Every finding on record at Garden Village

Based on observation, interview and record review the facility failed to protect a resident's right to be free from verbal and physical abuse for 1 of 8 residents (Resident 2) reviewed for abuse investigations. This failure placed residents at risk for further abuse, injury, and diminished quality of life. Findings included.Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation revised on 09/13/2022, showed the facility would keep residents free from abuse, neglect, and exploitation of residents and misappropriation of resident property.Resident 1A record review showed Resident 1 was admitted on [DATE] with multiple diagnoses including stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations) and depression. The resident was discharged on 05/26/2026.Review of a 04/26/2026 comprehensive assessment showed that Resident 1 had moderate cognition impairment and required extensive assistance from staff with activities of daily living (ADLs).Review of Resident 1's 05/22/2026 care plan showed they had behaviors related to their anxiety, restlessness, and agitation. The residents' specific behaviors were listed as yelling/screaming, throwing items, and physical aggression.Resident 2A record review showed Resident 2 was admitted on [DATE] with diagnoses to include vascular dementia (a loss of mental ability severe enough to interfere with ADLs) and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).Review of Resident 2's 05/02/2026 comprehensive assessment showed the resident had severe cognitive impairment, verbal behaviors directed toward others and had delusions (a fixed false belief that is resistant to reason or confrontation).Review of Resident 2's 04/29/2026 care plan showed the resident had behaviors related to their dementia. The residents' listed behaviors were verbal aggression, accusations towards staff and rejection of care.Record reviews showed that Resident 1 and Resident 2 were roommates in room [ROOM NUMBER] from 05/20/2026 to 05/25/2026.Record review of a 05/25/2026 investigation report showed that at 10:30 PM, staff heard a noise from room [ROOM NUMBER] and found Resident 2 bleeding from their upper lip. Resident 1 and Resident 2 were each in their beds and a plastic water pitcher was on the floor next to Resident 2. On examination, Resident 2 had a 1.5 centimeter (cm) laceration on their upper left lip area. Resident 2 was moved to another room and one to one staff supervision was provided for Resident 1.Record review of a 05/27/2026 at 8:00 PM progress note showed that social services staff followed up with Resident 2 regarding the incident between them and Resident 1. They reported that Resident 2 felt much better now that the other resident was gone. When asked if they felt safe, Resident 2 responded with yes, now I do.During a concurrent observation and interview on 06/03/2026 at 1:25 PM, Resident 2 was observed in their room, lying on the bed. A 1.5 cm abrasion was noted above their upper lip. They stated, a woman threw a coffee can at my face while asleep in bed. Resident 2 stated that it hurt some at the time and they were very glad that woman was gone.During a telephone interview on 06/04/2026 at 12:05 PM, Resident 1's Representative (RR1) stated that [Resident 1] told them they threw the water pitcher to hit their roommate and could not say why. During an interview on 06/04/2026 at 1:35 PM, Staff A, Administrator, stated that Resident 1 and Resident 2 were roommates for five days and were not aware of any issues between the two of them.Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure residents were assisted with activities of daily living (ADLs) for 1 of 5 sampled residents (Resident 2) reviewed for ADLs. Failure to provide assistance with bathing to residents who were dependent on staff for provision of such care, placed the residents at risk for poor hygiene, embarrassment, impaired skin integrity, and a decreased quality of life. Findings included.Record review of the facility's policy titled, Quality of Life, dated 11/2017, showed the facility would provide the necessary assistance to provide good personal hygiene that included bathing to resident's dependent on staff for their ADLs. If residents refuse assistance with their ADLs, staff were to document the refusal in the resident's medical record. Resident 2 Record review showed Resident 2 was admitted on [DATE] with diagnoses including heart failure (a progressive heart disease that affects pumping action of the heart muscles), respiratory failure and recent cervical spinal fusion (surgery to connect two or more bones in the neck). Resident 2 discharged home on [DATE]. Review of Resident 2's 10/20/2025 comprehensive assessment showed that the resident was cognitively intact, had incontinence of bowel/bladder, and was dependent on two staff for ADLs such as bathing and hygiene. During a telephone interview on 12/02/2025 at 11:35 AM, Resident 2 stated that they did not receive a shower or bath until they had been at the facility for two weeks. They stated they did not recall refusing showers during that time, nor did they recall being offered a shower. Resident 2 stated they got a shower after telling [Resident 2's Representative, RR2] that their perineal area (region located between anus and the genitals) was itching and burning. Resident 2 stated they had a yeast rash (overgrowth of a fungus on the skin that causes itching, redness, and discomfort commonly occurs in warm, moist body areas) and told RR2 they had not showered since admission. During a telephone interview on 12/02/2025 at 11:45 AM, RR2 stated on 10/27/2025 they told facility staff right away when [Resident 2] said they had no showers since admission. RR2 stated the staff gave [Resident 2] a shower that day, I was not happy that this took so long especially with a yeast rash. Record review of a 10/23/2025 at 5:58 PM progress note showed that Resident 2 was examined by the facility physician on 10/22/2025 and received an order for an antifungal (medicine to kill or stop the growth of fungi) treatment to the yeast rash in the perineal area. Review of Resident 2's shower record, in their electronic medical record, showed their first shower was on 10/27/2025. (11 days after admission). Further record reviews showed no documented refusals or alternative bathing methods such as bed/sponge bath in the bathing record, behavior monitoring or nursing progress notes during the first 11 days in the facility. During an interview on 12/17/2025 at 1:00 PM, Staff A, Administrator, stated they reviewed the shower book looking for Resident 2's showers and found the first shower was dated 10/27/2025 in the evening. Record review of Resident 2's Skin/Shower - Bathing Review dated10/27/2025, showed the resident had dry skin on their face and arms and the perineal area was hot/red. The form also included a prompt to document resident refusals after three approaches that included notifying a licensed nurse. During a telephone interview on 12/18/2025 at 3:00 PM, Staff C, Nursing Assistant, stated that they started as evening shift bath aide the middle of October 2025 and gave Resident 2 their shower on 10/27/2025. Staff C stated there was a different shower aide working evenings during the first two weeks Resident 2 was at the facility. Staff C stated when they looked at the shower/bath schedule book they found that Resident 2's name was not entered for Monday/Thursday evening showers until they wrote it down on 10/27/2025. Staff C stated, anyone looking at the book would not know it was [Resident 2's] shower day on the previous Mondays and Thursdays, they were not on the schedule. During an interview on 12/17/2025 at 4:30 PM, Staff A stated Resident 2 should not have gone that long without a shower. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview, and record review, the facility failed to ensure, 1) proper temperatures were consistently monitored accurately and legible for 3 of 4 months reviewed for meals temperatures and 2) equipment surfaces were cleaned and sanitized for 1 of 1 kitchen. This failed practice placed residents at risk for food borne illness.Findings included.Review of the 07/2018 policy titled, Food and Nutrition Services Food Safety, showed the facility would monitor foods for bacterial growth by checking the times and temperatures of foods to ensure safety. During a concurrent interview and record review on 09/02/2025 at 9:22 AM, Staff Y, Dining Services Director, stated they expected food temperatures to be obtained when food was taken out of the oven, right before it was served out, and at the end of serve out to monitor how well the food held heat in the warmers. Staff Y stated the food logs were not completed fully or accurately. A review of the kitchen's food temperature logs showed: In June 2025, 11 out of 93 meal temperatures were not accurately completed with an additional five meals where the temperature readings were illegible. In July 2025, 10 out of 93 meal temperatures were not accurately completed with an additional six meals where the temperature readings were illegible. In August 2025, six out of 93 meal temperatures were not accurately completed with an additional three meals where the temperature readings were illegible. Kitchen Equipment An observation on 09/02/2025 at 9:00 AM, the dual ovens to the right side of the stove had built-up brown, fuzzy, strings mixed with oil on the blades of the vents. An observation on 09/02/2025 at 9:04 AM showed an ice machine to the far-left corner of the entrance to the kitchen. The lid was soiled with dried food and dirt, the vents on the outside of the ice machine had dried, splattered white and brown food particles. Inside the ice machine, there was a white plastic cover in the front of the machine that had pink and black, moist sediment to the front and the creases of the cover. There were no cleaning logs on or around the machine. An observation on 09/02/2025 at 9:24 AM, showed the plate warmer (a machine that holds and heats clean plates prior to putting food on them) had visible food crumbs on the bottom of both sides of the machine. One side of the warmer was empty, and the other side held clean plates. During an interview on 09/08/2025 at 11:32 AM, Staff Z, Cook, stated cleaning of the kitchen and machines was supposed to be completed daily and then initialed by the person who cleaned it. Staff Z stated if the cleaning log had not been initialed then the cleaning had not been done. Staff Z stated there should have never been a time that food temperatures were not obtained or documented correctly/legibly. During an interview and concurrent observation on 09/08/2025 at 12:07 PM, Staff E, Maintenance Assistant, stated the ice machines were to be cleaned on a monthly schedule. Staff E observed the ice machine in the kitchen and the vents to the dual stove and stated they should not have that build up of dust or be soiled, they definitely could use some love. Review of a Work History Report provided by Staff E, for the past six months, March 2025 through August 2025, showed the ice machine had been cleaned twice, on 05/19/2025 and 07/28/2025. Review of the kitchen cleaning log for August 2025 showed daily cleanings of different kitchen items and equipment were to be completed by the AM/PM Cooks. The logs showed 25 different items had not been cleaned on 18 different days for the month. Review of the remaining clean logs provided showed no months, days, or dates as to when those cleanings took place. During an interview on 09/09/2025 at 9:04 AM, Staff Y stated they were aware of the missing entries and dates on the cleaning logs and that was a work in progress. Reference: WAC 388-97-1100(2)(3) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on observation, interview, and record review, the facility failed to ensure components of their infection prevention/control program, to prevent the development and transmission of infections with, A) the facility's water management program Legionella (a bacteria that can cause a severe respiratory disease) testing protocols, and identification of control measures (actions or steps taken) to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) were developed/implemented for 1 of 1 water management program (WMP) reviewed for infection control, B) hand hygiene and glove change when completing resident cares for 3 of 10 staff (Staff AA, BB, K) reviewed for infection control, and C) the cleaning/disinfecting of the facility's environmental surfaces and isolation precautions room (preventative measures used to reduce the transmission of infectious bacteria and organisms in the healthcare setting) with an Environmental Protection Agency (EPA) registered disinfectant reviewed for environmental cleaning/disinfection. This failure increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included .Review of the facility's policy titled, Water Legionella Water Management Program, reviewed September 2025, showed that it applied to all the facility's water systems including, water storage tanks, water heaters, water filters, shower heads, infrequently used equipment, eye wash stations, ice machines and more. The policy showed the facility would identify areas at risk for legionella growth and ensure the necessary maintenance/monitoring was carried out. The policy showed the facility identified areas where Legionella could grow and how they would conduct visual checks of the areas at risk and temperature checks on the facility's hot water distribution. The policy did not include control measures for the facility's ice machines, shower heads, areas of water stagnation (water that stops flowing for an extended period) or infrequently used equipment and eye washing stations. Additionally, the policy did not include how the monitoring of the control measures were being completed, the frequency for monitoring the control measures, the acceptable ranges of the control measures nor the established ways to intervene when the control measures were outside the acceptable ranges. Review of the Center for Disease Control and Prevention (CDC) toolkit titled, Developing a WMP to Reduce Legionella Growth and Spread in Buildings, dated 06/24/2021, showed a facility's WMP should identify areas or devices in the building where Legionella might grow or spread to people so the risk can be reduced. The toolkit showed that parts of a building water system that were a risk for spreading contaminated water included water storage tanks, water heaters, shower heads/hoses, infrequently used equipment like eye wash stations, ice machines, and decorative fountains. Additionally, the toolkit showed that water stagnation encouraged biofilm (a community of bacteria that stick together and to a surface forming a protective layer) growth, which can protect Legionella from heat/disinfectants and was common in water devices that went unused or infrequently used. Review of the facility's policy titled, Infection Prevention and Control Program (IPCP), dated 06/08/2022, showed the facility would maintain an IPCP to help prevent the development/ transmission of communicable diseases and the staff member responsible for the IPCP was the Infection Preventionist (IP). The IP would record identified infections or residents with symptoms suspicious of an infection. The policy showed that facility staff were to perform hand hygiene, even if gloves were used, after contact with blood/body fluids/visibly contaminated surfaces, after contact with objects in a resident's room and after removing PPE. The policy showed that residents isolation precautions would have their environment disinfected routinely using an approved disinfectant. Review of Centers for Disease Control and Prevention recommendations titled, Guidelines for Environmental infection control in Health-Care Facilities, updated July 2019, showed that cleaning and disinfecting environmental surfaces is fundamental in reducing their potential for transmission of diseases. Environmental surfaces can be medical equipment surfaces or .housekeeping surfaces (e.g., floors, walls, and tabletops), and need to go through a cleaning and disinfecting process. Additionally, the guidelines showed that environmental surface disinfectants were regulated by the EPA and labeled with an EPA registration number. During an interview on 09/09/2025 at 9:11 AM, Staff E, Maintenance Assistant, stated the facility did not have a current Maintenance Director. Staff E stated they were not familiar with the WMP but had access to what was being monitored in the facility. Staff E stated they completed water temperatures throughout the facility and presented documentation that showed the control measure was being completed. Staff E stated they had not been overseeing/completing the changing/flushing of the emergency water storage containers, the monthly water systems chlorine residual testing (a test that measures amount of chemical in the drinking water to ensure that it is safe and free from harmful microorganism), nor the weekly flushing/inspection of the eye washing stations. Additionally, Staff E stated the facility's ice machines were to be cleaned monthly, but was unsure if other monitoring/checks were performed in-between the monthly checks. Review of the control measure log documentation presented by Staff E on 09/09/2025 showed, The changing/flushing of the emergency water storage containers was every six months, last performed on 02/21/2025 (18 days late). The monthly water systems chlorine residual testing had not been completed for three of the four scheduled times in August 2025. No documentation presented for September 2025. The flushing/inspection of the eye washing stations had not been completed for 2 of the four scheduled weeks in August 2025. No documentation presented for September 2025. The ice machine, located by the main nursing station, log was last completed 08/06/2025 (three days late). During a concurrent observation/interview continued on 09/09/2025 at 9:11 AM, Staff E and surveyor observed the ice machine located by the main nursing station. Staff E opened the ice machine's storage bins lid and under the inner ice storage retainer plate (to secure or hold different items in place) was a two inch (a unit of measure) by one inch black substance that was noted. Staff E stated the black substance should not be there and the ice machine was not monitored properly. Additionally, Staff E stated the control measure logs for the emergency water storage containers should have been completed on time, along with the flushing/monitoring of the eye stations and the monthly chlorine residual testing. During a concurrent interview and observation on 09/09/2025 at 9:42 AM, Staff B, Director of Nursing Services (DNS), stated they were not familiar with the facility's WMP, control measures, the acceptable ranges for control measures or the testing protocols in place if control measures were not met. Staff B stated look like black mold when the staff member looked inside the ice machine located by the main nursing station. Staff B stated the facility's WMP needed to be fixed. Hand Hygiene, Glove Change Observation on 09/04/2025 at 3:37 PM showed Staff AA, Nursing Assistant (NA) and Staff BB, NA in room [ROOM NUMBER], just completed a mechanical lift transfer of a resident form the chair to the bed for an incontinent brief change. Both staff, after donning (putting on) gloves, assisted in rolling the resident and Staff AA performed a glove change but did not complete hand hygiene. Staff AA then proceeded to perform perineal care (cleaning of the private parts of a resident) then along with Staff BB assisted in rolling the resident again to the other side. Staff BB performed a glove change but did not complete hand hygiene and then proceeded to finish perineal care for the resident. Both staff were conversing/waiting for the nurse to come and assist with the resident rear end wound dressing change that had gotten soiled (dirty or contaminated). Staff AA noticed the resident was unaware of what was happening so, using the same soiled gloves, proceeded to communicate with the resident who was hard of hearing by writing down information on a piece of paper from the resident's bedside table. After finishing the brief change both staff doffed (taking off) their gloves and proceeded to touch/rearranged items on the resident's bedside table, closed the resident's privacy curtain and moved the resident's wheelchair without preforming hand hygiene. During an interview on 09/05/2025 at 4:25 PM, Staff BB stated that when performing incontinent brief changes and moving from a soiled area to a clean area they were required to change gloves and complete hand hygiene. Staff BB stated they had forgotten to bring their bottle of hand sanitizer into the room with them during the brief change in room [ROOM NUMBER]. Staff BB stated they should have completed hand hygiene in between each glove change but did not. On 09/08/2025 at 1:05 PM, Resident 34 received an incontinent brief change from Staff J, Nursing Assistant (NA), and Staff K, NA. While wearing gloves, Staff K removed Resident 34's soiled brief and cleansed the area with disposable wipes. Continuing to wear the same soiled gloves, Staff K redressed the resident, changed bed height with bed remote and put cleansing wipe container away. After tying off the soiled linen bag and waste bag, Staff K removed their gloves and disposed of them in waste container. Staff K then disposed of the bags in the soiled utility room across the hall. Next, without washing their hands with soap and water they entered another resident's room to assist transfer from their wheelchair to bed. Staff K applied clean gloves and proceeded to assist the resident. On 09/09/2025 at 11:13 AM, Staff B, Director of Nursing Services/ Infection Preventionist, stated that gloves should be changed between soiled tasks to clean tasks and hands should also be washed after removing gloves during incontinent care prior to starting new tasks. Environmental Surfaces During an interview on 09/09/2025 at 7:45 AM, Staff B stated that two residents, in the back 400's hallway, were placed on isolation precautions. During an interview on 09/09/2025 at 10:03 AM, Staff EE, Housekeeper, stated they utilized Medline Neutral Floor Cleaner when cleaning the resident rooms and all areas of the facility. During an interview on 09/09/2025 at 10:21 AM, Staff DD, Laundry/Housekeeping Director, stated all the housekeeping staff used the Medline Neutral Floor Cleaner, for the cleaning/disinfecting of all the residents' rooms within the facility. During an interview on 09/09/2025 at 10:50 AM, Staff FF, Housekeeper, stated that on that day they were charged with cleaning/disinfecting in the back 400's hallway. Staff FF stated that they were using the Medline Neutral Floor Cleaner on the two isolation precautions rooms in the 400's hallway and everywhere else in the facility. During a concurrent observation and interview on 09/09/2025 at 10:57 AM, Staff DD along with surveyor observed the Medline Neutral Floor Cleaner and were unable to find an EPA registration number on the chemical. Staff DD stated they were not aware that the chemical was not a registered disinfectant, .we should be using a disinfectant on all the floors of the facility. During an interview on 09/09/2025 at 1:00 PM, Staff A, Administrator and Staff B stated they were not aware the Medline Neutral Floor Cleaner utilized by housekeeping staff within the facility was not a disinfectant. Staff B stated the facility should be using an EPA registered disinfectant when cleaning/disinfection isolation precaution rooms within the facility. Reference: WAC 388-97-1320(1)(a)(2)(b)(5)(d)

