident 1) felt (Resident 1) could do that. (Resident 1) has no rights to my body. Resident 3 also stated they viewed Resident 1 as .a predator, and did not feel safe when Resident 1 was around. Review of Resident 1's medical record showed no evaluation of the effectiveness or appropriateness of the line-of-sight monitoring. <Resident 4> Review of the medical record showed Resident 4 admitted to the facility on [DATE] with diagnoses including stroke with left sided weakness (a blockage of blood flow in the brain that causes damage and impairs the body's ability to function) and diabetes. Review of the comprehensive assessment, dated 09/01/2023, showed the resident had moderately impaired cognition, required the extensive assistance of two people for ADLs and transfers, and was independent with mobility using an electric wheelchair. Review of the facility's investigation dated 10/02/2023, for the incident that occurred on 09/28/2023 at 1:21 PM showed Resident 4 reported to facility staff that Resident 1 had touched their breast while Resident 4 was sitting in their wheelchair in the doorway of their room. The investigation showed Resident 4 had called local law enforcement and reported being sexually assaulted and began expressing suicide ideation. The investigation summary showed new interventions included the initiation of a mood stabilizing medication and to continue .line of sight monitoring . During an interview on 10/04/2023 at 1:30 PM, Resident 4 stated the incident that occurred on 09/28/2023 .triggered memories of my past sexual abuse and that makes me want to die. During an interview on 10/04/2023 at 3:02 PM, Staff C, Resident Care Manager (RCM), stated the supervision level of Resident 1 was not changed after the incident on 09/28/2023 because they wanted to see if the new mood stabilizing medication would be effective. When asked if the new medication had been effective, Staff C stated no because another incident happened. <Resident 5> Review of the medical record showed Resident 5 admitted to the facility on [DATE] with diagnoses including dementia, delusional disorder (disorder causing the inability to identify what is real) and aphasia (inability to communicate effectively due to brain damage). Review of the comprehensive assessment, dated 07/29/2023, showed the resident had severely impaired cognition and they required the extensive assistance of two people for ADLs, transfers, and mobility using a wheelchair. Review of the facility's investigation dated 10/02/2023, for the incident that occurred on 09/30/2023 at 12:18 PM showed that a facility staff member observed Resident 1 in Resident 5's room, standing over them while touching their breasts. The investigation showed the staff member immediately separated the residents and assisted Resident 1 back to their room. The investigation summary showed no new interventions and Resident 1's supervision level continued to be line of sight monitoring. During an interview on 10/04/2023 at 2:26 PM, Staff D, Licensed Practical Nurse (LPN) confirmed they were the charge nurse when the incident occurred on 09/30/2023 between Resident 1 and Resident 5. Staff D stated they were familiar with the facility's process for initiating one-to-one supervision of a resident, but that process had not been considered after this incident, and Resident 1 continued to be .line of sight monitoring. During a phone interview on 10/06/2023 at 11:05 AM, a Resident Representative (RR) for Resident 5 stated their dementia was advanced and they were unable to verbally express their needs. The RR further stated Resident 5 would not have wanted to be touched by Resident 1 in a sexual manner and .unfortunately (they) could not speak up about it. Review of the daily staffing sheets for the nursing department showed, on 10/03/2023 (three days after the last incident), a staff member was designated to conduct one-to-one (one staff member dedicated to maintain supervision of the resident at all times, anticipate safety concerns, and report needs/concerns to nursing staff) supervision of Resident 1 on every shift. During an interview on 10/04/2023 at 3:30 PM, Staff B, Director of Nursing Services (DNS), stated the determination for Resident 1 to have one-to-one supervision occurred on Monday 10/02/2023, and there had been no more incidents since this implementation. When asked if they thought implementing the higher level of supervision at an earlier time could have prevented one or more of these incidents, Staff B stated, yes, absolutely. Reference: WAC 388-97-0640 (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure one of three residents (63) sampled for abuse, remained free from restraint by transfer of the resident to a locked unit that was imposed for purposes of staff convenience. Additionally, the facility failed to comprehensively assess and monitor the need for placement in the facility locked unit and did not disclose to the Power of Attorney the room change was to a locked unit. This failure led to psychosocial harm, which included disorientation to new environment, wanting to get out of the locked unit, and requesting to go back to previous room. Additionally, staff prohibited Resident 63's right to ambulate which led to the diminished right to be treated with dignity. Findings included . Review of the 12/12/2014 Garden Village admission Policy and Procedure for the Specialized Dementia Care showed the unit was a secure area that required a keypad operation to enter or exit the door between the unit and the next hallway in the facility. The unit was designed for residents with middle to late-stage dementia, . these residents roam and rummage and do not recognize personal space . a daily plan is individualized for their personal routine . Residents are assessed for admission to the unit by the interdisciplinary team .and family members participate in the admission decision and invited to tour. Resident 63. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include Huntington's Chorea (inherited progressive brain disorder that causes uncontrollable movements jerking or twitching and affects walking, talking and swallowing), dementia (cognitive decline) and multiple mental health issues. As of 06/07/2022 the resident was on an Extended Care Services Plus (ECS) program. ECS contracted with an outside behavioral health group to provide additional support to the facility for residents that required additional care with mental health services. The resident's 05/31/2022 quarterly assessment showed there was some impairment with cognition, but the resident could answer yes or no questions and did understand what was being asked. The resident was unsteady, impulsive with the jerky movements of their disease and had many falls. Additionally, on 03/28/2022 the resident and another resident previously had been in situations where inappropriate touching took place in the main dining area (Fireside) the resident was moved to a different room. During an interview on 06/14/2022 at 10:00 AM, the resident was in the general population at the facility seated in their wheelchair in the hallway at the medication cart. When asked how things were going, the resident said okay. Their hair was greasy, but they were dressed appropriately and got up out of wheelchair to walk without assistance. Staff reminded the resident to walk with an assistive device and the resident complied. During an observation on 06/15/2022 at 9:00 AM, the resident walked independently with balance issues, holding the side rail in the hallway. The resident asked for coffee and was easily redirected without their wheelchair. During an interview on 06/22/22 at 10:09 AM, Staff O, Licensed Practical Nurse (LPN), stated the resident was admitted (06/21/2022) to the locked dementia unit without an assessment. Staff B, Director of Nursing Services (DNS), made the decision to move the resident into the locked unit. During an observation on 06/22/2022 at 10:00 AM, Staff Y, Nursing Assistant Registered (NAR), was observed through the window of the locked unit moving the resident from the locked door. The resident was standing at the door and asked for the door to open. Staff Y abruptly placed their hand around the resident's arm and turned the resident quickly from a standing to a sitting position in their wheelchair. The resident sat hard into the wheelchair. During an interview on 06/22/2022 at 10:15 AM with Staff DD, Social Services Assistance (SSA), they stated they were not sure why the resident was admitted but there was a conversation about it. During an observation on 06/22/2022 at 10:17 AM, the resident had a distressed facial expression of panic and confusion and wanted out of the unit and was pushing on the door. The keypad code was not easy for the resident to understand how to exit the unit. During an observation on 06/22/2022 at 10:20 AM, Staff Y pivoted the resident from a standing position and impeded her movement then sat the resident in the wheelchair and stated to the resident not to get up. During an interview on 06/22/2022 at 10:54 AM, Staff A, Administrator, stated they were not informed of Resident 63's transfer to the locked unit and that the resident was not appropriate for that level of care. Staff A stated that they were in the facility this past Saturday and spoke with the resident who was redirectable and felt the experience they have had with the resident was positive. Staff A stated that nursing made the decision, and they were not included in the decision and was unaware of the resident's move, therefore it was not a comprehensive decision. During an interview on 06/22/2022 at 11:05 AM, Staff B, DNS, stated they decided to move the resident due to impulsiveness, rummaging and wandering on 06/15/2022 according to the 24-hour shift report. During a telephone conversation on 06/22/2022 at 11:15 AM, Resident 63's POA stated they were aware of a room change. The POA stated Staff Q, SSA, on the afternoon of 06/21/2022 and stated that the resident was being moved to another room. There was no mention of a locked unit and the POA wanted the resident moved back to their previous room. During an interview on 06/22/2022 at 11:20 AM, Collateral Contact for ECS, stated that nursing staff wanted to place the resident into the locked unit but, it was decided not to do that assessment for transfer due to updated care plan interventions to assist the resident and re-direct the resident. The contact stated the resident was aware