Based on observation and interview, the facility failed to provide a safe, clean, sanitary (the conditions that affect hygiene and health) and comfortable homelike environment regarding, A) the cleanliness of resident room Packaged Terminal Air conditioners (PTAC, a through-the-wall system that provides independent heating and cooling to a localized area) units for 3 of 7 resident rooms (301, 302 and 304), reviewed for environment cleanliness, B) soiled shower room ventilation and holes in wall tiles for 1 of 3 shower rooms (300's hallway) reviewed for environment, and C) a gouge (a hole or indentation) in a resident room flooring for 1 of 3 resident rooms (Resident 12) reviewed for a safe environment. This failure placed residents at an increased risk of injury and dissatisfaction with their living environment. Findings included. Review of the facility's policy's titled, Resident Rights Safe, Clean and Comfortable Environment, dated July 2018, showed the facility would provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior for residents. The policy showed the facility would provide residents a safe, clean and comfortable environment that delivered care and services safety and allowed residents to use their personal belongings to the extent possible. Observation in room [ROOM NUMBER] on 09/02/2025 at 3:32 PM showed dried food, crumbs and trash within the ventilation face plate of the rooms PTAC unit. During a concurrent observation and interview on 09/09/2025 at 8:50 AM the PTAC unit for room [ROOM NUMBER] showed a build-up of food crumbs and grime (dirt that is ingrained on the surface of something) within the ventilation face plate. Staff E, Maintenance Assistant, stated they had been cleaning the filters that were part of the PTAC units but not under the ventilation face plate. Staff E and surveyor observed room [ROOM NUMBER]'s PTAC unit and showed a moderate amount of dust build-up and liquid stains from something that spilled on the PTAC unit. Staff E stated the build-up and food particles needed to be cleaned up and could be a safety concern if the heater component of the PTAC unit was used. During an interview on 09/09/2025 at 1:00 PM Staff A, Administrator and Staff B stated the food particles and trash were a hazard within the PTAC units and they expected them to be cleaned out by the maintenance staff. Shower Rooms During a concurrent observation and interview of the 300's hallway shower room, on 09/09/2025 at 9:04 AM, showed two ceiling duct vents with thick dust/grime build-up. Staff E stated, we missed those ones . Observations behind the shower room door showed a black two inch (a unit of measure) one inch hole in the white tile. Staff E stated that the shower room door must have slammed into it and put a hole in the tile. When surveyor and Staff E observed closer, it was noted that the rubber doorstop (a device designed to prevent the door from swinging to far into the wall behind it) was installed incorrectly. Staff E stated the door stop needed to be reinstalled correctly and the tile needed to be fixed. During an interview on 09/09/2025 at 1:00 PM Staff A, Administrator and Staff B stated they were unaware of the shower room's doorstop being installed incorrectly and would need to be fixed. Staff B stated the ceiling ventilation ducts should have been clean and the hold in the tiled wall also needed to be fixed. Safe Environment Observation of Resident 12's room on 09/04/2025 at 4:31 PM showed a large one-foot (ft, a unit of measure) by half-foot area of the linoleum (a flexible and durable floor covering that can be glued down) flooring had a gouge scrapped out of it. The gouged section had three flapped sections of the linoleum that were draped back over the floor to cover the subfloor. During an interview on 09/09/2025 at 9:04 AM, Staff E stated they were aware of the gouged-out section of the linoleum flooring, .it is a hazard, and anyone can trip on that and needs to be replaced. During an interview on 09/09/2025 at 1:00 PM Staff A, Administrator and Staff B stated the gouge in the flooring was a hazard and would expect it to be fixed. Reference: WAC 388-97-3220(1)

Based on observation, interview, and record review, the facility failed to ensure residents were free from interference/coercion (the use of expressed or implied pressure to compel someone to act against their will) in a manner that promoted and/or supported the resident's individual choice in respect to their quality of life, without fear of reprisal, regarding the residents choice to smoke a cigarette for 1 of 3 residents (Resident 4) reviewed for the resident rights. This failed practice placed the resident at risk of increased confusion and/or frustration with facility staff regarding their individual choice to smoke and unmet care needs.Findings included .Review of the facility's policy titled, Physical Environment Smoke Free Facility, revised February 2025, showed the facility was designated as a smoke-free building and a smoke-free campus that would extend to the perimeters of the facility's property. The policy showed that residents smoking paraphernalia (items like cigarettes, electronic cigarette, vaping [inhaling a mist of nicotine from a handheld device] devices, lighters and matches) would need to be surrendered to facility staff to keep in a locked box until signed out. Residents were to be informed of violations of the facility's smoking policy that could place the resident at risk for discharge due to a safety threat and possible danger to other residents/individuals in the facility. Additionally, the policy showed, The non-smoking policy will be included in the admission packet and explained to new residents as part of the admission process. The smoking policy showed no information on smoking assessments or a process for facility residents that chose to continue to smoke cigarettes or new residents who chose to smoke, and how to safely dispose of them. Resident 4Review of the resident's medical records showed they were admitted on [DATE] with diagnoses including a fracture of their left arm, depression and anxiety. The 08/05/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 4's hospital documentation showed the resident was brought in 03/12/2025 after they had a fall and was found to have a shoulder injury and was admitted . The records showed Resident 4 smoked cigarettes every day and last attempted to quit 13.2 months ago. Review of Resident 4's signed admission documentation, dated 05/01/2025, 05/06/2025, and 05/09/2025 showed no documents regarding the facility's smoking policy and/or rules had been signed or given to the resident or their representative. Review of Resident 4's provider note dated 05/09/2025, showed the resident had been smoking for over 30 years, since they were [AGE] years old and had quit smoking cigarettes two to four months prior (between January 2025 to March 2025). During a concurrent observation and interview on 09/02/2025 at 12:01 PM, Resident 4 was observed in the dining room with their motorized wheelchair. Resident 4 stated that on an unknown date they had made the choice to smoke a cigarette, off of the facility's property, and the facility staff saw the resident smoking and stated they were in violation of the facility's smoking policy and would be discharged or transferred out to another facility if the resident did not switch to vaping. Resident 4 showed the surveyor their vaping device and observed the resident's ability to hold/maneuver the device, which weighed more than a cigarette, without complications. The resident stated they were currently using the vape device instead of smoking a cigarette, I don't want to leave. Resident 4 stated they were always smoking off the facility's property and still got my butt in trouble. Review of Resident 4's smoking evaluation, dated 08/25/2025, showed that Resident 4 smoked one to two times a day, liked to smoke in the afternoons/evenings, was cognitively intact, could communicate with others effectively, was able to demonstrate the ability to physically hold a cigarette, could call for help in the event of an emergency, and was able to light their cigarette safely. The evaluation also showed that Resident 4 was unable to retrieve their cigarette if it was dropped, and unable to demonstrate a safe technique for extinguishing their matches/lighter nor disposing of their cigarette ashes safely. The smoking evaluation determined that Resident 4 was unsafe to smoke independently, and that .we are a smoke free facility . The smoking evaluation did not include information on how the resident could dispose of the cigarette ashes safely or if the resident was able to demonstrate safe technique after education from staff on proper disposal of their cigarette ashes. During an interview on 09/05/2025 at 12:24 PM, Resident 4's representative (RR), stated facility staff had caught Resident 4 smoking about a week ago, off the facility's property and because of that, was going to send the resident somewhere else (as in transferring and/or discharging Resident 4 for smoking a cigarette). The RR stated the facility staff did not want Resident 4 to smoke at all, even off of the facility's property (Resident 4) wanted to try cigarettes again. Review of Resident 4's progress notes for August and Sep 2025 showed: 08/25/2025 at 3:27 PM, Staff Q, Social Services Director, stated on 08/22/2025 Resident 4 was observed taking a pack of cigarettes out of their pocket and was informed of the facility being a .100 percent non smoking facility . Resident 4 mentioned they had been unaware of this rule, so Staff Q educated them about having cigarettes in the building and provided the resident with a locked box to store the cigarettes. 08/25/2025 at 10:40 AM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), discussed events on 08/22/2025, the smoking policy and that by having possession of smoking paraphernalia, the resident was breaking the facility policy. Resident 4 stated they were holding onto the cigarettes for someone else and that they did not smoke. Staff D asked Resident 4 to hand over the cigarettes to the staff member or the RR, and the resident handed over two packs of cigarettes. Staff D stated, .however; I could visibly see more in (Resident 4's) purse. I told (Resident 4) I saw another pack, and (Resident 4) reluctantly (without really wanting to) handed me one more . 08/25/2025 at 1:00 PM, Staff B, Director of Nursing Services (DNS), stated the resident was noted to make their way out the front entrance of the facility, utilized their motorized wheelchair to go off the facility's property, and pulled out a cigarette and lighter from their phone pouch. Staff B stated, .Resident was asked if nursing staff could assess for smoking assessment to which resident allowed . and the resident stated they disposed of the cigarette butts (the end of the cigarette which is usually discarded after use) onto a rocky area down the road. Staff B stated they observed Resident 4 .improperly dispose of ashes and was immediately educated on proper disposal, strict adherence on safety measures, and sign in/out procedures. (Resident 4) was receptive to feedback, discussed tentative plan-as (Resident 4) failed to meet safe smoking practices. 08/25/2025 at 4:21 PM, Staff A, Administrator, and Staff B, informed the resident that based on the smoking assessment completed by Staff B, the resident was not safe to smoke. Resident 4 informed both staff that they would not smoke anymore and did not want to vape but would request a nicotine patch if the resident needed it. Staff A informed the resident that if they .were discovered to be smoking unsafely, we would potentially be discussing a discharge notice . 08/29/2025 at 12:28 PM, Staff A had observed Resident 4 smoking on the sidewalk .upon resident's return to facility, resident initially denied smoking until informed that (Resident 4) was witnessed . Resident 4 informed the Administrator they were smoking off of the facility's property .so there is nothing wrong with that , and Staff A stated they were aware that Resident 4 was non-compliant with the facility's smoking policy, had been informed of the facility smoking policy, and the resident had failed the smoking safety assessment. Staff A informed the resident that they would be looking for alternative placement. During an interview on 09/05/2025 at 3:20 PM, Staff A showed documentation that the facility became a smoke-free facility and implemented the smoking policy on 05/05/2025. Staff A was unsure when the facility residents were informed of the change in policy. Review of the facility's records showed that a meeting was held with the facility's known smoking residents on 07/02/2025 to discuss the transition of the facility to a smoke-free facility. No documentation showed that Resident 4 attended the meeting. During an interview on 09/05/2025 at 3:54 PM, the RR stated the resident was smoking prior to their hospital stay in March 2025 and that Resident 4 felt the facility staff were getting pretty upset with the resident for smoking cigarettes, even though they were off the facility's property. During an interview on 09/08/2025 at 10:26 AM, Staff R, Medical Records, stated they did not have any record of Resident 4 signing the facility's non-smoking policy nor was it given in the resident's admission paperwork. During an interview on 09/08/2025 at 10:52 AM, Staff G, Activities Director, stated the facility moved to a smoke-free facility in May 2025 and started reviewing the smoking policy for residents that previously smoked on 05/08/2025. Staff G stated that previous, current, or new facility residents were no longer allowed to smoke cigarettes at all while they were a resident at the facility. During a concurrent interview on 09/08/2025 at 10:53 AM, Staff A and Staff B stated some residents were still smoking off of the facility property. Staff A stated that residents who smoked had a smoking evaluation completed and the evaluation would explain why a resident was able to smoke independently. Staff A stated that residents had a right to smoke, but the facility wanted them to be safe when smoking. Staff A stated that a smoking receptacle for disposing of cigarette butts had been placed outside last week, before the survey team arrived. Both staff were aware of Resident 4 smoking cigarettes off of the facility's property, had observed Resident 4 smoking cigarettes, and documented progress notes on the resident. Staff B stated that Resident 4 was not safe to smoke independently, due to the resident improperly disposing of their cigarette ashes during the smoking evaluation and was unable to pick up the cigarette butt if the resident had dropped it on the ground. Staff B stated that Resident 4 was able to dispose of the cigarette butts on their own but the resident .should not be discarding it a couple of blocks away . The progress note made by Staff B on 08/25/2025 at 1:00PM was reviewed and Staff B stated they immediately completed education on the proper disposal/safety measures and yes the resident was receptive to the feedback/able to understand. Staff A stated based on the completed smoking evaluation by Staff B, Resident 4 posed a safety risk with smoking independently, so discussed with the resident/RR if the facility's smoking policy was not followed then the resident could potentially be discharged . Staff B stated they did not discuss with the resident how they could safely/properly dispose of their cigarette to smoke independently. Staff B stated that even though Resident 4 was admitted prior to the 05/05/2025 implementation of the facility's non-smoking policy they never indicated they wanted to smoke. During an interview on 09/08/2025 at 11:52 AM, Staff D, LPN/RCM, stated the resident had been utilizing their motorized wheelchair to travel outside since June 2025. Staff D stated they assessed the residents smoking evaluation along with the DNS on 08/25/2025. Staff D stated the resident was outside, off of the facility's property and the staff asked the resident to demonstrate how they would dispose of the cigarette ashes, so the resident demonstrated, right where everyone was at (off of the property, not by rocks), but would normally dispose of them in a rocky area. Staff D stated Resident 4 was cognitively intact and knew the rocky area was correct which showed they were aware of the potential for fire hazard, even so, it was improperly disposed of at that time. Staff D stated the resident would not be able to pick up a cigarette if it were dropped, but the resident did have a grabber (a device used to pick up items that are out of a person's reach), that even though the resident did not have on them at the time that would assist the resident in independently smoking. Staff D stated they remembered talking with Resident 4 about getting a little receptacle for (Resident 4's) wheelchair to put cigarette butts in. Staff D stated the resident was safe as long as they disposed of the ashes in the proper place. During an interview on 09/08/2025 at 2:35 PM, Staff C, Regional Clinical Director, stated the facility did not have documentation that all the facility residents or their RRs were informed about the non-smoking policy implementation nor was the smoking policy included in the admission paperwork given to residents. Staff C stated that Resident 4 should have been reassessed for safe smoking independently after they were receptive to the feedback/education provided by staff. Staff C stated the resident could have utilized their grabber to assist in independently smoking as safely as possible. Reference: WAC 388-97-0180(4)(b)

Based on observation, interview and record review the facility failed to protect the personal privacy for 2 of 4 residents (Residents 34, 72) observed for incontinent brief change and blood glucose checks (a blood test that measures the level of glucose (sugar) in the blood, the test can involve a finger prick, a nurse collects a drop of blood, the test involves a test strip and glucometer (glucose meter) with results in seconds). This failure placed the residents at risk for loss of the right to personal privacy. Findings included . Record review of the facility policy, Resident Rights Privacy and Confidentiality, dated 07/2018 showed each resident had the right to privacy during personal care and medical treatments. Resident 34 Review of a comprehensive assessment, dated 05/22/2025, showed Resident 34 had severe cognitive impairment, dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and an anxiety disorder (the mind and body's reaction to stressful, dangerous, or unfamiliar situations). Resident 34 was dependent on staff for their activities of daily living (ADL) that included personal hygiene and dressing. On 09/02/2025 at 11:03 AM, Resident 34 received an incontinent brief change from Staff F, Nursing Assistant (NA), in their bedroom. Staff F undressed, cleaned and dressed the lower half of the resident's body without pulling the privacy curtain around the bed. Resident 34's bed was positioned closest to the door, and their roommate was in bed by the window. The room door was closed. There were privacy curtains that hung from ceiling tracks for both beds, neither curtain was drawn to protect the view of the resident's body from Resident 34's roommate to the room entrance, in the event that someone entered the room. On 09/08/2025 at 1:05 PM, Resident 34 received an incontinent brief change from Staff J, NA and Staff K, NA. The resident's privacy curtains were not drawn to provide the resident privacy from anyone entering the room or from their roommate. On 09/09/2025 at 10:45 AM, Staff P, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated they expected staff to provide privacy during incontinent care. Staff P stated, The door should be closed. The privacy curtain dawn around the bed and if there were a roommate, the curtain should be closed to prevent view from the roommate. Resident 72 Review of a comprehensive assessment dated [DATE], showed Resident 72 had severe cognitive impairment, dementia and diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time). Record review of an 08/01/2025 physician's order showed an order to check Resident 72's capillary blood glucose (CBG) with a glucometer before meals and at bedtime. On 09/02/2025 at 12:15 PM, Resident 72 was eating their lunch in the dining room with other residents and Staff L, Licensed Practical Nurse (LPN), came in and knelt next to Resident 72 with a glucometer. Staff L stated I need to check your blood sugar to Resident 72 and the resident held out their right index finger. The nurse pricked the resident's finger and placed a drop of blood on the glucometer test strip and read the result. Resident 72 then returned to eating lunch. On 09/04/2025 at 8:44 AM, Staff N, LPN, stated Resident 72 was the only resident on the unit that required CBG checks, and when asked where they would perform the task, Staff N stated, out here in lobby or their room. On 09/04/2025 at 11:56 AM, Resident 72 was asleep in a chair in the lobby across from the nurse's station. Staff N pulled up a chair next to the resident and asked Resident 72 if they could check their blood sugar. Resident 72 gave a verbal ok and Staff N performed the CBG check in the common area without providing the resident privacy. On 09/08/2025 at 1:22 PM, Staff O, LPN stated Resident 72 refused their CBG check when approached in the dining room at lunch. Staff O stated [Resident 72] let me do it this morning when they were still in bed. On 09/09/2025 at 10:45 AM, Staff P, stated resident BCG checks should be done in the resident's rooms for privacy. On 09/09/2025 at 11:13 AM, Staff B, Director of Nursing Services, stated the resident's privacy should be protected during incontinent care by completely closing the privacy curtain around the resident's bed. Staff B stated treatments and procedures should not be done by staff in common areas but within the resident's room. Reference: WAC 388-97-0360(b)(d) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on interview, and record review, the facility failed to monitor person-centered behaviors and obtain informed consent when they received psychotropic medications (medications capable of affecting the mind, emotions, and behavior) for 2 of 5 residents (Residents 9 and 27) reviewed for unnecessary medications. This failed practice placed residents at an increased risk of receiving medications they did not want or they no longer needed and inadequate dosing of medications. Finding included . Resident 9 Review of Resident 9's medical records showed they admitted on [DATE] with multiple mental health diagnoses to include violent behaviors, hallucinations (false perception of objects or events involving your senses that seem real, but they are not), depression (a persistent feeling of sadness and loss of interest in activities that were once enjoyable), and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome). The 06/10/2025 comprehensive assessment showed Resident 9's cognition was moderately impaired and received psychotropic medications. Review of Resident 9's 07/03/2025 Care Plan (CP), showed a mood and behavior CP with interventions on 11/18/2024 to monitor episodes of behaviors, determine the underlying cause, and then document in the resident's record. The CP showed target behaviors would be monitored every shift. The CP additionally showed a 03/29/2023 Behavior Monitor focus that contained interventions initiated 09/06/2022 for system listed behavior monitoring and on 11/18/2024 Resident specific [person-centered] behavior monitoring dated 11/18/2024. Review of Resident 9's July through August 2025 Medication Administration Record (MAR), showed they received an order dated 01/02/2025 for Sertraline (a brand of medication used to treat depression) and an order on 03/07/2025 for Olanzapine (a brand of medication used to treat hallucinations). The July, August, and September 2025 MAR showed no person-centered behaviors were being monitored. Review of Resident 9's consents for psychotropic medications (education that provides the risks and the benefits of the medication, giving the resident an opportunity to consent or decline receiving the medication based off of that information) showed no consent was obtained for the Sertraline medication. During an interview on 09/08/2025 at 3:54 PM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) stated they participated in monthly psychotropic meetings to discuss whether medications were appropriate for a resident to continue taking or whether they were appropriate for a reduction/discontinuation of the medication. Staff D stated they would review the resident's behaviors and talk with staff to determine what was appropriate. Staff D stated they did not see person-centered behavior monitoring for Resident 9 and did not know why. During an interview on 09/08/2025 at 1:05 PM, Staff B, Director of Nursing Services (DNS), stated they could not find that a consent had been obtained for Resident 9's Sertraline medication and would have expected one to be done prior to the start of the medication. Resident 27 Review of Resident 27's medical records showed the resident was originally admitted on [DATE] and readmitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a complex mental health disorder that includes symptoms of hallucinations and delusions [false beliefs, not based in reality] along with mood disorders, such as depression and abnormally elevated/extreme changes your mood or emotions), anxiety, depression and drug induced tremors (a specific symptom that can occur from taking antipsychotic medications [a drug used to treat hallucinations and/or delusions] and is characterized by involuntary shaking of the hands, arms, head or eyelids). The medical record showed the resident was receiving behavior health services (a program that provides intensive behavioral and medical support). The 07/17/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known. Review of Resident 27's physician's orders showed monitoring for adverse side effects (undesirable or harmful response to a medication) of their psychotropic medications but did not include monitoring of the resident's behaviors for the effectiveness of the medications. Review of Resident 27's September 2025 MAR, showed Resident 27 was being administered Risperidone, Perphenazine and Fluoxetine (all specific types of psychotropic medication) for their schizoaffective disorder/ depression and all were started on 08/01/2025. The September 2025 MAR did not include monitoring for individualized resident-centered behaviors related to their schizoaffective disorder and/or depression diagnoses, to see if the medication was effective or not. Review of Resident 27's CP, July 2025 to September 2025, showed they had a mood and behavior CP related to the resident's schizoaffective disorder, depression and anxiety. The CP showed/listed targeted behaviors (also known as specific individualized, resident-centered behaviors) and they were to be monitored every shift. During an interview on 09/09/2025 at 11:15 AM, Staff D, LPN/RCM, stated that residents on psychotropic medications had individualized resident-centered behaviors that were monitored. Staff D stated that monitoring of behaviors was completed on a resident's MAR and some residents had general system selected and other resident's had resident-centered behaviors. Staff D stated they did not see that Resident 27's had orders in place for behavior monitoring nor were they noted on the resident's MAR. Staff D stated that Resident 27s general system selected behavior monitoring dropped off the resident's orders/MAR during their last hospitalization and that it was not restarted when the resident readmitted on [DATE]. During a continued interview on 09/09/2025 at 11:37 AM, Staff D confirmed that Resident 27's individualized resident-centered behaviors were not being monitored. During an interview on 09/09/2025 at 1:00 PM, Staff B, DNS, stated the facility had, in general, system selected behavior monitoring for all residents. Staff B stated that residents, like Resident 27, which had behavioral health services and were on psychotropic medications were to have monitoring and documentation on the resident-centered individualized behaviors. Staff B stated the correct process was not being followed regarding the monitoring of Resident 27's individualized resident-centered behaviors. Reference: WAC 388-97-1060(3)(k)(i)