of their condition, knew what was going on and able to make decisions. The meeting took place on Monday 06/13/2022 with the facility nursing and social services staff and the efforts by nursing to move the resident to the locked unit was vetoed (a decision to rule against) at that time. There was a plan in place to keep the resident in place and provide activities and redirection. During an interview on 06/23/2022 at 7:50 AM, the resident was seated in their wheelchair in the locked unit's dining room and wanted to go back to her previous room. The resident was not in a positive mood, not making eye contact, restless and refused further conversation. On 06/27/2022 at 11:59 AM Staff F, Social Services Director, (SSD), stated they were out last week when the resident was moved to the locked unit. Staff F stated they had a plan to keep the resident on the 100 hall and moved the roommate due to evening shift nursing assistants. Staff F stated the resident rummaged in the roommate's dresser. The resident's roommate was moved last week in with another resident to give a trial to see if the behaviors would reduce. The plan was to monitor and observe behaviors and to use the recommendations from ECS for interventions and then determine if there was more to be done. Staff F further stated they spoke with ECS, and it was determined not to move the resident to a locked unit and nursing was in agreement with the plan. Staff F stated that while they were out last week, nursing made a decision last Tuesday, 06/21/2022, and decided to move the resident to the locked unit without notice or orientation to the unit first. According to Staff F this caused confusion and increased behaviors to the resident. During a follow-up telephone interview on 06/27/2022 at 12:59 PM, the resident's POA stated they had spoken to the resident and asked if they were okay with room change but the resident was hesitant to answer. Additionally, the POA felt the resident needed to return to their previous room on the 100 hall and was upset about how the facility did this move and felt it was out of convenience to the staff. Review of Resident 63's June 2022 Tasks Electronic Health Record (EHR) showed no negative behaviors were documented. Reference WAC 388-97-0620(1)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of sexual abuse to rule out abuse and neglect, protect residents, and prevent further incidents of abuse for two of four sampled residents (4, 69) reviewed for abuse. This failure placed residents at risk for abuse and neglect due to lack of thorough investigations. This caused psychological harm to Resident 69 (expressions of fear and anxiety) related to continued sexual verbalizations by Resident 4. In addition, the facility failed to thoroughly investigate an unwitnessed injury for one resident (272) reviewed for substantial trauma injury to the right eye. Failure to thoroughly investigate the unknown eye injury disallowed an opportunity for evaluation of facility care practices to determine if appropriate care was provided and/or if practices needed to be revised to ensure the protection of the resident. Findings included . Resident 4. Review of the medical record showed the resident was re-admitted to the facility on [DATE] and was a long-term resident. The 05/26/2022 assessment showed the resident was oriented, required limited assistance with cares, and was able to wheel themself around the facility. The resident had behaviors to include delusions, hearing voices, and had been verbally threatening which provoked physical behaviors of other residents. Review of the 05/23/2022 incident report showed around 10:30 AM, a Collateral Contact from Extended Care Services (ECS) witnessed Resident 4 approach and kiss Resident 69. Resident 4 proceeded to inappropriately place their hands up Resident 69's shirt. Resident 69 indicated that they were uncomfortable and did not feel safe. Resident 69 stated that they would keep their distance from Resident 4. Additionally, the report showed that both residents will separate during smoke breaks and both residents were told this type of inappropriate behavior cannot be done in this facility. There were no other interviews from the Collateral Contact except that they told Staff DD, Social Services Assistant (SSA) about the incident. Staff DD and Staff Q, SSA interviewed Resident 4 and 69. Review of the 05/23/2022 progress notes showed that Resident 4 was placed on 15-minute checks for 72 hours. No other interventions were initiated, and Law enforcement was not notified. Review of the 05/24/2022 progress notes showed Resident 4 was being disruptive. They were yelling at their roommate and stated that they did the hiring in the building and wanted them out or the resident would call the cops. During an interview on 06/23/2022 at 10:12 AM, the Collateral Contact for ECS stated that they saw Resident 4 kiss and place their hands up Resident 69's shirt. They then notified social services. The contact was never called or notified to give a statement to the facility for any investigation. Resident 69. Review of the resident's medical record showed they were admitted on [DATE] with a history of mental and behavioral disorders. The 05/25/2022 comprehensive assessment showed the resident was oriented and able to make their needs known, and used a wheelchair for mobility. During an interview on 06/14/2022 at 11:11 AM, Resident 69 stated that there was an incident about a month ago on 05/23/2022. Resident 4 had kissed them and placed their hands up Resident 69's shirt. The resident stated that they were told to stay away from Resident 4. According to Resident 69, Resident 4 continually made sexual comments and it made them nervous, sad, and scared. Resident 69 stated I do not think people here care about me. Review of the 05/27/2022 1:15 PM progress notes showed that Resident 69 was agitated after seeing Resident 4 in the hallway and stated that they did not trust Resident 4. During an observation on 06/14/2022 at 11:20 AM, Resident 4 parked their wheelchair behind Resident 69 and wanted to talk to them. Resident 69 was anxious, and a staff member was asked to remove Resident 4. Resident 272. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behaviors (agitation, including verbal and physical aggression, wandering, and hoarding), delusional (an unshakable belief in something that's untrue) disorders, and depression. The comprehensive assessment dated [DATE] showed the resident required extensive assistance of one to two staff for all Activities of Daily Living (ADL's). The assessment also showed the resident had a severely impaired cognition. An observation and interview on 06/21/2022 at 9:13 AM showed Resident 272, reclined in a tilt-in-space (a wheelchair that reclines while keeping the knees at a 90-degree angle) wheelchair, parked directly across from the nurse's station, with her right side towards the nurse's station. The resident had a blue/purple colored bruise with swelling to the right, upper eye. They were unable to verbalize the source of the injury. When asked what happened to the resident's eye, Staff O, Licensed Practical Nurse (LPN), stated that they were not aware of any injury, even though the resident had AM cares (assisted by staff), ate breakfast in the dining room (assisted by staff), and was sitting directly across from the nurse's station. Review of the facility incident report created on 06/21/2022 at 10:01 AM, showed Staff 0, Licensed Practical Nurse (LPN), documented I observed a black and blue area round their right eye. They did have a fall on 06/11/2022. They had a bruise to their arm and hand when they became physically aggressive with cares. They currently receive Eliquis (a medication that thins the blood to prevent blood clots). During an interview on 06/22/2022 at 9:10 AM, Staff O stated that they were doing an investigation. They stated that a housekeeper had observed the resident sleeping with their arm across their face and that the resident used a Sit-to-Stand (a lift used to assist a resident from the seated to standing position), but there were no reports of injury. Staff O further stated that the resident was on Eliquis (blood thinner medicine used to prevent blood clotting) and that could explain some of the bruising. During a second interview on 06/23/2022 at 9:50 AM, Staff O stated that they were still working on the investigation but were unable to substantiate a cause at that time. They also stated that the injury was reported to Staff NN, Medical Director, and the resident's family. Conclusion of the investigation by Staff O on 06/23/2022 at 10:29 AM, showed that the resident had a large bruise around their right eye. It's unclear how the injury occurred. They had one non-injury fall and an incident in which they were striking out at staff, but those two incidents occurred over two weeks ago. They haven't had any incidents or falls since. They used a wheelchair for all mobility, locomotion. They were transferred using a Sit-to-Stand. The staff haven't indicated that they bumped their head during transferring. The injury was due to unknown origins. The injury was not the result of abuse or neglect. During an interview on 06/23/2022 at 2:05 PM, Staff A, Administrator, stated that Staff O had completed the investigation for Resident 272. During an interview on 06/28/2022 at 11:18 AM, this surveyor asked Staff NN, Medical Director, if they could determine what type of injury the resident sustained to their eye. Staff NN stated the resident was not on the schedule to be seen that day, however this surveyor observed Staff NN assess the injury. Staff NN stated that the resident definitely had some trauma to the right eye, but nursing staff would know better. Review of the resident's care plan dated 06/23/2022, showed the problem, Alteration in Mobility, with the goal of will not have any falls that result in a significant injury, and revised interventions that included: no longer able to ambulate related to medical conditions, Unable to walk in their room, and no longer able to walk related to medical conditions. There were no changes to the care plan with interventions related to the injury to the right eye. Record review of the facility incident report on 06/29/2022 at 10:35 AM showed no further information had been added to the investigation. The investigation regarding the injury to the resident's right eye was not thoroughly conducted as evidenced by incomplete investigative