Based on interview and record review, the facility failed to follow up on written notices of bed holds, (holding or reserving a resident's bed while the resident was absent from the facility) with resident and/or resident representatives (RR), given at the time of hospital transfers for 2 of 2 residents (Residents 27 and 82) reviewed for the discharge process. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed, any monetary charges associated with the bed hold while in the hospital and disallowed the resident and/or their representative an opportunity to fully understand the rationale/resident rights associated with the discharge. Finding included .Review of the facility's policy titled, Notice of Bed Hold Policy Before/Upon Transfer, revised November 2018, showed the facility would provide written information to the resident or RR on the bed hold policy, the reserve bed payment policy, policies regarding bed hold duration periods and information related to the resident's ability to return to the facility. The policy showed the information would be provided before a transfer or at the time of transfer of the resident to the hospital or within 24 hours if the transfer was an emergency. Review of the undated facility's guidelines titled, Hospital Transfer Packet, showed that copies of the bed hold policy, authorization to reserve a room/bed, and the notification of transfer were in a packet that was to be sent with the resident to the hospital. The guidelines stated that if the resident was unable to comprehend the information, then the RR should be notified. Facility staff were to make a progress note about the bed hold policy being reviewed with the resident or the RR and if unable to review, the progress note would show that the bed hold policy form was sent with the resident to the hospital and staff would be following up with resident/RR with 24 hours. Resident 27 Review of the medical record showed the resident was re-admitted to the facility on [DATE] with diagnoses including diabetes (a disease that affects how the body uses blood sugar), anxiety, depression and other mental/behavioral health disorders. The 07/17/2025 comprehensive assessment showed the resident had moderate cognitive impairments but was able to make their needs known. Review of the resident's progress note showed that on 07/17/2025 at 11:44 AM, nursing staff had received abnormal laboratory results, communicated with the facility's provider/resident and the resident was transported via ambulance to the hospital where they were admitted . The progress note showed the .hospital paperwork . was given to the paramedics. The documentation showed no written bed hold information was provided to the resident or their RR before/at the time of the resident's transfer to the hospital. During an interview on 09/08/2025 at 9:34 AM, Staff D, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), stated that the bed hold policy, included in a hospital packet, was provided to the resident/RR when transferring out to the hospital and the documentation would be in a progress note. Staff D reviewed Resident 27's progress notes and stated they did not see the resident or the RR were informed of the bed hold policy when the resident was transported to the hospital on [DATE]. Resident 82 Record review of a comprehensive assessment dated [DATE] showed Resident 82 had severe cognitive impairment, stroke (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living). Resident 82 was dependent on staff to meet their physical and cognitive needs. Review of a 07/19/2025 at 12:56 PM nursing progress note showed Resident 82 had a significant change in their condition and was transported to the hospital by ambulance and admitted . Review of the documentation in the resident's medical record showed no written notification that the resident or their representative received a bed hold notice. On 09/08/2025 at 2:43 PM, Staff Q, Social Services Director, stated their department was no longer part of the bed hold process and believed that now medical records handled the process. On 09/08/2025 at 2:56 PM, Staff R, Medical Records, stated they were aware residents were given a packet with the bed hold policy by the nurse sending them to the hospital. The nurse was to write a progress note that the bed hold policy was provided. On 09/09/2025 at 11:13 AM, Staff B, Director of Nursing Services, stated there was a break in system we will be improving the process. Reference: WAC 388-97-0120(3)(c)(4)(a)(b)(c) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on interview and record review the facility failed to ensure the safety and supervision of 1 of 3 residents (Resident 61) reviewed for accident risks. The facility's failure to implement their missing resident protocol when Resident 61 did not return from an outing with family at their indicated time put the resident's health and safety at risk. Findings included.Review of an undated facility policy titled, Actions for Suspected Resident Elopement/Missing Resident, showed when a resident had signed out and not returned to the facility at the indicated time, they were considered a missing resident. The protocol required the charge nurse to immediately make several telephone calls to locate the missing resident as follows: 1) Call the resident's contact phone number provided by the responsible person at sign out, 2) Call the Administrator and Director of Nursing Services (DNS) if unable to make direct verbal contact with the resident, 3) Call 911 (emergency services) and request a well-check at the resident's last known location, and 4) Call hospitals to identify if the resident was present. Resident 61 Review of a comprehensive assessment dated [DATE] showed that Resident 61 had impaired memory, depression, a chronic inflammatory lung disease that causes obstructed airflow from the lungs, and they required substantial assistance from staff for most activities of daily living and transfers. Record review of Resident 61's sign in/sign out sheet showed the following information at the top of the form for the person signing the resident out of the facility: 1) I acknowledge and accept responsibility for the safety and care of the Resident while away from the facility. 2) All residents on an outing must return to the facility by the expected time of return. If the resident had not returned by the expected time and cannot be reached by phone, the facility staff will notify police and implement the missing resident protocol. The last line on the sign out sheet showed the resident left with family on 09/03/2025 at 9:45 AM with an expected time of return at 8:00 PM. On 09/04/2025 at 2:00 PM during the facility annual recertification state survey, Staff A, Administrator, was asked about a missing resident incident that had been reported to the state hotline. Staff A stated that there was a missing resident who was signed out by family the previous morning. They stated Resident 61's failure to return to the facility was noted by staff at change of shift (evenings to nights). Staff A stated they were made aware of the missing resident last night shortly after 2:00 AM. The resident had not yet been contacted; however, Resident 61 had a history of leaving Against Medical Advice (AMA) on a previous admission. The police and their staff were currently working on locating Resident 61. Review of the facility investigation dated 09/04/2025 showed the following events: -On 09/03/2025 at 6:16 PM, Staff S, Registered Nurse (RN), was informed by the day shift nurse that Resident 61 was out with family. -On 09/03/2025 at 10:30 PM, Staff T, LPN, was informed by Staff S that Resident 61 had not returned from their outing with family. -On 09/03/2025 at 11:29 PM, Staff T texted Staff B, DNS, that Resident 61 had not returned to the facility (3.5 hours after their return time). -On 09/04/2025 at 2:08 AM, Staff B read the text from Staff T, called the facility and learned Resident 61 was still out. Staff B implemented the missing resident protocol and called 911 at 2:34 AM (6.5 hours past their return time). During an interview on 09/04/2025 at 4:55 PM, Staff B, stated that Resident 61 was located at the residence of a friend. Staff B stated they found Resident 61 at 3:45 PM in their wheelchair, watching television with a friend and stated they were fine and would not be returning to the facility. Staff B stated they had emergency services come to the house to assess the resident, the resident signed AMA paperwork. Supports were put in place such as medication, follow up physician appointment and a referral for home health. Staff B stated the facility staff failed to follow the missing resident protocol that delayed ensuring the safety of Resident 61. On 09/09/2025 at 11:24 AM, Staff B stated they completed the investigation on Resident 61. Staff B stated, our system did not work, the staff did not follow the policy for a missing resident, there were delays in reporting to administration and the staff should have telephone called me and Staff A, not leave a text. Reference: WAC 388-97-1060(3)(g) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on observation, interview, and record review, the facility failed to consistently implement interventions for 1 of 2 residents (Resident 9) reviewed for nutrition. This failure placed the resident at risk for continued significant weight loss and the loss of nutritional satisfaction. Findings included.Resident 9 Review of Resident 9's medical records showed they admitted with diagnoses to include dementia (a loss of thinking, remembering, and reasoning skills), malnutrition (inadequate intake of protein and/or energy over prolonged periods of time resulting in loss of fat stores and/or muscle wasting) and most recently, neck and tonsil cancer (06/06/2025, a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body). The 06/10/2025 comprehensive assessment showed Resident 9's cognition was moderately impaired, was independent for eating, complained of difficulty or pain with swallowing, and had no issues with weight loss. Additional review of Resident 9's medical records showed the resident had received weekly chemotherapy (a drug treatment used to kill cancer cells or stop them from growing) and daily radiation (a method using high powered energy beams to kill cancer cells) treatment for their neck and tonsil cancer at a local cancer center. During an interview and concurrent observation on 09/03/2025 at 8:32 AM, Resident 9 was observed sitting in their wheelchair (w/c) at their bedside table with their breakfast tray in front of them, their neck and lower part of their face was bright red. Resident 9 had scrambled eggs, crumbled sausage, dry cereal, canned pears in a bowl, a container of yogurt, and to drink they had a glass of milk, orange juice, and a cup of coffee. Resident 9 stated they tried to eat but it was painful to swallow. Resident 9 stated it was easy to get down the water and the coffee, but it was difficult to drink the milk. During an interview on 09/04/2025 at 9:21 AM, Resident 9 was lying in their bed and stated they were unable to eat any of their breakfast again today. The resident stated they were able to drink the milk today but nothing else. Resident 9 stated the staff did not offer them an alternative to not eating breakfast and stated their swallowing was a little better today but not good enough to eat. During an interview and concurrent observation on 09/04/2025 at 11:58 AM, Resident 9 was sitting in their w/c in front of their bedside table. Resident 9 had a five out of a ten pain level to their throat (on a numerical scale with zero being no pain at all and 10 being the most excruciating pain ever felt) and was able to drink the milk but nothing else. Resident 9 had soft noodles with some grounded up brown meat and soft vegetables on their tray, untouched. Resident 9 stated the staff had not offered them an alternative nor did they ask them what they would be able to eat or if they wanted something else to eat. During an interview and concurrent observation on 09/05/2025 at 12:18 PM, Resident 9 was sitting in their w/c at the bedside table with their meal tray placed on the nightstand beside their television. Resident 9 stated they could not eat because it was too painful to swallow, but that they were hungry. Resident 9 stated they received a medication that they would swallow, and it would offer them pain relief for a short time but then their throat would go back to being painful. Resident 9 stated no staff had discussed their weight loss, diet, or meal refusals with them to determine a different plan. Review of Resident 9's weight tasks from 08/05/2025 through 09/05/2025 showed on 08/05/2025 the resident weighed 212.5 pounds (lb., a unit of measurement) and on 09/05/2025 they weighed 185.5 lbs. The weight tasks showed Resident 9 had a 12.71 percent weight loss (27 lbs.) in the past 30 days which was a significant weight loss. During an interview on 09/05/2025 at 12:29 PM, Staff V, Nursing Assistant, stated that when a resident did not eat the meal served, they should be offered the alternative meal. Staff V stated if the resident did not want the alternative meal either, they had other options they could offer for example a sandwich, or yogurt. Staff V stated they were unaware Resident 9 had not been eating. During an interview on 09/05/2025 at 12:40 PM, Staff W, Registered Dietician (RD), stated they would obtain a generated report, once a month, that showed which residents had weight loss/gain. Staff W stated they attended nutritional meetings once a week and notes were completed by the Unit Managers during those meetings. Staff W stated they had not reviewed Resident 9 themselves in the past two weeks but had discussed Resident 9 at the nutrition meeting earlier that day (09/05/2025). Staff W stated the resident had experienced some increased pain and did not alert the staff to that, so they only received their pain medication as needed, and it had been changed to more of a routine schedule. Staff W stated they had discussed a plan with the RD outside cancer provider, and they had given some recommendations to help with Resident 9's weight loss that they had implemented. Staff W stated one of the interventions was a high calorie supplement that was being supplied by the cancer center and nutritionally enhanced meals. Review of the RD from the cancer provider notes on 08/11/2025 showed the resident was a potential risk for significant weight loss but had not yet met the criteria. The note showed the resident should avoid spicy/acidic foods, eat small amounts at a time, eat lukewarm or room temperature foods rather than very hot or very cold foods, and suggested adding gravy or sauce to their foods for extra moisture. The note showed the resident was educated on good oral hygiene with frequent brushing and rinsing as they could tolerate it and their weight was 209 lb. Additionally, review of a note on 08/25/2025 showed the resident's weight had dropped to 192 lb. (a loss of 17 lbs since prior weight) and had severe calorie malnutrition. The note showed the same interventions that were listed on the 08/11/2025 visit. The note also showed a call was made to Staff W and it was discussed that Staff W would ensure Resident 9 would be started on nutritionally enhanced meals, snacks offered between meals, and Staff W would review downgrading the resident from a mechanical soft diet to a pureed diet as needed. During an interview on 09/09/2025 at 8:50 AM, Staff Y, Dining Services Director, stated nutritionally enhanced meals (NEM) meant a resident required extra protein and calories so staff would add extra protein portions, mighty shakes, magic cups, or super cereal (all NEM supplements) to the resident's diet. Staff Y stated if a resident required extra protein or calories, it would be reflected on the bottom of their diet slip. Review of Resident 9's 09/08/2025 diet slip showed the resident would receive orange juice (an acidic juice) and at the bottom of the diet slip the resident would receive salt and pepper and citrus fruit. The diet slip showed no NEM, extra snacks, no acidic or spicy foods, to add gravy/sauces as needed, or to offer lukewarm or room temperature foods as needed (11 days after the call with the outside RD). Review of Resident 9's 07/03/2025 Nutritional care plan showed no nutritional interventions had been added to the care plan or updated since 07/03/2025 nor had the texture of the diet been assessed or changed. Review of Resident 9's meal monitoring from 08/10/2025 through lunch on 09/08/2025, a total of 89 meal opportunities, showed Resident 9 ate less than 25 percent of their meals 28 times, less than 50 percent of their meals 9 times, 75-100 percent of their meals 33 times, 5 meals not documented, and 14 meals the resident refused or was not available. Review of nutrition meeting notes showed on 08/06/2025, resident was stable, and weight was 212.5 lbs. A note on 08/25/2025 (19 days from previous assessment) showed there was a conversation with the dietician at the cancer center and Resident 9's intake had decreased due to their swallowing difficulties and that a nutritional supplement would be offered in between meals. A note on 09/05/2025 (11 days after previous note) showed Resident 9 was on a very high calorie boost drink from the cancer center, was eating more over the past week and to obtain a re-weigh. The notes showed no other interventions. During an interview on 09/08/2025 at 3:54 PM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated they reviewed residents with weight loss/gain weekly and they would document in the nutrition notes. Staff D stated they were currently offering Resident 9 high calorie boost shakes supplied by the cancer center and ensured a snack went with them on their treatment days. Staff D stated they had not discussed intake alternatives with Resident 9, if they should continue to lose weight. Staff D stated they had not requested, nor had they seen the dietician notes from the previous cancer treatment appointments. During an interview on 09/09/2025 at 2:44 PM, Staff B, Director of Nursing Services, stated when a resident would go out of the facility for an appointment, they were sent with a post visit order slip that they should return with for any new orders. The RCM would then process the orders, and then medical records should have requested the visit notes from the providers for the RCMs to review. Reference: WAC 388-97-1060(3)(h) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident 9) were free of unnecessary drugs due to lack of monitoring and care planning of high-risk cancer (a disease in which some of the body's cells grow uncontrollably and spread to other parts of the body) medication. This failed practice placed the resident at risk of adverse side effects and unmet care/personal needs.Findings included.Review of Lippincott Nursing Procedures 8th edition, dated 2019, titled Chemotherapeutic [a drug that kills cancer cells] Drug Administration, Special considerations, showed for 48 hours after receiving a chemotherapy drug, the resident's feces and urine would be contaminated and required special handling for washing clothes and linens and feces and urine, and hand washing would be completed often. The guidelines showed healthcare workers who were pregnant, were trying to become pregnant, or breast-feeding should not be exposed to chemotherapy drugs. The guidelines showed adverse side effects (ASE) were unique to the medication being administered so monitoring needed to be specific. Resident 9 Review of Resident 9's medical records showed they admitted with diagnoses to include dementia (a loss of thinking, remembering, and reasoning skills) and cancer of the neck and tonsil (06/06/2025). The 06/10/2025 comprehensive assessment showed Resident 9's cognition was moderately impaired and had pain or difficulty with swallowing. During an interview and observation on 09/04/2025 at 9:21 AM, Resident 9 was lying in bed, their lower part of their face/skin from below the eyes down to the beginning of the chest was bright red. Resident 9 stated they had pain to the areas that were red and difficulty eating due to their chemotherapy and radiation (a method using high powered energy beams to kill cancer cells) treatments. On the entrance of Resident 9's door was a sign for Neutropenic [decreased white blood cells that help to fight off infections] precautions, which directions were to wear a mask if sick, if you are visiting, check with the nurse first, and no plants or flowers. The sign showed no precautions for the chemotherapy treatment. Review of Resident 9's cancer treatment notes on 07/08/2025 showed Resident 9 would start weekly treatment of Cisplatin (a brand of chemotherapy medication) plus XRT (radiation treatment) was to begin on or around 07/21/2025. During an interview on 09/04/2025 at 9:27 AM, Staff GG, Certified Medication Assistant, stated they were responsible for monitoring Resident 9. Staff GG stated they monitored Resident 9 for pain and if they had pain, they would notify the nurse. Staff GG stated there was no other monitoring being completed that was specific to the chemotherapy and/or the radiation treatment they received. Staff GG stated there was a commode in Resident 9's room and the precautions they were monitored for were posted on the door. An observation on 09/04/2025 at 11:58 AM, showed Resident 9 used the commode in the corner of their room, to the left of the big picture window. Resident 9 did not use toilet paper or complete hand hygiene after using the commode and sat back at their table to continue their lunch. Review of Resident 9's September 2025 Medication Administration Record showed no monitoring for ASEs for the chemotherapy medication. During an interview on 09/09/2025 at 1:49 PM, Staff HH, Licensed Practical Nurse, stated they monitored Resident 9 for infection and neutropenia. Staff HH stated they did not know what chemotherapy medication Resident 9 received nor the specific precautions for the chemotherapy medication. Review of Resident 9's 07/03/2025 care plan (CP) showed no resident specific CP had been created for the use or monitoring of cisplatin. The CP showed no handling of linens/urine/feces/clothing after treatment, or the use of the bedside commode. The CP showed no special staff restrictions for pregnancy, possible pregnancy, or breast feeding. The CP showed no contact information for staff to contact if issues from the chemotherapy should arise. During an interview on 09/08/2025 at 4:25 PM, Staff D, Licensed Practical Nurse/Resident Care Manager, stated Resident 9 had chemotherapy treatment weekly and radiation treatment daily. Staff D stated they had developed a cancer treatment care plan but was not specific to the resident, the medication they received, nor did the care plan show who to contact in case there were issues or an emergency related to their cancer treatment. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review the facility failed to maintain an effective pest control program ensuring that flies (an insect that can develop/breed in various environments, rapidly reproduce and known for spreading diseases) were not entering/gathering in hallways and resident rooms for 1 of 4 Hallways (Hall 3 [H3, 300's rooms]) reviewed for environment. This failure placed the resident at risk of infection, infestation (the state of being overrun by pests) and unmet care needs. Findings included .Review of the facility's policy titled, Physical Environment Safe, Functional, Sanitary Environment, dated July 2018, showed the facility would maintain an effective pest control program (measures to eliminate and contain common household pest like roaches, ants and flies) to control pests and rodents.Resident 12 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including kidney complications, history of a stroke with dysarthria (speech disorder that occurs when the muscles used for speech are weak or difficult to control, leads to slurred or slow speech that can be hard to understand), and multiple wounds that required daily dressing changes. The 08/11/2025 comprehensive assessment showed the resident had some cognitive impairment but was able to make their needs known. During a concurrent observation and interview on 09/04/2025 at 8:09 AM, showed on H3, Resident 12 was lying in their bed. Multiple flies were observed buzzing around the resident's face and bed. The flies would land on the resident's beard/mustache, lips, head, arms, bedsheets near the resident's legs and on the bedside table. The resident communicated with the surveyor in writing and stated the flies had been in their room since they were admitted on [DATE].During a concurrent observation and interview on 09/04/2025 at 4:01 PM, showed on H3, Staff L, Licensed Practical Nurse (LPN), Resident 12's room for a wound care dressing change. Two flies were observed buzzing around the resident's face and mouth, and Staff L was waving their hand to get the flies away from the resident. During the dressing change Staff L stated, ah fly! (swatting at the fly in the air). Staff L stated they had been seeing more of the flies in the past month.During an interview on 09/09/2025 at 8:42 AM, Staff E, Maintenance Assistant, stated the facility had flies that started coming into the facility around the middle of June 2025 like every year. Staff E stated the flies would come into the facility when staff would leave open the outer door to the parking lot, where the garbage cans were at, because that was where all the supplies brought into the facility would come through and was located across from H3. Staff E stated they had placed two fly control devices up in the facility two weeks ago, because the one by the main entrance was broken. Staff E stated that three more of the fly control devices went up after the surveyors had entered the facility on H1/H2/H3, and then Staff E added two more outside the two main outer doors that went to the facility's parking lot. Staff E stated they should have started putting up more fly control devices up in the facility in June 2025 and it would have been more effective in controlling the number of flies in the facility.During an interview on 09/09/2025 at 1:00 PM, Staff A, Administrator, stated they had noticed the increased number of flies in the facility and had been looking into the facility pest control company, but they were unable to do anything. Staff A stated they started putting up fly control devices within the last week, due to the increase of the flies in the building.Reference: WAC 388-97-3360(1)

Based on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 3 of 3 days of the survey period. This failed practice prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff. Findings included .During an observation on 09/05/2025 at 10:30 AM, there were no nursing staff postings within the facility available for the residents/resident representatives, staff or visitors to view the actual staff available to provide resident care. During an observation on 09/08/2025 at 1:36 PM, the facility had no nursing staff postings viewable for residents, family or visitors to show actual available staff to provide resident care. The nursing staff posting was found within a binder along with the nursing staff assignments for the day. The nursing staff posting did not reflect any staffing changes. During an observation on 09/09/2025 at 2:38 PM, a nursing staff posting was hanging up in the nursing station, not viewable to residents and visitors. The nursing staff posting did not reflect any staffing changes. In an interview on 09/09/2025 at 2:41 PM, Staff H, Staffing Coordinator, stated they had a binder for the nursing staff postings, and the binder also contained nursing staff assignments for the current day. Staff H stated they were new to their position and were not aware that the nursing staff posting needed to be available for residents, family, and visitors to view current staffing available for resident care. In an interview on 09/09/2025 at 3:01 PM, Staff B, Director of Nursing Services, and Staff A, Administrator, acknowledged that the nursing staff posting had not been readily available for residents, family, or visitors to view the current nursing staff available for resident care. Reference: WAC 388-97-0020

Based on interview and record review, the facility failed to ensure the facility assessment (a required document describing resident population, acuity, and needs to determine staff and other resources necessary to completely care for residents) was updated to include and consider specific staffing needs for each resident unit/each shift and plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs. Findings included . A review of the Facility Assessment, dated August 2025 did not show documentation of residents' acuity or specific staffing needs (resources) for each resident unit in the facility and staffing needs for each shift. It showed they did not have documentation on how the facility would develop and maintain plan to maximize recruitment and retention of direct care staff. In an interview and record review on 09/04/2025 at 1:40 PM, Staff A, Administrator, stated they reviewed the Facility Assessment annually and as needed, and that they expected it to be completed as required. Staff A stated the facility assessment had not specifically included the correct staffing needs based on the overall resident acuity, and population needs of the facility. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure that direct care staffing information, including information for agency and contract staff, was electronically submitted to the Centers for Medicare and Medicaid Services (CMS), for 1 of 3 quarters (3rd quarter of 2024), reviewed for Payroll Based Journal (PBJ, mandatory reporting of staffing information based on payroll data) submission. This failure caused the CMS to have inaccurate data related to nursing home staffing levels and had the potential to impact resident care and services. Findings included . Review of the Certification and Survey Provider Enhanced Reports (CASPER) Payroll-Based Journal Staffing Data Report showed the facility failed to report data for the period of July 1, 2024, through September 30, 2024, as required. During an interview on 04/16/2025 at 1:42 PM, Staff C, Business Office Manager, stated that they were responsible for reporting the PBJ data in 2024. The 3rd quarter report was the last one they transmitted, and now corporate accounting were responsible. During a telephone interview on 04/16/2025 at 2:00 pm, Staff D, Director of Business Intelligence at corporate, stated they were looking at the CASPER and it showed the data was not submitted and there should have been a report sent back that the submission went through to CMS. During an interview on 04/16/2025 at 2:05 pm, Staff C stated they could not remember if they ran the report and were not aware the submission did not go through. During an interview on 04/16/2025 at 2:20 pm, Staff A, Administrator, stated they were not the administrator at that time, and this was the first they were aware CMS did not receive the staffing data for 3rd quarter of 2024 Reference: WAC 388-97-1090(1)(2)(3) This is a repeat citation from the Statement of Deficiencies dated 04/05/2024.

Based on interview and record review, the facility failed to notify the physician and resident representative for 1 of 4 residents (Resident 2) reviewed for falls. This failure placed the resident at risk for a delay in medical treatment and of not having a resident representative involved in health care decision making. Findings included . Record review of the facility's policy titled, Notification of Changes of Condition, dated 07/2018, showed that the facility would inform the resident representative and the resident's physician changes in condition or accidents resulting in injury. Record review of the facility's policy titled, Accident Hazards Supervision Devices, dated 07/2018, showed that when a resident experienced a fall, the facility would assess for injuries, provide necessary treatment, address risk factors and revise the resident's care plan as needed. <Resident 2> Record review showed Resident 2 was admitted to the facility on [DATE] with diagnoses to include cerebral vascular accident (stroke, when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and hemiplegia (paralysis to one side of the body). Review of the 12/02/2024 comprehensive assessment showed Resident 2 had moderate cognitive impairment, required substantial physical assistance from staff for transfers and was at risk for falls. Review of the 12/10/2024 care plan showed the resident was at risk for falls due to confusion and unaware of safety needs. The resident had interventions in place to reduce their risk of falls. Record review of a 02/03/2025 incident report showed Resident 2 had a fall on 01/22/2025 that was not reported to facility management, the resident's physician or resident representative until 02/03/2025. Review of a 02/03/2025 witness statement, Staff C, Registered Nurse (RN) and agency nurse, showed they were Resident 2's nurse on 01/22/2025 and had started the post fall paperwork; however, they did not document in the resident's electronic health record (EHR). During an interview of 03/06/2025 at 12:55 PM, Staff D, Licensed Practical Nurse (LPN) and agency nurse stated they started work at the facility in December 2024. Staff D showed where the fall packets were at the nurse's station and stated they would follow all the steps when a resident had a fall. They stated that should the resident require assessment and treatment at the hospital, they would call the physician and the resident's representative to notify of the fall and need to go to the hospital. If there was no apparent injury, they would put a communication form in the doctor rounds file and report to the oncoming shift notifications that still need to be made. Record review of an example of the Post-Fall Checklist showed steps required after resident falls that included: -the event was entered into the EHR, -date and time the director of nurses notified, -date and time the medical provider was notified, -place the resident on alert charting for three days. Record review of Resident 2's progress notes from 08/30/2024 to 02/03/2025 showed the last documented fall was on 10/16/2024. During a telephone interview on 03/10/2025 at 9:10 AM, Resident 2's representative stated they were not notified of Resident 2's fall until a week later. During an interview on 03/06/2025 at 3:25 PM, Staff B, Director of Nurses, stated that when Staff C worked night shift on 01/22/2025 and responded to Resident 2's fall they started filling out the fall packet forms with the resident's head to toe exam, vital signs and neuro checks; however, Staff C had a family emergency that morning, did not give report to the next shift and the forms they started were not found until 02/03/2025. Staff B stated they were not aware Staff C had left abruptly and would have expected notification via a phone text message at a minimum. Reference: WAC 388-97-0320(1)(a) This is a repeat citation from the Statement of Deficiencies dated 10/29/2024.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised for 1 of 3 residents (Resident 1) reviewed for care plan revisions after a significant change. This failure placed the residents at risk for injury and unmet care needs. Findings included . Review of a policy titled, Comprehensive Care Plans, dated 11/2017, showed the care plan was comprehensive, person-centered, and would drive the type of care and services a resident would receive. The care plan would describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences, and how the facility would assist in meeting those needs. The Minimum Data Set [(MDS) a federally mandated assessment tool that helps nursing homes evaluate the health and functional capabilities of their residents] would be used to assess the resident's clinical condition, cognitive and functional status, and use of services in developing the comprehensive care plan. The care planning process would be an on-going process; care needs and interventions would be communicated to direct care staff. <Resident 1> Review of the medical record showed Resident 1 was readmitted to the facility on [DATE] with diagnoses including a left neck of the femur (the narrow, cylindrical portion of the thigh bone that connects the ball-shaped part of the bone to the long, straight part of the bone) fracture. The 12/09/2024 Significant Change comprehensive assessment showed Resident 1 required substantial/maximum assistance of one staff member for activities of daily living and dependent (helper does all of the effort; resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity ) on one to two staff for transfers from the bed to a chair. The assessment also showed Resident 1 had a severely impaired cognition. Record review of a nursing Functional Data assessment dated [DATE], showed Resident 1 was dependent for sit to lying and chair/bed-to-chair transfers. Record review of Resident 1's comprehensive care plan revised 11/18/2024, showed transfer equipment - gait belt (a device used to prevent falls). There were no additional interventions related to Resident 1's transfer needs, including how many staff members were required for a safe transfer. During an observation on 12/18/2024 at 12:15 PM, Staff C, Nursing Assistant (NA), entered Resident 1's room to assist them from their bed to their wheelchair for lunch. Staff C was observed reviewing Resident 1's Kardex (a brand name for an informational filing system that is used as a quick reference for resident care needs) to see how Resident 1 transferred from a bed to a wheelchair. Staff C was unable to locate the information and asked Staff D, Licensed Practical Nurse (LPN), how the resident transferred. Staff D stated they did not know but if Staff C needed help to let them know. At 12:21 PM, Staff C was still in the hallway outside of Resident 1's room. They asked Staff E, NA, if Resident 1 used the sit-to-stand (a mechanical lift that helps residents transfer from one seated surface to another). Staff E stated no, (they) can kind of stand and turn to the chair. Staff C asked if Staff E knew Resident 1's weight bearing status. Staff E replied no. Staff F, NA, came to Resident 1's room to assist Staff C with the transfer. Staff F stated, I was told (they) can stand and pivot. Staff F lifted Resident 1's legs off the bed as Staff C assisted Resident 1 to sit at the edge of the bed. Staff C placed both of their arms under Resident 1's arms and lifted Resident 1 off of their bed and placed them into their wheelchair. Neither Staff C nor Staff F used a gait belt. Resident 1 stayed in the seated position during the transfer and did not place either foot on the ground. During an interview on 12/19/2024 at 1:27 PM, Staff G, LPN, stated Resident 1 had a fracture of their left hip. Staff G stated staff should have used two staff members and a gait belt to transfer the resident. Staff G stated the information for transfers should have been updated on Resident 1's care plan , that would then be reflected on the Kardex for the NAs to see. During an interview on 12/19/2024 at 1:44 PM, Staff H, MDS Coordinator, stated they completed a significant change MDS when Resident 1 had a change in their ability to transfer and needed additional help with personal care. They stated it was their normal process to update the care plan with changes immediately after they completed the MDS. Staff H stated they missed this, I should have updated it. During an interview on 12/20/2024 at 10:31 AM, Staff A, Director of Nursing, stated the process for care plan revisions was the nursing staff/unit manager should be updating the care plan upon readmission of the resident. They stated they were unsure why that was not completed for Resident 1. Reference: WAC 388-97-1020(4)(f)(5)(b)