tasks, which included: lack of individual statements by all staff responsible for the care of the resident during the shifts prior to the injury to determine how the injury occurred, timelines of when it occurred, and environmental assessments. The investigation did not determine what had occurred and there were no changes to the care plan related to the eye injury. Reference WAC 388-97-640(6)(a)(b) Reference F-600 Abuse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards for two of three residents (35, and 26) reviewed for quality of care. These failures resulted in harm when the facilty failed to A) Evaluate/monitor and take appropriate measures for one of one resident (35) reviewed for changes in condition. This failed practice resulted in actual harm to Resident 35 who experienced and expressed significant pain/discomfort and (requested to go to the hospital) however, because the resident was on comfort care the facility delayed medical treatment. B) Failed to facilitate timely follow-up/ treatment plan for one of one Resident (26) diagnosed with breast cancer - this delay in treatment resulted in psychological harm as Resident 26 expressed worry and statements that they were not worthy to receive treatment and were going to die. Findings included . Resident 35. Review of the medical record showed the resident admitted to the facility 06/01/2012 with diagnoses of seizures, anxiety and delusions. The record showed the resident had a hospitalization on 04/27/2022 due to sepsis (life-threatening infection) and esophageal erosion (back-up of stomach acid which caused ulcers) and the resident returned to the facility on [DATE]. The 05/31/2022 admission assessment showed the resident had some impaired cognition but was able to make their needs known and required extensive assistance in daily cares. Review of the 05/16/2022 resident's Physican Orders for Life-Sustaining Treament, (POLST ) instructions showed the resident was to have limited interventions such as oxygen, Intravenous fluids (IV-fluids through a vein) and antibiotics (medications to treat infection). The resident had a Power of Attorney (POA). During an observation on 06/21/2022 at 9:33 AM, the resident had vomit on their shirt, down their face and neck and was lying flat in bed covered with a white sheet. The surveyor pushed the call light for assistance on 06/21/2022 at 9:38 AM, Staff GG, Nursing Assistant (NA) arrived to assist Staff CC, NA to clean the resident and change their clothing. During an observation and interview on 06/21/2022 at 10:00 AM, Staff H, Licensed Practical Nurse (LPN) came into the resident's room to change the dressing on the resident's back side. After the dressing change on 06/21/2022 at 10:12 AM, staff moved the resident up in bed and the resident began throwing-up profusely. Staff H stated the resident drank too many fluids and was on a fluid restriction. Review of the resident's May and June 2022 orders did not show a fluid restriction. During an observation on 06/22/2022 at 9:01 AM, Resident 35 was on oxygen, had vomited and was lethargic, sweaty and had stomach pain. The resident stated they wanted to go to the hospital. During an interview on 06/22/2022 at 9:04 AM, Staff H stated that when they came in this morning the resident's oxygen level was 86% room air (normal 95%-100%). The resident continued to express pain and wanted to go to the hospital. Staff H stated to the resident you don't need to go to the hospital and could do a chest x-ray at the facility. The resident clearly stated again they wanted to go to hospital. Staff H kept on repeating that the resident was a Do Not Resuscitate (DNR) but eventually called the physician. The medical record showed the resident was hospitalized on [DATE] with significant dehydration (body does not have enough fluids) with acute kidney failure (kidneys stop working properly) and aspiration pneumonia (food or liquid is breathed into the lungs). The resident was treated with IV fluids and IV antibiotics for aspiration pneumonia. The resident readmitted to the facility on [DATE]. During a telephone interview on 06/27/2022 at 9:33 AM, the resident's POA stated they were not informed by the facility of the resident's change of condition on 06/22/2022 until the hospital called the POA about the resident's admission to the hospital. The POA stated the resident can make decisions about whether to go to the hospital. Resident 26. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include breast cancer, delusional behaviors and was hard of hearing. Review of the 04/06/2022 quarterly assessment showed the resident required assistance with walking, toileting and limited assistance dressing. The resident was cognitively impaired, very hard of hearing and does not always understand what was being said but, at times they were able to express themselves and understand what was being said. During an interview on 06/14/2022 at 8:52 AM, the resident stated that they had breast cancer again. The resident stated, If these people would please explain the treatment I would have taken the chemotherapy (cancer treatment to prolong life or reduce symptoms). Resident 26 stated that the people here could care less if I get treatment or