Based on observation, interview, and record review, the facility failed to ensure residents received assessments and supervision for 2 of 5 residents (Resident 84 and 143) reviewed for elopement/missing person, implement risk assessments and supervision for 1 of 3 residents (Resident 73) reviewed for hot liquids, and implement safety interventions for 1 of 2 residents (Resident 12) reviewed for smoking to prevent accidents and hazards. This failed practice placed residents at risk for accidents, injuries, and the potential risk of fire. The lack of a system to ensure the elopement process was followed timely, resulted in an Immediate Jeopardy (IJ) when Resident 84 went missing from the facility between the hours of 11:30 PM on [DATE] and 2:00 AM on [DATE], and was later located at 8:11 AM on [DATE] deceased in the community. Additionally, Resident 73 experienced harm when they were served hot coffee without a lid and suffered a second-degree burn (involves the first two layers of skin, may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin). On [DATE] at 3:57 PM the facility was notified of an IJ at, F689 42 CFR S483.25(d)(1)(2), Free from accidents and adequate supervision, when a resident left the facility unattended and unaccounted for without staff knowledge. It was determined that the IJ began on [DATE] and the immediacy was removed on [DATE] with an onsite verification from investigators. The facility removed the immediacy by Nursing staff identifying all residents at risk for elopement who also had diagnoses of Substance Use Disorder (SUD, the inability to control the use of a particular substance or substances despite harmful consequences) and updated the care plan, implemented education on the elopement/missing person policy and process, identifying and recognizing at risk resident's and the process for resident's who wished to access the community. All education was to be completed prior to all staff's next scheduled shift. The measures put in place by the facility ensured that all staff were educated and trained and all at risk residents were identified. Findings included . <Elopement/Missing Person Policies> Record review of an undated facility policy titled Elopement, showed the elopement procedure was to ensure that in an event a resident was missing every measure possible would be taken to ensure the safe return of that resident. The policy directed the staff to immediately: .overhead page the code word for all staff to report to the named location. Begin searching inside, outside and surrounding areas in a block radius. If unable to locate after following directives in attempt to locate resident, the Administrator and Director of Nursing Services needed to be notified, and staff were required to call 911 . Record review of a policy titled Quality of Care, Accidents/Hazards/Supervision/Devices, dated ,d+[DATE], showed .the facility would recognize the high-risk nature of the facility population and setting. All level of staff would be trained on safety and individualized care plans with interventions would be developed to reduce the potential for accidents. Evaluate for a history of SUD on admission, develop an appropriate care plan with interventions to address risk . Additionally, the policy showed for wandering and elopement risk residents the facility would: .Identify potential safety issues for residents who wander, evaluate to identify root cause, develop a care plan for those identified at risk with interventions to minimize the risk of a resident leaving a safe area . <Hot Liquids Policy> Record review of the facility's policy titled, Hot Beverage Temps dated [DATE], showed hot beverages must not exceed a temperature of 160 degrees Fahrenheit (F) when leaving the kitchen and prior to placing on serving cart, the temperature will be monitored with an environmental thermometer to assure the 160-degree F temperature. <Smoking Policy> Review of the policy titled Smoking Policy for Independent and Supervised dated ,d+[DATE], showed residents assessed to smoke supervised and/or assisted would have their smoking materials kept by staff in a large lock box. The policy showed residents assessed to not be independent would be provided assistance/supervision during all smoking activities. Lastly, the policy showed there would be no smoking or use of smoking allowed on the grounds except for in the Fireside Courtyard (the patio used for smoking at designated times). <Elopement/Missing Resident> <Resident 84> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including encephalopathy (a brain disorder that effects how the brain functions, thinks, feels, and acts), myoclonus (brief, sudden, and involuntary muscle jerks or twitches that a person cannot control, and diabetes (a chronic condition the occurs when the body has high levels of blood sugar). Review of the [DATE] comprehensive assessment showed the resident required the assistance of one staff member for activities of daily living (ADLs) and had a moderately impaired cognition. Record review of the [DATE] admissions assessments showed no elopement risk assessment had been completed for Resident 84 on admission. Record review of the care plan dated [DATE], showed no care plan was in place for SUD/Elopement. Review of a progress note dated [DATE] at 9:05 AM, showed Staff F, Social Service Director, (SSD), was notified that Resident 84 was missing and 911 was called with a description of the resident. During an observation on [DATE] at 9:08 AM, a Code Vegas (a code word for a missing resident) was called over the facility intercom system for Resident 84. Upon entering Resident 84's room (112) the television was on, the blanket and sheet were pulled back on the bed, and the bathroom was clear. All staff started searching inside the facility for Resident 84. An observation and concurrent interview on [DATE] at 9:10 AM, showed staff expanded the search to the outside and the surrounding areas. Staff C, Administrator Designee, (AD), stated Resident 84 was last seen at midnight and was not recognized as missing until their Significant Other (SO) came to take them out around 8:30 AM. Staff C stated the facility had called the police. During an Interview on [DATE] at 9:12 AM, Staff CC, Nursing Assistant (NA) and Staff M, Licensed Practical Nurse (LPN), stated they did not know what Code Vegas meant and had to ask other employees. Staff CC and Staff M stated it was not normal for Resident 84 to leave the facility without checking out. During an interview on [DATE] at 9:16 AM, Staff B, Director of Nursing Services, (DNS), stated they had last seen Resident 84 at 11:30 PM last night on [DATE]. Staff B stated they were unaware what time they were last seen by staff after that. Staff B stated they were notified of Resident 84 missing between 8:15 AM and 8:30 AM on [DATE] when their significant other (SO) came to take them out for an appointment. During an interview on [DATE] at 9:53 AM, Staff B stated Resident 84 was found deceased by Local Law Enforcement (LLE) at 8:11 AM that morning. Staff B stated Resident 84 always signed out when they were leaving, and this was the first time they had left on their own. Staff B stated the process was for staff to visually observe and provide care for the residents every two hours. During an interview on [DATE] at 10:10 AM Staff M, LPN, stated they noticed Resident 84 was missing when they did their first rounds at 7:20 AM. Staff M stated they checked Resident 84's room, the 100, 200 hallway and an outside perimeter check and did not find Resident 84. Staff M stated they were waiting to see if the SO came to the facility at the scheduled outing time before calling them. Staff M stated the SO came to the facility between 8:10 AM and 8:15 AM. Staff M stated the SO went into Resident 84's room and noticed they were not there. Staff M stated the SO had not heard from Resident 84 since bringing them back to the facility the previous night. Staff M notified Staff B, and the administrative staff completed a search of the facility and the grounds. Staff M stated when Resident 84 was not found, Code Vegas, the missing resident alert was sent out (at 9:08 AM). During a telephone interview on [DATE] at 10:51 AM, Staff O, NA, stated they were assigned to the 100 hallway and were responsible for Resident 84 during the night shift on [DATE]. Staff O stated they were short staffed, and were the only NA assigned to the 100 hallway with 25 residents to care for. Staff O stated the last time they had seen Resident 84 was between 1:00 AM and 2:00 AM in the lobby, by the front entrance, watching television. Staff O stated Resident 84 did not have a history of leaving the facility on night shift. Staff O stated they started their last rounds at 4:00 AM and did not see Resident 84 in their room (112), as the blankets on Resident 84's bed were pulled down and they just assumed they were somewhere in the facility. Staff O stated they should have notified the nurse, but they did not think nothing of it. Staff O further stated they had not had any training on what to do for an elopement or a missing resident. During a telephone interview on [DATE] at 1:48 PM, Resident 84's SO stated they got to the facility between 8:,d+[DATE]:00 AM that morning to pick up Resident 84 for an appointment. The SO stated two NAs approached them on their way to Resident 84's room and stated Resident 84 was not in the facility. The SO stated this caught me by surprise. The SO stated Resident 84 would never leave the facility without them or another family member. The SO stated they verified the resident did not leave with any other family. The SO stated the last known communication they had knowledge of was an electronic transaction that was made by Resident 84's bank card close to 6:00 AM. The SO stated they were upset they had not been notified when Resident 84 was first noticed missing. The SO further stated they were informed from LLE close to 9:15 AM that Resident 84 was deceased . During an interview on [DATE] at 4:35 PM, Staff PP, NA and Staff HH, NA, stated they had not received any training on hire or during their employment on the process if a resident went missing. Staff PP and Staff HH stated they did not know what Code Vegas meant and they were not educated how to initiate that process. Review of the employee files showed Staff PP had a hire date of [DATE] and Staff HH had a hire date of [DATE] During an interview on [DATE] at 4:46 PM, Staff QQ, Maintenance Director, stated they had recently completed an elopement drill ([DATE]). Staff QQ further stated they were unsure if new employees received the elopement training on hire. Record review of the Employee Participation Log for an elopement drill completed by Staff QQ, dated [DATE], showed 16 of the 144 staff members participated in the drill. Staff O, Staff M, Staff K, LPN/Unit Manager, Staff PP and Staff HH, were not on the participation log sign in sheet. During an interview on [DATE] at 10:47 AM, Staff E, LPN/Minimum Data Set Coordinator, stated their process was to do an elopement risk assessment the day of admission on all new residents. Staff E stated they did not complete an elopement assessment on Resident 84, and they did not follow the correct process. During an interview on [DATE] at 9:33 AM, Staff B stated the process for an elopement/missing resident was to notify the nurse immediately to ensure the elopement process was implemented in a timely manner. Staff B stated Staff O and Staff M did not follow the correct process for the elopement/missing resident, Resident 84. <Resident 143> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including stroke (occurs when blood flow to the brain is cut off, which can damage and kill brain cells), frontal lobe deficit (causes personality changes, difficulty concentrating or planning, and impulsivity), diabetes, and psychoactive substance abuse (the use of illegal/legal drugs or alcohol for purposes other than for which they are meant to be used, or in excessive amounts). The [DATE] Brief Interview for Mental Status (BIMS, a standardized assessment tool that's used to screen the cognitive functioning of residents), showed Resident 143 had moderately impaired cognition. Review of a nursing progress note, dated [DATE], showed the resident required the assistance of two staff members for ADLs. Record review of the care plan, dated [DATE], showed no care plan was in place for SUD. Review of a progress note, dated [DATE], showed Resident 143 left the building at 4:30 PM on the afternoon of [DATE] and verbalized to staff they were leaving with their family member. Review of a progress note, dated [DATE] at 11:15 PM, showed Resident 143 had not returned from their outing. An elopement drill was started at 11:15 PM by Staff K. All staff completed a search of the facility and Resident 143 was not found during the drill. Further review of the progress note showed no notification to the administration or LLE. Review of a progress note, dated [DATE] at 1:54 AM, showed Resident 143's family member was contacted by Staff K. Staff K wrote the family member verified the resident was not with them or any other family member (nine hours and 54 minutes after Resident 143 left the facility). Review of a progress note, dated [DATE] at 7:02 AM, showed Staff K called 911 and provided a description of the missing resident (14 hours and 32 minutes after Resident 143 left the facility). During an interview on [DATE] at 8:00 AM, Staff C stated they had another missing resident last night ([DATE]), Resident 143. Staff C stated they went out for an outing and never returned. During a telephone interview on [DATE] at 11:18 AM, Resident 143's representative stated they did not pick Resident 143 up from the facility and they were concerned that Resident 143 was still confused from the stoke and did not have any identification on them. Resident 143's representative further stated they had called other family members, and was told the resident was not with them, and no other family members had picked Resident 143 up from the facility. During an interview on [DATE] at 9:33 AM, Staff B stated the process for elopement/missing person for Resident 143 was not followed correctly by Staff K. During a follow up interview at 12:54 PM, Staff B stated, Staff K had not notified LLE in a timely manner. Staff B stated LLE located Resident 143 and the resident informed them they had no plan to return to the facility. <Hot Liquids> <Resident 73> Record review showed Resident 73 was admitted with diagnoses to include dementia (a loss of mental ability severe enough to interfere with normal ADLs), and depression. Review of the [DATE] comprehensive assessment showed the resident had severe cognitive impairment and was independent with meals. Record review of a [DATE] nursing admission assessment showed Resident 73 was identified as a safety risk for impaired cognition related to dementia when drinking hot beverages and required lids on their coffee cups. Record review of Resident 73's care plan, dated [DATE], showed they required lids on their cup when drinking hot beverages. Record review of a [DATE] incident report showed at 7:40 AM on [DATE], Resident 73 was served coffee with cream and sugar by Staff JJ, NA, from a coffee carafe in the dining room. There was no lid on the cup and coffee spilled in the resident's lap. Record review of a [DATE] skin assessment showed a second-degree burn measuring 4.7 centimeter (cm, a unit of measure) by 1.8 cm on the right middle thigh and 5.5 cm by 4.0 cm on the left thigh with intact blisters. On [DATE] at 12:04 PM Resident 73 was observed seated in their wheelchair (w/c) eating lunch on an overbed table. Resident 73 appeared comfortable with no facial expression of discomfort. Staff KK, NA, stated Resident 73 now had lids on their coffee cups after the spill this morning and had been doing fine. During an interview on [DATE] at 11:16 AM, Staff B stated Resident 73 had a hot liquid assessment that required lids on their coffee cup. The coffee carafe temperature was 157 degrees Fahrenheit (F, unit of measure) right after the spill. Resident 73 did not express they were in pain, so they obtained an order for routine Tylenol for the next four days. During an interview on [DATE] at 9:14 AM, Staff R, Dietary Manager, stated the coffee carafes went out to the dining rooms at about 6:00 AM and they had not been consistently checking the temperatures prior to leaving the kitchen. Staff R stated the carafes should not go out above 160 degrees F for resident safety. During an observation on [DATE] at 11:22 AM, Staff LL, LPN, removed the dressings on Resident 73's inner thighs. The blisters were now flat, and the skin showed no drainage or signs of infection. During an interview on [DATE] at 11:29 AM, Staff B stated that Resident 73's burn should not have happened. <Smoking> <Resident 12> Review of the resident's medical record showed the resident was admitted with diagnoses to include chronic obstructive pulmonary disease (COPD, a lung condition caused by damage to the airways that limit airflow in and out of the lungs) and emphysema (a lung condition that causes shortness of breath). The [DATE] comprehensive assessment showed Resident 12's cognition was intact and dependent on staff for transfers, did not walk, and used an electric w/c for mobility. A concurrent observation and interview on [DATE] at 11:51 AM, Resident 12 was observed outside, in the parking lot, sitting in their electric w/c behind a parked vehicle, smoking a cigarette. Resident 12 stated that was where they were designated to smoke if they wanted to smoke. To the right of area, stood a gazebo with seating and an ashtray receptacle that was not accessible for a w/c. Resident 12 stated that was where the employees smoked. A concurrent observation and interview on [DATE] at 10:30 AM, Resident 12 was observed in their electric w/c, out in the hallway, and stated they were headed outside to smoke. Resident 12 had a purple blanket propped up under their left side, their upper body leaned towards the left, over the top of the w/c armrest. Resident 12 then exited out the back door of the facility with the help of staff. Resident 12 was followed out of the facility by two staff, one identified as Staff L, Infection Preventionist, who reminded the resident they needed to go off the facility property to smoke. Resident 12 stated they kept their own cigarettes in their room, locked up in a drawer. Resident 12 stated they were given designated smoking times they could smoke out on the facility patio, with the other smokers, but if they wanted to smoke outside of those designated times, they had to go outside of the facility to smoke. Resident 12 went to extinguish their first cigarette smoked by flicking off the end of the burning cigarette with their fingers, which landed on the ground, and placed the remnants of the cigarette into their black sweat jacket made of terry cloth or cotton (both highly flammable clothing material). Resident 12 then lit a second cigarette and extinguished it in the same manner as the first one and then re-entered the facility and went to their room. Review of the [DATE] and [DATE] smoking safety assessments, showed Resident 12 required a smoking apron and staff supervision while smoking. During an observation on [DATE] at 1:38 PM, Resident 12 was observed outside the back door that led directly to an alleyway and the parking lot. Resident 12 was sitting in the entrance/exit of the alleyway faced towards the street, with their back to the alleyway behind them. A silver car was observed attempting to exit the alleyway onto the street and had to turn into the parking lot to exit a different side of the parking lot. There was no staff supervision. During an interview on [DATE] at 4:10 PM, Staff L stated they assessed Resident 12's smoking safety on [DATE]. Staff L stated Resident 12 should have been smoking in a supervised area with a smoking apron on due to their left leaning while in their w/c that appeared not safe. Staff L stated Resident 12 would often go outside of the facility to smoke and they were not responsible for ensuring the resident's safety once they signed themselves out in the sign-out book. Staff L stated they were not aware the resident was smoking on facility grounds nor were they aware the resident extinguished their cigarettes in the manner that they were and then bringing them back into the facility. During an interview on [DATE] at 4:27 PM, Staff B, DNS, stated they were not aware Resident 12 was assessed to smoke supervised. Staff B stated the resident had previously been assessed to be an independent smoker but because they had been giving cigarettes to other residents that required supervision, and they had to re-evaluate Resident 12. Staff B stated Resident 12 was not given a designated device or area they could dispose of their cigarettes prior to re-entering the facility nor were they given a smoking apron to utilize when they went outside to smoke. Staff B stated they needed a better process. During an observation on [DATE] at 9:59 PM, Resident 12 and another resident were signing themselves out of the facility to go smoke. Two staff, Staff AAA, Scheduler/NA, and Staff E, Minimum Data Set Coordinator, followed both residents out and did not ensure Resident 12 had a smoking apron on or an extinguishing device. During an interview on [DATE] at 10:23 PM, Staff C, AD, stated they were upset hey arrived at the facility and observed the two residents outside smoking without smoking aprons on and supervised by staff. Staff C stated they did not know how the other resident with Resident 12 got cigarettes to smoke because their cigarettes were locked up in the Activities room. Staff C also stated when they asked Resident 12 where their extinguishing device was, Resident 12 told them they had left it in their room. Staff C stated they are not supposed to be in their room they were supposed to be given to the nurse upon re-entering the facility so the nurse could ensure the cigarettes had been completely extinguished. Staff C stated further education needed to be completed with the staff on that process. Reference WAC: [DATE](3)(g) 30528 44922

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 10/10/2024 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)

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 completed a lab slip. Staff J stated the night shift nurses would obtain the blood specimens for the lab orders, daily, and deliver the specimens to the lab the following morning. When Staff J was asked what the stack of incomplete labs in the medication room were for, Staff J stated those were labs that were not obtained and still needed to be completed (the labs had varying dates ranging from April 2024 thr [TRUNCATED]

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)

Based on interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents related to resident-to-resident altercations for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for accidents, hazards, and supervision. This deficient practice allowed Resident 1 to initiate physical altercations with five different residents (2, 3, 4, 5 and 6), successfully leave the facility unsupervised (elope), and placed other residents at risk for serious injury, serious harm, serious impairment, or death. On 07/11/2023 at 5:15 PM, the facility was notified of an immediate jeopardy (IJ) at CFR 483.25 (d)(1)(2) F689, Free of Accident/Hazards/Supervision/Devices, related to the facility's failure to provide supervision to protect, prevent, and safeguard residents from physical altercations and elopement. The facility removed the immediacy on 07/13/2023, with onsite verification from investigators, by designating line of sight supervision of Resident 1 at all times, re-education of staff (prior to working their next scheduled shift) regarding de-escalation of aggressive residents, redirection techniques for residents seeking to exit the facility, and the process of notifying emergency medical services and local law enforcement when residents become a threat to themselves or others. Findings included . <Resident 1> Review of Resident 1's medical record showed they admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), depression (a constant feeling of sadness), anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and post-traumatic stress disorder[(PTSD) a disorder that develops in some people who have experienced a shocking or dangerous event]. Review of the admission assessment, dated 07/06/2023, showed the resident had moderately impaired cognition and was independent with walking, dressing, eating, toileting, and personal hygiene. Additionally, the assessment showed the resident exhibited physical and verbal behaviors that impacted other residents one to three days out of the past seven days since admission. Review of the local hospital referral documents, received by the facility on 06/23/2023, showed the resident was in the emergency department (ED) due to aggressive physical and verbal behaviors from their previous facility which included breaking the nose of a staff member and threatening to harm others with a lamp. The ED notes showed the resident arrived in four-point restraints (tying down both arms and both legs when a person poses a danger to themselves or others) and had since required a one-to-one supervision level .due to aggressive outburst during NOC (night) shift. During an interview on 07/11/2023 at 3:30 PM, Staff B, Director of Nursing Services (DNS) confirmed they reviewed the hospital referral documents prior to the admission of Resident 1 to the facility. Staff B stated despite the documented history of aggressive behavior, they determined Resident 1 was safe and an appropriate placement for the facility. Review of nursing progress notes (PNs), on 07/10/2023, showed the following documentation: *On 06/30/2023 at 10:04 PM, Resident 1 was observed wandering in and out of other residents' rooms, stating they wanted to go home, and dismantling the bed remote. *On 07/01/2023 at 6:22 AM, Resident 1 was observed during the night removing metal rods from their bed frame, attempting to climb the patio fence, and entering resident rooms and holding the door closed. The resident was observed to be agitated, aggressive (attempted to hit staff) and resistant to staff's attempts to redirect. The resident .is a high risk for elopement due to (their) strength, mobility, and disorientation. (The resident) is also a potential harm to other residents and staff due to (their) observed combative behaviors. *On 07/02/2023 at 1:13 PM, Resident 1 was observed wandering into resident rooms and was difficult to redirect.All staff are watching (the resident) closely and redirecting (them) before (they) enter someone else's room. *On 07/03/2023 at 5:54 AM, Resident 1 was observed wandering in and out of resident rooms in the 100 Hall, and tried to hit staff with towels, clothes hangers, and other residents' items. The resident showed an angry affect with redirection to the nurse's station. Review of nursing progress notes, dated 06/30/2023 through 07/03/2023, showed no interventions were put in place to increase supervision of Resident 1, despite staff's daily documentation of behaviors such as intrusive (causing disruption or annoyance throught being unwelcome or ininvited) wandering, exit seeking, verbal and physical aggression towards staff. <Resident 2> Review of Resident 2's medical record showed they admitted to the facility on [DATE] with diagnoses of heart disease, mood disorders, and chronic kidney disease. Review of the comprehensive assessment, dated 06/17/2023, showed the resident had intact cognition, used a wheelchair for mobility, and was independent with personal hygiene, transfers, toileting, dressing and bed mobility. Review of the nursing PN, dated 07/03/2023 at 6:14 AM, showed Resident 1 wandered into room [ROOM NUMBER] and hit Resident 2 with two plastic hangers on the torso (the central part or core of the body) and legs. Resident 2 was able to get one hanger away from Resident 1, and called 911 for help. The emergency operator notified the facility of the incident. During an interview on 07/10/2023 at 2:45 PM, Resident 2 stated they were frustrated because the incident was unprovoked (Resident 2 was asleep in their own room) and should have never occurred. When asked if they felt safe at the facility, Resident 2 stated Yes, as long as people like that (Resident 1) are not here. Review of the facility's investigation report, dated 07/06/2023, for the incident that occurred on 07/03/2023 at 5:05 AM between Resident 1 and Resident 2 showed the intervention to prevent reoccurrence was to move Resident 1 to the dementia unit when an open bed was available. <Resident 3> Review of Resident 3's medical record showed they admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease [(COPD) a group of diseases that cause airflow blockage and breathing related problems], diabetes (a disease that occurs when the body can't use glucose/sugar normally), and heart disease. Review of the comprehensive assessment, dated 06/14/2023, showed the resident had intact cognition, used a wheelchair for mobility, was independent with transfers, and required the extensive assistance of one person for dressing, personal hygiene, and toileting. Review of the nursing PN, dated 07/03/2023 at 9:45 PM, showed the facility was notified by phone from a resident representative of Resident 3 that a resident-to-resident altercation occurred in room [ROOM NUMBER]. The resident representative said they were on the phone with Resident 3 when Resident 1 entered the room and .physically assaulted . them. Emergency medical services (EMS), local law enforcement, and the on-call provider were called. The provider gave direction to send Resident 1 to the hospital if needed. During an interview on 07/10/2023 at 3:05 PM, Resident 3 stated that Resident 1 had wandered into their room several times before but had not shown aggression. Resident 3 continued to describe their fear of Resident 1 and stated they only felt safe once Resident 1 moved to the secure dementia unit(which occurred three days later). Review of the facility's 07/06/2023 investigation report for the incident on 07/03/2023 at 9:45 PM between Resident 1 and Resident 3 showed the interventions to prevent reoccurrence were to move Resident 1 to the dementia unit and to utilize as needed (PRN) Seroquel (an anti-psychotic, a type of medication that changes the actions of chemicals in the brain) for mood regulation. Review of nursing PNs and facility investigation reports showed facility staff were unaware of Resident 1's whereabouts just prior to the altercations on 07/03/2023 and were notified of the incidents by sources outside of the facility (EMS and resident representative). Additionally, no interventions were put into place to increase supervision of Resident 1. During an interview on 07/10/2023 at 3:30 PM, Staff B stated the determination to move Resident 1 to the facility's secured dementia unit was because of its smaller size with less stimulation compared to the general area of the facility, and staff would be able to monitor the resident more closely. Review of the medical record showed Resident 1 moved to room [ROOM NUMBER] in the dementia unit on 07/06/2023. <Resident 4> Review of Resident 4's medical record showed they admitted to the facility on [DATE] with diagnoses of dementia, chronic bronchitis (inflammation of air passages causing coughing and breathing problems), and narcolepsy (a brain disorder that causes people to fall asleep suddenly and makes it hard to stay awake for long periods of time). Review of the comprehensive assessment, dated 04/15/2023, showed the resident had severely impaired cognition, required the extensive assistance of two people for transfers, toileting, and personal hygiene, and required the extensive assistance of one person for eating, dressing, and walking. Review of the nursing PN, dated 07/06/2023 at 1:55 PM, showed Resident 1 had a resident-to-resident altercation at 12:45 PM while in the dining room of the dementia unit when Resident 4 walked by and tried to take a soda can from the table where Resident 1 was seated. Resident 1 grabbed Resident 4's arm and twisted it. During an interview on 07/11/2023 at 12:10 PM, Staff C, Resident Care Manager (RCM), stated interventions put in place after the incident between Resident 1 and Resident 3 (on 07/03/2023) were to have staff monitor Resident 1 closely and redirect them when necessary. When asked to clarify if those interventions were new since this incident, Staff C stated no. Review of the nursing PNs, on 07/11/2023, showed the following documentation: *On 07/07/2023 at 10:30 PM, Resident 1 was observed going in and out of resident rooms and showed verbal and physical aggression toward staff and other residents. Staff .made efforts to stay nearby, interposing (place themselves between residents) between (Resident 1) and other residents on the unit . *On 07/08/2023 at 4:47 AM, Resident 1 was observed to go in and out of other resident rooms, became agitated and resistive to redirection, and gestured as if they were punching staff as they walk by. *On 07/08/2023 at 7:20 AM, Resident 1 grabbed onto licensed nurse's (LN's) arms and refused to let go but the LN was able to release the resident's grip.Resident continued to go into other (resident) rooms, not concerned with healthy boundaries . *On 07/09/2023 at 4:59 AM, Staff reported to the LN that Resident 1 was aggressive with them and threatened .to beat them up and (was) going in and out of rooms . *On 07/10/2023 at 3:49 AM, Resident 1 was threatening staff and entering other resident rooms telling them to get up for work. The resident had blocked the medication assistant-certified (MAC) in the nurse's station making them tearful and afraid. *On 07/10/2023 at 7:32 AM, Resident 1 was exit seeking and kicking the door from the dementia unit to the outside patio. The resident tried to kick staff when redirection was attempted and continued .walking into resident rooms yelling and waking them up. Redirecting with snack unsuccessful . *On 07/10/2023 at 7:06 PM, Resident 1 was observed exit seeking at multiple doors on the dementia unit, at times hitting and kicking the doors. Review of nursing PNs, dated 07/07/2023 through 07/10/2023, showed no interventions were put in place to increase supervision of Resident 1, despite continued daily documentation of behaviors such as intrusive wandering, exit seeking, verbal and physical aggression towards staff, and the potential for self-inflicted injuries. <Resident 5> Review of Resident 5's medical record showed they admitted to the facility on [DATE] with diagnoses of malnutrition (poor nutrition), alcohol induced dementia (problems with memory and thinking that are most likely caused by drinking too much alcohol), depressive and anxiety disorders. Review of the comprehensive assessment dated [DATE] showed the resident had intact cognition, required the extensive assistance of one person for personal hygiene, used a wheelchair for mobility, and was independent with bed mobility, dressing, eating, toileting, and transfers. Review of the nursing PN, dated 07/11/2023 at 12:45 AM, showed staff reported to the LN that Resident 1 was observed shoving a wheelchair against Resident 5's legs and proceeded to follow Resident 5, who was assisted by staff, to the lobby and attempted to hit them with the wheelchair again. Resident 1 and Resident 5 were roommates. <Resident 6> Review of Resident 6's medical record showed they admitted to the facility on [DATE] with diagnoses of malnutrition, dementia, and bipolar disorder (mental illness that cause unusual shifts in mood). Review of the comprehensive assessment, dated 04/23/2023, showed the resident had moderately impaired cognition, required limited assistance of one person for dressing, toileting, and personal hygiene, and was independent with transfers and walking. Review of the nursing PN, dated 07/11/2023 at 3:41 AM, showed Resident 1 was observed throwing a ball three times at Resident 6, hitting them in the abdomen and trunk. Resident 1 showed increased aggression toward staff when redirection was attempted. Review of the nursing PN, dated 07/11/2023 at 1:23 PM, showed Resident 1 continued with physical aggression toward staff and was observed exit seeking and kicking the door. The resident was also observed picking up and throwing chairs in the foyer (an entrance hall or other open area in a building) of the dementia unit. After the facility moved Resident 1 to the dementia unit, on 07/06/2023, there continued to be daily documentation in nursing PNs of physical and verbal aggression towards others and exit seeking behaviors. Although three additional resident-to-resident altercations occurred (a total of five altercations in 12 days), no interventions were put in place to increase the supervision of Resident 1. During an interview on 07/11/2023 at 2:00 PM, Staff C stated that Resident 1 had a flat affect making it difficult to observe a change in their mood or demeanor. Staff C further stated they had observed Resident 1's mood and behaviors change quickly without any warning signs. When asked if they felt the other residents were safe, Staff C stated no. During an interview on 07/11/2023 at 2:30 PM, Staff D, Social Services Director (SSD), stated they had not observed any of Resident 1's behaviors, only heard about them. When asked if they felt the other residents were safe, Staff D stated no. During an interview on 07/11/2023 at 3:18 PM, Staff B stated that Resident 1 had been evaluated by the provider today (07/11/2023) and received an order for medication changes to manage mood and behaviors. When asked what interventions were in place to keep Resident 1 and the other residents safe, Staff B stated they were continuing to monitor Resident 1 for increased behaviors, attempting to de-escalate situations with verbal and physical aggression, redirect the resident, and wait for the new medication to take effect. Staff B stated they felt all the residents were safe in the facility. The IJ notification was delivered to the facility on [DATE] at 5:15 PM regarding the supervision of Resident 1 and the risk they posed to themselves and other residents. Review of the nursing PN, dated 07/12/2023 at 10:38 AM, showed Resident 1 was noted to be missing from the dementia unit common area. The entire unit was searched and the window in a resident room was found open with the screen on the ground outside. A search outside of the facility was initiated, and Resident 1 was located one city block away from the facility. During an interview on 07/12/2023 at 11:15 AM, Staff B stated that Resident 1 was not always supervised due to staff needing to provide care to other residents. Staff B stated the gaps in supervision by staff allowed Resident 1 the opportunity to elope. During an interview on 07/12/2023 at 4:00 PM, Staff E, Medical Director, stated they were unaware of Resident 1's aggression toward other residents or that Resident 1 had initiated five resident-to-resident altercations since admission. When asked if they felt the other residents were safe, Staff E stated no, and explained that Resident 1 needed medication management and one-to-one supervision until they were medically stable. Reference: WAC 388-97-1060(3)(g) This is a repeat deficiency from the statement of deficiencies dated 09/06/2022.