not, they can't be bothered it makes me feel sad. The resident explained that they lost a family member earlier this year and had some sadness about that death. Review of the 04/01/2022 progress note showed Social Services met with Resident 26 and they agreed to a guardian since the resident's POA had passed away and there were no other resident representatives able to take on the responsibility. Review of the resident's 03/21/2022 Radiology reports showed the resident had a mammogram on 02/27/2019 and an ultra-sound done on 03/29/2019, and a mammogram on 11/11/2014. Cancer (masses) were identified in both the left and right breast. On 03/29/2022 a biopsy of the left and right breast was done. Review of the nurse's progress notes showed the resident was scheduled for an appointment at a local cancer treatment center on 05/23/2022. The progress notes showed no follow-up to the appointment. During an interview on 06/23/2022 at 1:40 PM, the resident stated that they wanted cancer treatment and the facility wants me to just die and not do anything. Review of the April, May and June 2022 behavior monitoring notes showed the resident was tearful with a sad affect at least daily. There were no charted interventions with the exception to monitor the behavior. During an interview on 06/27/2022 at 3:13 PM, Staff B, Director of Nursing Services, (DNS) stated that Staff H, Licensed Practical Nurse (LPN) stated the medical director and the cancer center never coordinated or spoke to each other about the cancer treatment plan for cancer for the resident. During an interview on 06/28/2022 at 8:00 AM, Staff H stated the people at the cancer center were all gun-ho and wanted to consult the Medical Director (MD) to get the resident into treatment then nothing happened. During an interview on 06/28/2022 at 10:33 AM, the MD stated that they wanted to try an oral cancer agent but had to go through the oncologist (cancer physician) at cancer treatment center and the MD had not called or made contact with the oncologist. During an interview on 06/28/2022 at 11:18 AM, the resident stated they wanted treatment for breast cancer, but no one will talk to them about it. During a telephone interview on 06/28/2022 at 12:33 PM with a Registered Nurse at the cancer treatment center, stated that they recalled that the resident had come to their appointment on 05/23/2022 with an attendant. The resident was appropriate and spoke with the oncologist and told the physician about more lumps in their breasts and wanted treatment. The resident also stated they had these lumps in their breast for years. Reference WAC: 388-97-1060(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards for one of one Resident (22) who experienced increased care needs when they were no longer able to use an ostomy bag (an opening in the body for the discharge of body wastes into a collection bag) to contain their waste matter. This failure caused physical and psychosocial harm to the resident when they experienced painful burns to their skin from fecal matter (FM) feelings of isolation and despair and placed the resident at risk of infection and potentially other medical complications. Findings included . Resident 22. Review of the medical record showed the resident admitted in November 2020 with diagnoses which included post-surgical procedure for an ileostomy (an opening in the abdominal wall wherein the lowest part of the intestine is brought through this opening - waste no longer comes out of the body through the rectum). Review of the 04/05/2022 comprehensive assessment showed the resident was dependent on one to two staff for transfers, bed mobility and was not ambulatory. The assessment showed the resident was cognitively intact. Review of the Resident's November 2020 hospital discharge orders showed the resident had the ileostomy placed in August 2020 with the intent for the resident to recover and be seen in 3 months to start discussing ileostomy takedown (reversal- the intestine is surgically placed back to exit through the rectum). Review of the resident's medical record from April 2021 to March 2022 showed the facility attempted to schedule the reversal procedure however was unable due to scheduling conflicts. During a concurrent observation and interview on 06/14/2022 at 10:46 AM, the resident was observed in bed with their abdominal/ ileostomy area exposed. Fecal matter (FM) was pooled across the midriff to the corners of the abdomen (approximately 2 1/2 inches in width and 10 inches in length). The area around the fecal pooling showed burned/reddened areas with inflammation (3 inches above and below the FM and along the resident's left side showed an area of approximately 6 inches by 12 inches). The resident stated their skin was burning and wanted medication to control the pain. The resident had a white washcloth which was saturated with thick fecal matter and also a transparent bag, next to the resident on the bed, which contained four to six soiled washcloths. The resident stated see, they do not bring me clean towels or clean me up . they just do not care, you come to a place like this to get care. No one cares here. During an observation and interview on 06/14/2022 at 3:58 PM, the resident was holding