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 [CONDITION(S)] 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] placed in August 2020 with the intent for the resident to recover and be seen in 3 months to start discussing [CONDITION(S)] 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/ [CONDITION(S)] 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 [CONDITION(S)] 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 Kardex (care plan directed to NAs) showed no scheduled times for NAs to remove the fecal matter from the resident's open and oozing [CONDITION(S)] 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 [CONDITION(S)] 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 [CONDITION(S)] 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 [CONDITION(S)] 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 [CONDITION(S)] 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)

Based on observation, interview, and record review, the facility failed to ensure one of four residents, Resident (69), reviewed for abuse, was free from non-consensual sexual contact of any type with another resident. The facility failed to provide adequate supervision, effective interventions to assure the safety of the resident, and evaluate the effectiveness of current interventions to prevent further abuse. These failures resulted in Resident 69 feeling anxious, scared, and unsafe resulting in psychological harm. Findings included . Resident 69. Review of the medical record showed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 05/25/2022 comprehensive assessment showed the resident was alert, oriented, made needs known, and required supervision with most activities of daily living. The resident used a wheelchair for mobility. The comprehensive assessment also showed the resident expressed sadness and unworthiness most of the time. During an interview on 06/14/2022 at 10:11 AM, the resident was asked about an incident with Resident 4 that occurred on 05/23/2022. Resident 69 stated that they went outside to smoke, and another resident (4) came out to the patio. Resident 4 approached and kissed them, then placed their hand under their shirt. Resident 69 stated that they got away from Resident 4 and told them to leave them alone. A Social Services Assistant (SSA), Staff DD, talked to Resident 69 about the situation. They told Resident 69 to stay away from Resident 4 and to make sure they were not alone with Resident 4. Resident 69 told the SSA they did not feel safe around Resident 4. Resident 69 further stated that they spoke to Staff Q, SSA, a few days after the initial incident (05/23/2022). Resident 4 had continued to harass them, and they did not feel safe. The resident stated there were staff that took them out to smoke at designated times, but Resident 4 continued to seek her out. Resident 69 stated that they felt like nobody listened to them. They stated that they could not go outside by themself early in the morning now to smoke because there were no staff to supervise them. Resident 69 stated that Resident 4 seeked them out during smoke breaks and in the hallway by the nurse's station. Resident 4 continued to ask the resident to raise up their shirt and asked them if they were in their room last night for sex because they could smell (Resident 69's) perfume. The resident stated that they would not do that and felt very anxious, scared, and did not trust Resident 4. During an interview and concurrent observation on 06/14/2022 at 11:20 AM, Resident 4 came in from the outside patio and parked their wheelchair a few feet behind Resident 69 during our interview and tried to get Resident 69's attention. Staff I, Activities Assistant (AA), who witnessed the interaction had to be asked to remove Resident 4 from the area. The incident was reported on 06/14/2022 at 11:45 AM to Staff B, Director of Nursing Services (DNS), regarding Resident 4's continued harassment of Resident 69. During an interview on 06/21/2022 at 10:07 AM, Staff I stated that they and another AA supervise the residents who smoke on the patio four times a day, by giving the residents cigarettes and lighting them, and to make sure they wear a fireproof apron while smoking. They were unaware of the incident between Resident 4 and Resident 69 on 05/23/2022 and did not know they were to keep them separated until 06/17/2022. During an interview on 06/21/2022 at 11:51 AM, Staff Q stated that they, and Staff DD, SSA, were told by a collateral contact who saw Resident 4 approach Resident 69 on 05/23/2022. The collateral contact stated that Resident 4 approached Resident 69, kissed them, and inappropriately touched them under Resident 69's shirt. Staff Q stated it was not consensual. Resident 4. Review of the medical record showed the resident initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple mental health issues to include hallucinations, delusions, and health concerns. The 05/26/2022 comprehensive assessment showed the resident was alert and able to make their needs known, needs limited assistance but was able to propel themself in a wheelchair. Behaviors included trouble concentrating, physical behaviors, and verbal threatening to others. The resident received specialized behavioral management service from a contracted behavioral health provider. During an interview on 06/14/2022 at 11:42 AM, the resident stated that they went out to smoke a cigarette and nothing happened. The resident stated that they kissed Resident 69 once and staff said they saw what happened. Resident 4 stated he was lonely and would like a companion. During an interview on 06/21/2022 at 10:58 AM, Staff DD stated that Collateral Contact from the behavioral management service saw Resident 4 kiss Resident 69 and place their hand up Resident 69's shirt. The contact came to get Staff DD, but by the time they got to the patio, the residents were separated from each other. Staff DD interviewed Resident 4 and stated that if there was a mutual thing going on, and if Resident 69 was fine with it, that was okay. Staff Q spoke to Resident 69, and they were not in favor of the relationship with Resident 4. Reference WAC: 388-97-0640(1)

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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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)

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 readmitted 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICATION(S)] (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 [MEDICATION(S)] (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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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

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 [CONDITION(S)] - 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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 [CONDITION(S)] again. The resident stated, If these people would please explain the treatment I would have taken the [CONDITION(S)] (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 [MEDICAL RECORD OR PHYSICIAN ORDER] . 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)

Based on observation, interview, and record review, the facility failed to ensure one of five residents (#2) reviewed for abuse was free from physical abuse. Resident #2 was seated in the dining room prior to dinner when Resident #1 slapped him, grabbed him by the throat, and bit his face. Resident #2 experienced harm as a result of the physical attack and facial injury. Findings included: According to the 09/13 facility Abuse Prohibition Policy the technical definition of abuse is, Conduct or behavior that results in physical, mental or emotional harm . A. Physical Abuse: conduct that result (sic) in inappropriate or violent physical contact. i. Slapping, hitting, batting, kicking, biting, etc. ii. Rough handling. Review of the facility's Admit policy (sic) Addendum dated 9/10/18 showed All new admits, regardless of where they come from will be put on q (every) 15 min (minute) checks 24 hrs (hours) a day for minimum of a week, unless the MDT (multi-disciplinary team) (Stand-up) says differently. Resident #2. Review of the medical record showed the resident had multiple [DIAGNOSES REDACTED]. According to the resident's 08/19/09 Alteration in Mobility plan of care (last reviewed on 10/23/18), the resident had left sided [MEDICAL CONDITION] (weakness on his left side). Resident #2 required staff assistance for transferring between his bed and wheelchair, was able to walk a short distance with staff assistance, but typically utilized his wheelchair to propel himself throughout the facility. The Self Care Deficit plan of care, also dated 08/19/09, stated the resident had his meals in the dining room. He was able to feed himself in the dining room after staff set up his meal. The resident's Thought Process Altered plan of care, dated 08/19/09 (last reviewed on 10/23/18), referenced the resident's mental health issues, developmental disability, and the associated behaviors of perseverating (uncontrollable repetition), verbal aggression (cussing), disruptive behaviors, and impaired memory . The resident had short and long term memory loss. I'm only able to answer short/simple, yes/no questions. Review of a 01/03/19 nursing entry showed at approximately 5:00 PM the nurse was alerted that a resident-to-resident altercation had occurred in the dining room. The nurse found the resident in his room with an approximate 50 cent piece (sic) size raised area on his right cheek with a slight open area and bleeding noted. It was reported that (Resident #2) was attacked by resident in the Arbor dining room. The resident who attempted to attack and bite Resident #2 on the cheek was attempting to strangle him. The resident's bite was cleansed and an antibiotic ointment was applied. No redness or bruising was found on the resident's neck. A 01/03/19 physician's orders [REDACTED]. On 01/04/19 the social service entry showed Resident #2 recalled the resident-to-resident altercation and told the social worker what had happened. He denied fear but had told the other social worker that morning, I want to beat him. Later that morning the resident stated to the social worker that he did not want to press charges against Resident #1 but wanted a restraining order against the other resident. The social worker followed up with the district court related to the process of filing a restraining order. The 01/04/19 nursing entry showed the resident continued with a red mark from the bite. Area is swollen and starting to bruise. The facility was still waiting on the pharmacy for the tetanus injection. The resident received the tetanus injection on 01/05/19. Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. According to the initial 12/27/18 plan of care the resident had limited eyesight, an unsteady gait, and poor insight. He was able to transfer independently. Resident #1 had a history of [REDACTED]. The resident was able to use a wheelchair independently. Additionally, the resident was noted to have delusions that his wheelchair had been stolen, his dad shot his mom, auditory hallucination, agitation, verbal aggressions with profanity, resistance to care, exit seeking, and physical aggression with combativeness. At the time of admission, the resident was not receiving medication to address his delusions or hallucinations. Per the documentation, staff were providing every 15 minute staff checks on the resident. According to the medical record entries, on 12/27/18 the resident was extremely delusional stating his dad shot his mom and he bit the jugulars out of people in the military. The delusional statements continued on 12/28/18. He bumped into another resident and they started yelling/cursing at each other. Entries on 12/29/18 showed the resident was concerned about his roommates and refused to go into his room to sleep. He wandered into other residents' rooms. A blanket became tangled in his wheelchair wheels. Another resident's visitor attempted to help. Resident #1 raised his fist as if to strike the visitor but was stopped by staff. A 12/30/18 entry showed the resident continued to refuse to go to bed in his room stating, There are queers in there. On 12/31/18 the entries noted the resident raised his fist when another resident was walking by him. He also moved his wheelchair and was blocking the exit to the dining room for staff and residents. Later that evening Resident #1 hit the charge nurse in the nose and was throwing items. He also took a pill crusher off the medication cart and was swinging it at the staff. Resident #1 also kicked and hit staff. An emergency order for a one time dose of an anti-anxiety medication, [MEDICATION NAME], was received on 12/31/18 but he refused the medication. On 01/01/19 the resident continued to be physically and verbally aggressive with staff and residents but did not make any physical contact. The facility called the police and the resident was taken to the hospital. An order was provided by the hospital for [MEDICATION NAME] 1 milligram three times daily as needed. On 01/02/19 the resident settled down and rested with a one-on-one staff member until the end of night shift. According to the 01/03/19 staff documentation, the resident had a resident-to-resident altercation that morning when he ran into Resident #3's wheelchair in the hallway. Resident #3 made a comment and then Resident #1 raised his fist. Next, Resident #1 yanked the other resident's glasses off his face, bent the glasses, and then threw them. The mental health professionals (MHPs) were notified. At around 2:30 PM Resident #1's roommate started yelling in their room. Resident #1 was standing with his roommate's walker in hand. Staff intervened to prevent contact. The resident was then seen by the MHP and by the Psychiatric Nurse Practitioner. Medications were ordered but were not scheduled until later. The resident continued on an every 15 minute staff monitoring program thereafter. Per a 01/03/19 nursing entry at 4:50 PM (a little over two hours after the roommate incident), the nurse heard yelling and responded to an incident. Resident #2 had a large rounded indentation (tooth marks) with swelling in the center on his cheek. A nursing assistant said it was from Resident #1. Upon arrival in the dining room, staff were evacuating other residents and staff. The dining room doors were closed as Resident #1 was throwing, kicking, and striking at others. The police and ambulance arrived later. A MHP was also present. Resident #1 was taken to the hospital. Review of the facility investigation showed the residents were gathering in the Arbor Dining Room (before dinner). Resident #2 was at a table and Resident #1 entered the dining room. It appeared Resident #1 bumped into Resident #2's wheelchair which made Resident #2 mad. Resident #2 started cursing loudly as he usually does. Staff A, Medication Assistant, was outside the dining room getting the medications ready. According to the investigative witness statement from Staff A, she was preparing her medications by Arbor Dining Room when she heard Resident #2 yell something about his chair. She put her medications away before responding to check on what was happening. Staff A heard a smack. When she entered the dining room she saw Resident #1 standing over Resident #2 smacking him in the face. Staff A ran to help Resident #2 and yelled for another staff member to get the nurse. Staff A approached the residents and tried to protect Resident #2. Resident #1 grabbed Resident #2 by the throat. Staff A tried to remove Resident #1's fingers but he bit down on Resident #2's face. Staff A tried to pull Resident #1 off Resident #2's face but she was unable. She continued to scream for help. Staff B, Medication Assistant, entered the dining room and pulled Resident #1 off Resident #2's face and sat him down in his wheelchair. On 01/08/19 at approximately 11:45 AM, an interview was conducted with Resident #2. The resident was in his wheelchair at the first table from the doorway into the Arbor Dining Room, his usual placement in the dining room. He stated he got in fight with a resident one day and they called the county sheriff .The county sheriff took him away . Bit me in the face . Have a restraining order now . He not here long. Observations of the resident's face revealed he had slight swelling on his right cheek. The right cheek area was pinkish in color and there was a gray bruise present on the lower aspect, approximately 1 1/2 inches in length in a V shape. There was a purple spot also in the middle of the bruised area. An interview was conducted with Staff B on 01/08/19 at approximately 2:00 PM. Staff B stated she was working on the floor that evening as a nursing assistant in the adjacent dementia unit. She heard a scream and someone ran into the dementia unit to request a nurse. Staff B ran to the dining room to help. As she entered she saw Staff A trying to separate the residents as Resident #1 was choking Resident #2 and biting his cheek. Resident #1 was standing and Staff B placed Resident #1 back into his chair from behind him causing him to let go of Resident #2. He got more feisty. Resident #2 was pretty shooken up (sic). Staff called 911 and they responded. Staff B returned to her previous assignment thereafter. On 01/08/19 at approximately 4:00 PM, Staff A discussed the details of the resident-to-resident altercation. She had the medication cart near the dining room. Resident #1 had passed her earlier and he mumbled something as he passed. She recalled hearing Resident #2 say a cuss word and state, my chair. She then heard a smack. Resident #1 was standing and smacking Resident #2 in the face. He then grabbed Resident #2 by the front of the neck and bit his face. When she tried to remove his face, Resident #1 attempted to bite harder. According to Resident #1's one-on one log, on 01/03/19 at 4:45 PM Resident #1 was in the dining room at the sink inside the door on the south side of the room and near Table #1. On 01/09/19 at approximately 3:05 PM, Staff C, Nursing Assistant, was interviewed. Staff C recalled on 01/03/19 she was Resident #1's assigned caregiver. She was also caring for residents on the dementia unit. She returned from her break after 4:45 PM. Staff C recalled looking in the dining room and seeing residents present in the dining room. Resident #2 was seated at his usual table closest to the door. Resident #1 was sitting behind Resident #2 between the tables. Staff C returned to the dementia unit. She then heard yelling and responded to the dining room. Staff C observed Staff B pull Resident #1 into his wheelchair and Staff C took Resident #2 out of the dining room. He was cussing. Staff C tried to calm Resident #2 and tell him that he was safe. Staff D, Nursing Assistant, was interviewed on 01/09/19 at approximately 3:25 PM and she recalled she was doing the every 15 minute checks for Staff C, his assigned caregiver, as Staff C was be working in the dementia unit during the dinner timeframe. On 01/03/19 at 4:45 PM , Staff D had observed Resident #2 was in the dining room with other residents. Resident #1 was also in the dining room in front of the sink. Staff D left the dining room to get another named resident. Staff D had never been a caregiver for Resident #1. Reference (WAC) 388-97-0640(1) This is a repeat deficiency from Statement of Deficiencies dated 08/24/18.