a washcloth over the open area which was oozing FM. The resident stated the area was very painful, which was observed to be reddened and inflamed all along the center of the fold of the belly and left side, as observed previously. The resident's hands, shirt and bedding had displaced FM in areas which ranged from less than an inch to over six inches. Observation showed dark matter (FM) beneath the resident's fingernails, on their shirt, call cord and pillow. During an observation on 06/15/2022 at 9:19 AM, the resident was observed holding a soiled washcloth over their abdomen, the cloth was soiled with FM, the fingernails, call cord and pillow had same dark matter (FM) as observed on the day prior. The resident stated they were having pain and showed this surveyor reddened area of abdominal area and side. The ileostomy area was oozing FM which was pooled from one side of the abdomen to the other. The resident stated, I just want to go home, go to heaven . no one cares here. The resident began crying. During an observation and interview on 06/15/2022 at 2:55 PM, the resident was pressing washcloth with a large amount of fecal matter over the abdominal area. The resident asked if they could get something as they were having a great deal of pain/burning in the area. The facility was notified about the resident's pain. During an interview on 06/16/2022 at 11:20 AM, Staff K and Staff CC Nursing Assistants (NAs) stated they were assigned to the resident and that the resident had towels at their bedside to clean up their fecal matter. Staff CC stated that the ostomy bag had been off for a couple of months because the resident had been picking at the tape which held the bag in place. Staff CC stated that NA staff were to check the resident every three hours to ensure supplies were at the bedside and to remove the bag of soiled washcloths as needed. Review of the Resident's 06/16/2022 [NAME] (care plan directed to NAs) showed no scheduled times for NAs to remove the fecal matter from the resident's open and oozing ileostomy area and no interventions to ensure the area was assessed for burn, infection and/or monitored by licensed nurses (LNs). Review of a 03/24/2022 Nurse's progress note showed Ostomy bag left off to allow skin to heal. LN to clean skin and assess healing q [daily] shift prn [as needed]. NAC [Nursing Assistant Certified] cleans abd [abdominal] area with personal care. [Resident] has wet wash cloths & dry cloths at bedside to clean self prn. Review of the Resident's March, April, May and June 2022 Medication Administration Records and Treatment Administration Records showed no orders for Licensed Nurses to clean and assess the area daily nor PRN as shown in the 03/24/2022 progress note . During an interview on 06/16/2022 at 2:58 PM, Staff J, Resident Care Manager stated that the licensed nurses had not been conducting weekly skin checks nor monitoring the area for signs of infection. Staff J stated that the treatment Medication Assistant Certified (MAC - NAC with endorsement to pass medications), Staff P applied skin cream and would tell a nurse if there were changes to the area. Further, Staff J stated there had not been any measurements or assessments of the excoriation/burn from the fecal matter sitting on the skin - that's on me and acknowledged the skin had not been assessed for care/treatment options. Further, Staff J acknowledged the record did not show notification or discussion with the medical director when the decision was made to permanently remove the bag. During an interview on 06/16/2022 at 3:26 PM, Staff B, DNS stated the record showed no specific training to NA staff regarding care to the ileostomy site or additional infection control practices. During an interview on 06/16/2022 at 3:43 PM, Staff RR, MAC stated they regularly provided medication to the resident, I do not do anything with the area, the aides do all that . [Resident 22] frequently asks for pain medication and that the resident told him the pain was from the skin around the ileostomy area. During an interview on 06/17/2022 at 10:00 AM, Staff B, DNS stated there should be weekly nursing assessments of the resident's skin and then Staff B reviewed the Weekly Pressure Sore Progress Report binder for Resident 22. The binder showed no weekly assessments were documented. During an interview on 06/21/2022 at 9:30 AM, Staff P, Treatment MAC stated they had observed the area on Resident 22's abdomen, and a large area on the resident's side to be excoriated and reddened. Staff P further stated that NA staff were to inform them when they provided care to the resident's ileostomy area, so that Staff P could apply ointment. However, there were many times/days that NA staff did not inform Staff P and therefore the application of ointment did not occur. During an interview on 06/21/2022 at 10:10 AM, Staff A, Administrator acknowledged the failure to ensure professional standards of care were adhered to in the care of Resident 22's ileostomy and skin breakdown. Staff A stated that the facility had not had a Director of Nursing Services for a period of time and that staff here function in [NAME]. Staff A stated there were working on correcting the issues. Reference WAC: 388-97-1060(3)(j)(iii)