Based on observation, interview, and record review, the facility failed to ensure two of eight sample residents (#11 & # 12), reviewed for abuse, were free from physical abuse when they were struck by another resident (#10) and injured. The failure resulted in actual harm to Resident #11, who was hit with a wheelchair pedal on the head/face by Resident #10, which resulted in extensive, serious injuries requiring hospitalization . In addition, soon after the incident with Resident #11, Resident #12 was physically abused by Resident #10, which resulted in skin and tissue trauma, as well as probable psychological trauma, as he continued to recount the physical attack by his new roommate days after the incident. Findings included: According to the facility 09/13 Abuse Prohibition Policy, the technical definition of abuse is, Conduct or behavior that results in physical, mental or emotional harm. A. Physical Abuse: Conduct that result (sic) in inappropriate or violent physical contact. i. Slapping, hitting, batting, kicking biting etc. ii. Rough handling Resident #10: Review of the medical record showed the resident was admitted from a hospital to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Prior to hospitalization , Resident #10 had exhibited hallucinations (such as seeing/hearing things that were not actually present), and bizarre behaviors. According to the 08/13/18 plan of care, the resident had altered thought processes. Per record review, he saw demons and bugs (as hallucinations). A nursing entry on 08/13/18, during the evening shift, showed the resident had a fall and stated he hit his head. The note showed no injury was identified, but neurological (neuro) checks were initiated. An 08/14/18 nursing entry showed the resident was independent with walking, but required supervision to get to the right location. The note showed he was pleasant and cooperative but delusional (had thoughts not based in reality) and was confused. According to an 08/15/18 social service entry, He believes people are in his house .Also showing verbal aggression toward roommate (for being in his house) and almost becoming physically aggressive by raising his fists at roommate. Staff intervened -removed him from the situation and offered activity. An 08/16/18 social service entry documented the resident had agreed to move to another room due to problems with his roommate, and the room change was to occur that day. A nursing entry on 08/17/18 documented the resident needed maximum assistance with his activities of daily living. Per the note, he was able to self-propel his wheelchair, but needed assistance finding his room and the dining room. He was verbal but very delusional. The record showed when the nurse was completing a neuro check, the resident thought he was being checked for intoxication. An 08/17/18 social service entry showed the resident was very confused and disoriented and continued to go through his roommate's belongings. The resident was also found in another resident's room, but was easily redirected. Per an 08/18/18 night shift nursing entry by Staff A, Registered Nurse (RN), she responded to yelling by a nursing assistant. The note showed when Staff A entered the room, she witnessed the resident's roommate (Resident #11), lying in bed covered in blood. Staff immediately called 911 for assistance. Res (Resident #10) had a foot pedal of w/c (wheelchair) in hand and was raising it at other Res (#12), Res striking other roommate in the head, foot pedal; immediately removed .Res continued with verbal (and) physical threats. The note showed police arrived and escorted Resident #10 from the room to an alternate location. Additional 08/18/18 nursing entries by Staff D, Licensed Practical Nurse (LPN), documented Resident #10 was taken to the hospital, medically cleared, and released into police custody. Staff D also documented Resident #10 was not to return to the facility because it would be too dangerous. Resident #11: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to a recent change of condition comprehensive review, dated 08/15/18, the resident had recent poor intake and was dependent on staff for his activities of daily living. The resident also had delusions and impaired cognition. An 08/18/18 night shift nursing entry by Staff A, RN, showed a nursing assistant had yelled from the room for the nurse. Per the note, as Staff A entered, Resident #11 was seriously injured. The resident's face covered in blood, foot pedal of w/c (wheelchair) at top of his head, Res (resident's) mouth open. Res breathing. A 911 emergency was called by facility staff and the resident was transported to the hospital at 3:35 AM. A follow-up 08/18/18 nursing entry showed the resident had been admitted to hospital's ICU (intensive care unit), and was unresponsive. Review of the 08/18/18 emergency room documents showed Resident #11 had been assaulted with a metal wheelchair foot pedal by another resident. The document showed the resident had Head injury complex facial lacerations(.) The resident was being sent to the ICU. During an interview with Staff B, Registered Nurse/Assistant Director of Nursing Services, on 08/23/18 at approximately 9:15 AM, she stated Resident #11 remained in the hospital. Staff B stated the resident had a feeding tube placed at the hospital (a flexible tube inserted into the stomach to provide nutrition/hydration/medication), to address his swallowing problems. The feeding tube was thought to be temporary, until the resident's condition improved. Re-admission to the facility was pending, at a date as yet to be determined. Resident #12: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's 06/04/18 plan of care showed he had a shuffling, unsteady gait. Per the record, the resident had altered thought processes with hallucinations. An 08/18/18 night shift nursing entry by Staff A noted Resident #12 was stating, he is hitting me. Staff A got between Resident #12 and Resident #10. Per the note, Resident #10 was provoking the altercation. Resident #12 showed Staff A his wrist, which appeared to have abrasions. The resident also reported he was hit on the head and he requested to be sent to the hospital. The resident returned from the hospital with a family member. The resident reported his arm hurt and he appeared to be trembling. The resident was provided [MEDICATION NAME], an anti-anxiety medication, and [MEDICATION NAME] for the pain. Review of a facility investigation summary report, dated 8/18/18 at 3:10 AM, showed Resident #10 had already physically abused Resident #11 before staff intervened to protect Resident #12 from further physical abuse. Review of an 08/19/18 nursing entry showed the resident continued to repeat that he was at the hospital this morning and showed the areas where he was hit. The resident's right leg was reddened and his face had a small scratch. Per the note, dressings were present and intact. An 08/20/18 social service entry documented the resident exhibited both fear and recall, related to the incident on the weekend (08/18/18). According to the 08/23/18 nursing entry, the resident's right lower extremity was red, swollen, and painful, from the ankle to the upper shin; an antibiotic was then ordered. On 08/24/18 at approximately 12:30 PM, an interview was conducted with Resident #12. The resident was seated in his recliner. There was an area on his right forearm, approximately five inches in length that was slightly raised and had yellowish discoloration. Two bandaids were in place. The resident also had an ace wrap around his right lower leg, below the knee. Resident #12 stated, I hurt my leg. He kicked it. The resident also stated his roommate had bit his right forearm. He doesn't live here anymore. Resident #12 also discussed his trip to the hospital (emergency department). An interview was conducted with Staff C, Director of Nursing Services (DNS) on 08/24/18 at approximately 1:50 PM. Staff C stated Resident #12 had originally reported he was hit on the right leg, but wouldn't allow an assessment for a while. Per Staff C, the area became hot and swollen over time and it appeared a [MEDICAL CONDITION] (an infection in the tissue) developed in the wound site. Review of the facility investigation showed staff heard yelling and responded to the room. Resident #10 was sitting on the arm of Resident #12's recliner with a wheelchair foot pedal in his hand. Resident #12 was sitting on his bed facing Resident #10. Per the investigation, Resident #12 yelled for help and Resident #10 swung the foot pedal and hit Resident #12 on the head. A nursing assistant took the foot pedal away from Resident #10. Staff called 911. Resident #11 was taken to the hospital first, due to his injuries. Resident #12 was then taken to the hospital and he returned within four hours. The investigation showed Resident #12 has total recall of the incident. He is fearful. Additionally, the facility investigation noted Resident #11 remained at the hospital. He had many sutures and some open areas that could not be closed. He failed a swallowing evaluation, so a feeding tube was placed. Resident #10 was not going to be readmitted . Resident #11 would be readmitted into another room, so Resident #12 would not be upset. Per the investigation, Staff C, DNS, had reviewed the inquiry packet prior to admission and there were no red flags suggesting Resident #10 might be violent. Resident #10 had only been a resident since Monday (less than a week). During an interview with Staff E, Nursing Assistant (NA), on 08/22/18 at approximately 10:50 AM, she recalled working with Resident #10 when he arrived. Staff E stated the resident self-propelled in his wheelchair, which did not have foot pedals on it. The day after admission, Staff E stated she had to redirect the resident to the foyer because he became fixated on his roommate's things. She stated the following day the same problem occurred but this time Resident #10 began to enter into his roommate's space and was swinging at him. No contact was made. Per Staff E, Resident #10 made statements such as: What are you doing in my room? and Why are your things in my room when I'm paying for it? Following these incidents, Resident #10 was moved to another room where Resident #11 resided; he used a wheelchair with foot pedals. Staff E further stated on 08/18/18, during the night shift, she was working with Staff F, NA. They had last provided care for Resident #11 at approximately 1:30 AM. After Staff F returned from lunch, at approximately 3:00 AM, they started to provide care for other residents. Shortly thereafter, they entered the hallway and heard yelling for help (later identified as Resident #12) and responded. Staff E stated when she entered the room, she knew there had been an altercation. Resident #11's face was covered with blood. Resident #12 was yelling for staff to get Resident #10 out because he was hurting him. Staff E witnessed Resident #10 sitting on the arm of Resident #12's recliner. Resident #10 then hit Resident #12 on the left side of his head with a wheelchair foot pedal before she could grab it. Resident #10 stated, I'm sick of this Mother F---er in my room. Staff A was summoned to the room. Staff E called 911. A similar recounting of the incident was made by Staff F, NA, when interviewed on 08/22/18 at approximately 11:35 AM. Per an 08/22/18 interview with Staff A, RN, at approximately 12:55 PM, she was working the night shift when the 08/18/18 incident had occurred. She had not met Resident #10 prior to that night shift and had seen him walking with a walker at approximately 1:15 AM. Staff A stated she had been down the hallway later and looked in the room but didn't see anything unusual. Staff A was seated at the nurses' station charting when she heard staff call for her to come quickly. Her recall of what she witnessed was similar to those of Staff E and Staff F. When she arrived, she noticed Resident #11 and his injuries. A wheelchair foot pedal was located near the top of his head. Resident #12 was calling out for help. Staff A stated she remained in the room with the residents and directed staff to call 911 and other entities. Per Staff A, emergency responders arrived and took action; first the police and then the ambulances. An interview was conducted with Staff G, NA, on 08/23/18 at approximately 2:20 PM. Staff G recalled she had cared for Resident #10 one day after he had been transferred to the new room. Resident #1 self-transferred out of his wheelchair. He didn't seem to like to be touched. Resident #10 moved around a lot in the room and would entered into Resident #12's side of the room. He thought his roommates were stealing from him. Another staff member had reported to her that she witnessed Resident #12 in Resident #10's drawers in the room on an occasion. Staff G also stated Resident #11 required total care and didn't respond much verbally during care. Resident #10, a newly admitted resident with a history of prominent delusions and hallucinations, had verbal escalations and an attempted physical altercation with his first roommate. Consequently, Resident #10 was moved into another room with two other roommates. One roommate was very dependent and fragile. During the night shift, Resident #10 utilized a wheelchair foot pedal and physically abused/attacked his roommates causing physical harm and psychosocial distress. Reference (WAC) 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure 2 of 5 residents (#s 20 and 82), reviewed for weight loss, maintained acceptable weight status. Failure to consistently implement a system to monitor weight changes and to respond to weight and eating changes resulted in continued and avoidable weight loss for both of these residents. Findings include: Resident #82. admitted in 2012 with [DIAGNOSES REDACTED]. The 04/29/15 comprehensive assessment revealed she was severely cognitively impaired and required extensive assistance with eating. On 06/15/15 at approximately 5:20 p.m., Resident #82 was walking around in the dining room with continual face, tongue and mouth movements (abnormal) noted while she was walking. She then seated herself in a chair and immediately closed her eyes. Fifty minutes later, at 6:10 p.m., a Nursing Assistant (NA) approached the resident, attempted to wake her and fed her a bite of food after she opened her eyes. The aide reminded her to chew her food. The resident closed her eyes and appeared to be sleeping. She consumed only 1-2 bites during the meal. On 06/16/15 at approximately 12:15 p.m., the resident was observed in the dining room seated in a recliner in an upright position. Abnormal face, tongue and mouth movements were again observed. At 12:25 p.m., she was served her food. She continued with the abnormal facial movements. At 1:08 p.m., a NA assisted the resident with eating some of her food. The abnormal face and tongue movements caused some of the food she took to spill from her mouth. She did not consume any food independently. On 06/17/15, the resident's current plan of care for feeding and nutrition revealed goals of 140 to 150 pounds (lbs.) weight and maintaing the ability to feed herself with cues. It also noted she would receive small portions of food one at a time in individual containers; she was restless during meals. No new interventions were identified for the resident's change in eating abilities. According to the pharmacist's review on 05/12/15, [MEDICATION NAME] (an anti-psychotic medication) was tapered due to an identified side effect of akathesia (a movement disorder characterized by restlessness and constant motion). The 06/16/15 [MEDICAL CONDITION] Medication Rounds noted a new antidepressant had increased the abnormal movements with her mouth and tongue; the medication was discontinued. On 06/01/15 a nursing entry noted the resident ate dinner but pocketed food in her mouth. The physician examined the resident on 06/02/15 and documented she had continual movements with her mouth (abnormal repetitive movements). In an interview on 06/18/15 at 9:55 a.m., Staff Member M, a NA, stated she had seen a definite change in Resident #82. The NA stated she used to feed herself and now she did not. She noted that at breakfast today she had to feed her oatmeal and eggs. She noted the resident fed herself a few pieces of toast only after they were presented to her on a fork. She stated if a resident had a change in their eating abilities, they should tell the charge nurse. On 06/18/15 at 2:35 p.m., Staff Member T, a NA, stated she frequently cared for Resident #82. She stated about one month ago, the resident really changed. She stated before that time, the resident fed herself and did well with eating. Then, about a month ago, she started stuffing her mouth with food to the point she was unable chew the food, so she was served a small amount of food in a bowl. The NA explained more food was brought to the resident as she finished the small amounts that were in front of her. The NA further stated, a week or so ago, Resident #82 stopped eating her food by herself and required help to eat. About the same time, she started staying in bed, when in the past she walked a lot. The NA stated she told the charge nurse about Resident #82's changes. Review of a nutrition assessment done by Staff Member F, the Registered Dietitian (RD), dated 02/11/15 revealed the resident's current weight was 148 lbs. Her feeding ability was independent and noted no chewing/swallowing problems. Her intake was noted to average 75%. Review of the latest nutrition assessment done by the RD and dated 05/04/15, it noted her weight, taken on 04/29/15, had decreased to 141.6 lbs. and her feeding ability had decreased to require a limited amount of assistance from staff. Chewing problems were noted and intake had declined to 50-75%. The resident diet order was changed to include double portions. Record review of the bath book revealed after 04/29/15, the following 8 weights for Resident #82: 140.8 lbs. (05/06/15), 136.4 lbs. (05/20/15), 135 lbs. (05/27/15), 142.2 lbs. (06/03/15), 135.2 lbs. (06/07/15), 139.4 lbs. (06/10/15), 131.6 lbs. (06/13/15) and 131.4 lbs. (06/17/15). Between 04/29/15 and 06/17/15, the resident lost 10.2 lbs., a 7.2% loss of body weight over an approximate 6 week time period. Review of the weights in the CareTracker system revealed only 1 of the 8 bath book weights were entered in the system after 04/29/15. That weight was entered on 06/07/15. There was a 3 lb. or greater difference between the 06/07/15 weight in comparison to the immediately previous weight on 04/29/15. During an interview on 06/18/15 at 9:25 a.m. with Staff Member L, a NA, and bath aide, she stated each resident was supposed to be weighed with each shower. She explained the weights were entered in the both the bath book and in the electronic record, called CareTracker. If the weight increased or decreased 3 lbs. or more from the previous weight, the bath aide was to notify the charge nurse. On 06/22/15 at 1:50 p.m., Staff Member J, a Case Manager and Licensed Nurse (LN), stated he did not recall weight loss for Resident #82 being reported to him, but he would check on her weights in CareTracker. He stated Resident #82's intake was not monitored or documented. On 06/17/15 at 2:25 p.m., Staff Member F, the RD, stated she evaluated nutrition status of residents quarterly, or more often if she was notified of or noticed a weight change. She stated she used the CareTracker weights to determine weight loss. She also noted the NA's were supposed to report weight changes of 3 lbs. or more to the charge nurse or her. With regard to Resident #82, the RD stated she was not aware of the (recent) weight change. It apparently didn't trigger in CareTracker. She noted there were some recent medication changes with the resident and speculated that this may have caused the weight loss and the increase in facial movements. I will have to look at her (weight loss). Despite the identified Akathesia and significant weight changes, the facility failed to implement and/or evaluate current interventions to address her decreased nutritional intake and the change in her eating ability. Resident #20. admitted on [DATE] with [DIAGNOSES REDACTED]. Her latest comprehensive assessment dated [DATE] revealed she was severely cognitively impaired and required extensive assistance from staff for eating. On 06/17/15 at approximately 1:15 p.m., Resident #20 was seated in the dining room in her wheelchair. She ate some bites of her beans and hot dog, and then took a bite of watermelon. After taking the watermelon, she immediately started coughing and spit out the hot dog, beans and watermelon. After sitting without eating for a few minutes, at 1:20 p.m., she took another bite of food and coughed again, losing the food from her mouth. Review of latest nutrition assessment for Resident #20, completed by Staff Member F, the RD, and dated 04/06/15, revealed the resident had a 5% weight loss over the previous 3 months, but her weight had been stable during the last month. The most recent weight on the assessment was 126.2 lbs. on 03/18/15. The plan was to provide adequate intake to prevent significant weight change, with a goal weight of more than 125 lbs. Record review of bath book weights after 03/18/15, revealed the following 13 weights for Resident #20: 145.6 lbs. (03/22/15), 119.8 lbs. (04/08/15), 121.2 lbs. (04/12/15), 122.4 lbs. (04/19/15), 122.2 lbs. (04/22/15), 121.4 lbs. (04/26/15), 122 lbs. (04/29/15), 121.6 lbs. (05/20/15), 115.6 lbs. (05/31/15), 118.6 lbs. (06/03/15), 115 lbs. (06/07/15), 116.4 lbs. (06/14/15) and 112.6 lbs. (06/21/15). Between 03/18/15 and 06/21/15, the resident lost 13.6 lb., a 10.8% loss of body weight over an approximate 3 month time period. Review of the weights in the CareTracker system revealed only 5 of the 13 bath book weights were entered in the system after 03/18/15. Weights were entered on 04/08/15, 04/12/15, 04/29/15, 05/20/15 and 06/17/15. There was a 3 lb. or greater difference between the 04/08/15 weight in comparison to the immediately previous weight on 04/08/15. There was also a 3 lb. or greater difference between the 06/17/15 weight and the previous weight. On 06/23/15 at 9:50 a.m., Staff Member J, a Case Manager and LN, stated Resident #20's weight loss had not been reported to him by the bath aides. If weight loss was reported, he stated he worked with the Dietitian to develop a plan to try to correct the issue. In an interview on 06/24/15 at approximately 8:00 a.m., Staff Member F stated she had not heard about Resident #20's weight loss until late last week. The RD acknowledged if all the weights are not entered into the CareTracker system, she may lack the data to accurately assess the resident. On 06/23/15 at 12:20 p.m., Staff Member B, the Director of Nursing Services, stated all weights were to be entered into the CareTracker program and she did not know it was not being done consistently. She stated there was also a communication problem if the RD and the charge nurse were not being notified of weight changes. Failure by the facility to consistently implement a system to record weights disallowed the RD and the charge nurse access to accurate data about weight changes. Further, failure to report and respond to changes in eating abilities contributed to a decrease in food consumption. These failures resulted in continued and avoidable weight loss for Resident's #20 and 82.

Based on observation, interview, and record review the facility failed to complete necessary skin assessments and implement appropriate preventive measures for 1 of 3 residents (#66) sampled for pressure ulcers. This failed practice resulted in the development of a pressure ulcer on the resident's back with subsequent pain/discomfort and potential risk for medical complications. Findings include: Resident #66. Initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. readmitted from the hospital on [DATE] with an additional [DIAGNOSES REDACTED]. On 06/15/15 at 3:00 p.m. the resident sat in her wheelchair. She reported she had a pressure sore on her right heel and another wound on the left side of her back. The resident stated she was scheduled for three showers a week but generally only received one (skin check opportunity). On 06/17/15 at 10:00 a.m. Staff Member K, a Licensed Nurse (LN) reported, When the wound on her shoulder over her (left) scapula (shoulder blade) developed, I did a complete assessment and investigation. She has a backpack over the back of her wheelchair. It has a buckle on one side and I found that's exactly where her wound developed. On 06/23/15 at 3:48 p.m. Staff Member DD, a LN who routinely changed Resident #66's dressing on the left shoulder blade reported she believed the new wound was caused by pressure from the resident leaning against the buckle on the backpack. On 06/24/15 at 7:35 a.m., the resident was dressed and sitting in her wheelchair. Staff Member K changed the wound dressing on the resident's left shoulder blade. The wound was oval in shape, about 1.5 inches by 3.5 inches; it was covered by black/dark brown tissue/eschar (dead tissue) with the exception of a narrow area on the wound's lower edge. A backpack hung over the back of the wheelchair with straps extending over the inside of the chair so when the resident sat in it, her back came in contact with the straps. The nurse said there had been buckles on the straps which the resident sat up against. Staff Member K stated, after the wound developed, the resident's family removed the buckles. The nurse also reported, No, it (the wound) wasn't open when she arrived (on 04/07/15). It opened up after that. During the dressing change, Staff Member K reported when the resident came back to the facility on [DATE], there was no sign of any trauma such as bruising or redness to the area on or about the left shoulder blade. Documentation dated 12/20/14 from the resident's primary physician revealed a history of skin problems including two Stage II (partial thickness skin loss) pressure ulcers in September 2014 and recurring shearing (parallel tissues within the body moved in opposite directions, one cause of pressure ulcers) under left and right buttocks and small ulcers on both thighs due to moving around in (wheelchair). In addition, the resident's history included skin problems of excoriation and blisters on the resident's thighs. On 03/02/15 staff received physician orders [REDACTED].#66's left waist/flank. Licensed staff completed the Braden Scale for Predicting Pressure Sore Risk for the resident on 02/03/15 and again on 04/17/15. The score on 04/17/15 showed the resident had increased in her risk of developing pressure ulcers. Her ability to feel discomfort/pain became slightly limited whereas it had been without impairment on 02/03/15. Related to moisture, the resident's skin declined from occasionally moist to very moist. Additionally, the resident's nutrition declined from excellent on 02/03/15 to adequate on 04/17/15 (good nutrition is important for pressure sore prevention). On 04/15/15 the resident's re-admission assessment noted there was no skin problem on the resident's left shoulder blade. The care plan dated 05/08/15 directed care staff to Assess skin with baths. Report any open or red area to charge nurse. However, the care plan did not include specific interventions related to the wound on the resident's left shoulder blade. Documentation from the resident's hospital stay in April 2015 did not identify any skin issue on the resident's left shoulder blade. Licensed staff documented on treatment sheets completion of skin assessments every one to two weeks for the wound on the resident's right heel, every week for the wounds on the resident's right and left inner/posterior thighs, and every two to three days for the wound on the resident's left posterior hip/flank. Although the Licensed staff were completing treatment on previously identified wounds, there was no documentation to reflect general skin audits were conducted for potential skin breakdown. On 05/22/15 a LN wrote, (Caregiver) called LN into resident's room, left shoulder below scapula above bra band is an 8 cm (3.5 inches) round-like area with 7 cm (3.25 inches) scabbed. On 05/26/15 Staff Member K wrote, Due to resident's morbidities (health issues) of diabetes, [MEDICAL CONDITION] (weight over 300 pounds), diabetic [MEDICAL CONDITION] (altered/decreased sensation), leukocytosis (increase of white blood cells generally caused by an infection), and [MEDICAL CONDITION], it is believed resident is prone to skin breakdown. During my investigation this LN noticed backpack strapped to wheelchair with straps coming over front side of wheelchair with buckles approximately at same level as wound. It is noted resident leans more to left side, possibly putting pressure causing breakdown.Resident also lies in bed on left side which could also exacerbate that area on left scapula. On 05/29/15 documentation from the local wound clinic included, Left Scapula - 5 cm x 2.5 cm (about 2.25 inches x 1 inch), black eschar (dead tissue). Despite the facility identifying the resident at high risk for skin breakdown, the facility failed to perform frequent and thorough skin assessments of the resident to identify early signs and symptoms of skin breakdown before the resident developed a pressure ulcer with eschar (dead tissue/necrosis) to the area over/around her left shoulder blade. The facility failed to recognize when the resident was up in her wheelchair, the buckles on the resident's backpack and the way she tended to lean to her left were potential risk factors to the development of the pressure sore on the left shoulder blade.

Based on observation, record review, and interview, the facility failed to recognize the ongoing risk that existed for facility residents and implement necessary protective measures to ensure resident safety. Deficient practice was identified for 5 of 9 sampled residents (#1, #2, #6, #7, & #8). Resident #1, was admitted to the facility with a history of inappropriate sexual touching of peers and staff at the previous facility. After placement at the current facility, there were ongoing sexual behaviors including sexual touching of Resident #2 and unwanted touching of Resident #8, thought to have sexual intent. Resident #2 was exhibiting alterations in her thought processes resulting in sexual behaviors and potentially self-injurious behaviors necessitating close staff supervision to ensure her safety. The facility's failure to identify the ongoing risk of recurrence and the failure to implement necessary supervision resulted in a finding of Immediate Jeopardy. Findings included but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] from a specialty hospital setting. The resident had multiple medical [DIAGNOSES REDACTED]. Record review noted physician documentation, dated 8/23/13, from the hospital stating the resident was showing signs of "mental and physical deterioration characteristic of (his physical condition). Insight and judgment are grossly impaired. He has difficulty processing information." The 9/03/13 Psychosocial Assessment at the hospital documented the resident had demonstrated significant improvement in his behaviors that lead to a discussion about discharge. "Then there would be an incident of (the resident) inappropriately touching the breast of a female peer or staff. He would be put on hold for a month and would seem to be doing fine, be referred again, be on the waiting list for placement for months and then have another episode of inappropriate touch. This happened two or three times." While at the specialty hospital, the resident received injectable anti-psychotic medication to treat his symptoms. The facility's Pre-Admission Inquiry, dated 12/30/13, documented a list of behaviors of concern while at the specialty hospital including: refusal of food, delusions of angels telling him not to eat, fear of baths related to fear of drowning, aggressive behaviors, masturbation, and sexually inappropriate behaviors. On 9/17/14 at approximately 1:55 p.m., Staff Member A, the Social Service Director, was interviewed about the specific behaviors reported under the category of "sexually inappropriate" behaviors. Staff Member A recalled receiving the inquiry and hearing about the resident occasionally touching staff, "nothing toward other residents." Review of the Resident #1's current Behavioral/Environmental Plan revealed the resident's target behaviors/symptoms included monitoring sleep hours; refusal of medications, treatments, and cares; and sexually inappropriate touching. No resident specific interventions were documented to address the sexually inappropriate touching that was identified as a behavioral issue for the resident. The nursing care plan, printed 6/11/14, noted the resident had altered thought processes with auditory hallucinations and delusions. Additionally, it was documented he had a history of [REDACTED]. The resident was the recipient of additional community mental health support services and received visits from the mental health providers at the facility. According to the care plan, Resident #1 received long acting Haldol (an anti-psychotic) injections every four weeks to address his sexual inappropriateness and aggression. The 6/18/14 nursing entry documented the resident was "sexually inappropriate in dining room during lunch." The resident was encouraged to go to his room where he had privacy. The mental health worker met with the resident on 6/19/14 and "explained to (the resident) that sexually displaying behavior was not appropriate in public." A 6/19/14 3:51 a.m. nursing entry documented, "Res. (resident) tried to kiss another resident and an NAC (nursing assistant) but was redirected before he could do it." Later during the day on 6/19/14 the mental health worker documented, "Accepted redirection from kissing writer." Two entries from the mental health worker on 6/20/14 noted the resident was sexually inappropriate with a licensed nurse (LN) who was fixing his blankets. Later the mental health worker conferenced with the Director of Nursing about the staff report that the resident was following female NAs. There was a recommendation to utilize male NAs as much as possible. Review of a Medication Management Note, dated 7/09/14, documented the resident had experienced an increase in hypersexual behavior. "He has attempted to grope several staff members and also attempted to kiss them." A 7/17/14 nursing entry noted the Nurse Practitioner (ARNP) was at the facility. Staff reported to her about the resident's increase in sexual inappropriateness. Over the weekend the resident had grabbed hold of a specific NA in the hall and attempted to kiss her several times and would not left go until another staff member intervened. Identified Staff Member B, a NA, was interviewed, on 9/17/14 at approximately 9:50 a.m., and stated on one occasion Resident #1 had tried to rip her scrub top off her in the dining room. The resident didn't understand boundaries. On another occasion he had grabbed her arms while she was in the hallway. On 7/17/14 there was a new order to decrease the interval of the Haldol injections from every 28 days to every 21 days. Despite the new order, the 7/2014 and 8/2014 medication administration records (MARs) documented an interval of 25 days between injections instead of 21 days as ordered. Administrative LN C was interviewed on 9/17/14 at approximately 10:55 a.m. and stated she was not notified about the medication error/delay in administration. According to the 8/24/14 nursing entry, at 2150 (9:50 p.m.) on 8/23/14, Resident #1 was involved in a resident to resident incident. Resident #1 was found in his room giving a female resident (Resident #2) a breast massage with his hands under her shirt. Resident #2 was seated in a chair in Resident #1's room and Resident #1 was standing behind the chair. The facility investigation, dated 8/23/14, recorded Resident #1 had been going after female staff that evening and was repeatedly redirected. Staff Member D, a NA, arrived at the room (where three male residents resided) to answer a call light. As noted above, Resident #2 was seated in a chair and Resident was standing behind her with his hands under her shirt rubbing her breasts. Staff Member D asked Resident #2 to leave. She was initially mad and refused but eventually left. Resident #1 then came after Staff Member D so she ran away and closed the door. Staff Member D was interviewed on 9/16/14 at approximately 11:18 p.m. and recalled that on 8/23/14 prior to the resident to resident sexual incident, Resident #1 had been attempting to grab the buttocks of a NAC when she was walking in the hallway headed toward the back unit. Following the resident to resident sexual incident, Resident #1 was out in the hallway. Female Resident #8 was walking in the hallway. Resident #1 was looking at Resident #8's breasts and was attempting to touch her. Reportedly, staff were busy with Resident #1 that evening due to his behaviors. A nursing entry, dated 8/24/14 at 6:20 a.m. documented Resident #1 had been persistent about "being around the resident he had resident to resident with." The 8/24/14 8:30 p.m. nursing entry documented Resident #1 was "holding his hands on (Resident #8's) shoulders (and) trying to get his hands lower toward res's (resident's) breasts." Resident #8 was stating, 'Do not touch me.' Resident #1 was stopped and redirected to his room. Review of the 8/2014 behavior monitoring sheet noted the resident demonstrated sexually inappropriate touching during the day shift of 8/28/14 but no details were documented. On 9/16/14 at approximately 1:32 p.m. Resident #1 was observed walking independently in the hallway toward the area of the day room. On 9/16/14 at approximately 3:10 p.m., Staff Member F, Social Worker, stated she had not been aware of any other sexual behaviors (except on 8/23/14) directed toward other residents, only the caregivers. Reportedly, Resident #1 walked up and down the hallways and enjoyed going out onto one of the outside patios. On 9/17/14 at approximately 11:30 a.m., Staff Member E, the Nurse Manager, was interviewed about Resident #1 and his behavioral issues. Staff Member E stated there were issues around care and masturbation. When asked about the details of the 6/18/14 incident in the dining room, she stated he might have been trying to touch himself (his private parts) so he was redirected to his room. Staff Member E stated she was aware he had attempted to kiss the mental health worker a time or two. When asked which resident Resident #1 had attempted to kiss on 6/19/14, the Nurse Manager stated she "vaguely" recalled and thought it was Resident #9. Staff Member E could not recall the specific details/timeline pertaining to the medication delay/error. Staff Member E printed care directives for staff contained on the computer. The directives for Resident #1 identified he needed two person care due to his sexual inappropriateness. Staff were to tell him what he did was inappropriate and if inappropriate to caregivers they were to document in the system, their approaches, and report to social service staff and/or the nurse. The facility failed to recognize Resident #1's history of sexually touching his peers. Staff characterized his sexual behaviors as only directed at staff or himself. However, some his sexual behaviors were associated with care and possible misinterpretation of intent but other behaviors were aggressive, seeking behaviors. The facility failed to identify his attempt to kiss another resident and a mental health worker as additional problematic behaviors requiring specific interventions. Depite the sexually aggressive/touching behaviors directed at residents thereafter, there were no specific interventions related to supervising Resident #1 to protect his peers and others visiting the facility. Resident #2: Review of the medical record revealed the resident was admitted from a specialty hospital on [DATE] with multiple [DIAGNOSES REDACTED]. She was placed at the facility with legal requirements that she take her medications. According to her plan of care the resident was independent with transfers and ambulation. The 8/01/14 comprehensive assessment noted the resident had not displayed any aggressive physical or verbal behaviors and she had not exhibited other inappropriate behaviors (such as disrobing). The 8/05/14 care conference note documented Resident #2 had demanded to leave, had paranoid accusations, was very guarded, and had negative statements at times. She did appear to respond to internal stimuli. The resident "mostly appears pleasant with staff and residents." She would "sit in the foyer or hall and talk to people as they walk by." An 8/18/14 nursing entry documented the resident was "very suspicious about her medications." On 8/20/14 the resident requested a room change to a room (two doors down from Resident #1 per observation on 9/16/14 at approximately 5:00 p.m.). Later on 8/20/14 Resident #2 began yelling at another resident for taking her seat in the dining room. Review of the 8/2014 MAR revealed the resident had refused some of her medications but beginning 8/21/14 she began to refuse her psychoactive medications. An 8/21/14 late evening shift entry documented the resident had made physical advances toward the LN with her arms/hands out as if she was gong to choke the LN and the LN had to back away. On 8/22/14 the entry noted the resident was not compliant with her medications , she was yelling out, cussing, slamming doors, and wearing dark glasses. She was to be placed on alert with the mental health professionals. A late 8/22/14 nursing entry noted a dinner knife was found hidden in the resident's room. The resident had been yelling profanities all shift and had refused care. According to the 8/23/14 nursing entry during the night shift, the resident had been yelling and cursing at staff and accusing them of stealing her clothes. She went to the dining room and stripped her shirt off. She was also in the family room throwing books and magazines. A 15 minute staff check was initiated. The Mental Health Professional (MHP) arrived and evaluated the resident. The corresponding nursing entry documented recommendations to continue every 15 minutes checks and continue to attempt to give the (as needed) psychoactive medication. Staff were to send the resident to the hospital for an infection work-up as she would not allow the testing at the facility. Review of the 8/23/14 report from the MHP noted she had attempted to locate placement for mental health treatment at two settings but there was no bed availability. "Recommendation was made for a 1 on 1 sitter to provide additional support and supervision for the ct. (client) as behavioral concerns persisted. Ct will continue to be monitored by (facility) staff and alternative placement options will be considered as available." Staff documentation noted every 15 minute checks rather than direct one on one supervision. Resident #2 was sent to the hospital on [DATE] and was medically cleared. Staff spoke to a MPH during the evening shift. An 8/23/14 9:50 p.m. entry documented a NA reported a resident to resident incident. Resident #2 was found in another resident's room (Resident #1) sitting in a chair with a male resident standing behind the chair with his hands under her shirt giving her a breast massage. The resident was "mad when told to leave." She said she was looking for ice. The MPHs were notified after the incident. When interviewed on 9/16/14 at approximately 11:18 p.m., Staff Member D, the NA who discovered the residents engaged in the sexual touching on 8/23/14, recalled the details as noted above. Reportedly, on other occasions Resident #2 would lie on her bed without clothes from her waist down and her legs apart (exposing her private parts). Staff would pull the privacy curtain if they observed her exposed. The resident remained on every 15 minute staff checks despite the resident to resident incident. Resident #2's supervision plan had not been enhanced despite awaiting a placement in a psychiatric facility related to her instability, medication non-compliance, and her ongoing behaviors and recommendation for 1 on 1 staffing. An 8/24/14 late entry for the (previous) night shift documented the resident casting spells, cursing, and screaming at people. She was found with a gait belt (canvas type belt utilized by caregivers for transferring residents) wrapped across her shoulder and then wrapped around her neck. She was sitting in the dining room with the male resident she previously had a resident to resident incident with. There was no touching noted but when separated she became angry. She appeared to be talking to several people who weren't there. There was no documentation of how and where the resident found the gait belt. According to the 8/24/14 8:30 a.m. nursing entry, when the LN arrived at the facility she found Resident #2 sitting in the hall with "two gait belts around her neck". It took four individuals to surround her to remove the belts. The resident was striking out at staff. The physician ordered the resident be sent to the hospital. The MHP had been called and he refused to come to the facility because of the presence of a gastrointestinal outbreak at the facility. The resident was sent to the hospital, received some psychoactive medications, and was returned to the facility. After her return she took some of her medications but continued to demonstrate aggressive and unstable behaviors. The nursing entries on 8/25/14 on the night shift documented continued every 15 minute checks. The resident continued to be paranoid with staff. The MHPs came to the facility on [DATE] and she was detained to a psychiatric facility. On 9/17/14 at approximately 11:30 a.m., Staff Member E, the Nurse Manager, was interviewed about the resident's baseline behaviors. Prior to the refusal of her medications there were no noted sexual behaviors. The facility was unaware of the MPH's recommendation for 1 on 1 staffing (on 8/23/14). Despite the staff reports of being unaware of the MHP recommendations for 1 on 1 staffing, Resident #2's altered thought processes, sexual behaviors, aggressive behaviors, and potentially self injurious behaviors while awaiting psychiatric detention necessitated one on one supervision to protect the safety of the resident and other facility residents. Resident #6: Review of the medical record revealed multiple [DIAGNOSES REDACTED]. The resident's plan of care identified she was at risk for falling. The resident was unable to walk even with assistance. She exhibited behaviors that included hitting, striking out, and resistance to care. Observations on 7/16/14 at approximately 4:45 p.m. noted Resident #6 was in the hallway in a reclining wheelchair. The wheelchair was angled away from the wall with her feet extending into the hallway. The resident demonstrated fierce facial expressions, angry vocalizations, and kicking/grabbing behaviors directed at others who were within her reach, staff and other residents. Staff Member G, a LN, was positioned further down the hallway involved in the process of medication preparation and administration. The LN stated the resident been in the dining room but residents needed to enter the dining room for the dinner meal. Thus, the resident had been positioned in the hallway. The LN expressed concern about Resident #6's fall risk if placed in her room. Although NAs were in and out of the area near Resident #6, there was no consistent supervision of Resident #6 and the other residents who were passing Resident #6 to go to the dininig room. At approximately 4:50 p.m. on 9/16/14, the LN's eyes were directed on her medication book. Resident #7 was walking down the hallway next to Resident #6. As Resident #7 attempted to pass by Resident #6 she reached out, grabbed his shirt, and began to forcefully pull him toward her. The Investigator intervened to free Resident #7 from the grasp of Resident #6. Although other staff intermittently interacted with Resident #6 while in route to other destinations/duties, it was approximately 5:08 p.m., more than 20 minutes before a staff member responded to stay with Resident #6 to monitor her safety and to ensure the safety of the others including residents who were walking in the hallway to and from the dining area and other adjacent areas. The facility failed to implement sufficient, timely supervision to maintain resident safety.

Based on observation, record review, and interviews the facility failed to ensure adequate supervision was provided to prevent accidents for 1 of 3 residents (#1) reviewed for falls. This failed practice resulted in actual harm to Resident #1 who fell out of her wheelchair (w/c) and sustained a large laceration to her forehead requiring 13 stitches. Findings include: Resident #1: Had [DIAGNOSES REDACTED]. Review of an annual assessment dated [DATE] noted the resident required extensive assistance with all activities of daily living. Documentation noted the resident leaned forward in her wheelchair when fatigued. Review of an investigation report revealed on 6/6/14 at 1:30 p.m. Staff Member A (Nursing Assistant) was in the process of transferring the resident from her reclining w/c to her bed. Staff Member A was in the back of the w/c using the release pedal to bring the chair forward from the reclined position. The chair went forward faster than expected ejecting the resident out of the w/c onto the floor. The investigation noted the resident's weight (100 pounds) and her stiff body contributed to her falling forward from the chair. The investigation noted the resident's risks for falling were poor balance, immobility, impaired cognition, and loss of range of motion. The resident sustained [REDACTED]. She was transferred to the emergency room for treatment. Staff Member B (Nursing Assistant- primary caregiver for resident) stated on 6/17/14 at 1:10 p.m. that for approximately 1.5 years the resident had a tendency to lean forward in her wheelchair. She also stated she seemed more contracted and rigid. She would hold onto the resident's left shoulder when engaging the w/c to go forward from the reclined position so she would not fall forward. She stated the w/c needed to be engaged slowly. An interview on 6/17/14 at 1:20 p.m. with Staff Member A revealed she did not care for the resident on a consistent basis. She stated the resident sat in her wheelchair with her shoulders hunched forward and her body was stiff. When she released the w/c forward from the reclined position on 6/6/14 the resident fell forward out of the w/c so fast she was unable to stop her from falling. She stated she had not placed her hands on the resident during the process. On 6/17/14 at 1:00 p.m. the resident was observed seated in her w/c with a seat belt around her waist. The w/c was tilted back and her shoulders were flexed forward (not touching the back of the w/c). Staff Member B engaged the w/c slowly to an upright position while keeping her hand on the resident's left shoulder. Despite the slow engagement of the w/c and holding the resident's shoulder she still leaned extensively forward during the procedure. Following the resident's fall on 6/6/14 she was seen by the Physical Therapist (PT) on 6/9/14 to assess her w/c posture. He recommended a shoulder type harness to be utilized to maintain the resident's posture in the w/c. A seat belt was approved until the harness was obtained. A telephone interview on 6/17/14 at 3:50 p.m. with the PT revealed the resident sat in her w/c in a forward flexed position. In addition she did not have any trunk control and was "so rigid" thus had no "balance reaction" when her position was being changed. He stated the resident was at risk for falling if not positioned correctly. Despite the resident's [DIAGNOSES REDACTED].

Based on record review and interviews the facility failed to ensure 1 of 2 sampled residents (#1) at risk for developing pressure ulcers received timely treatment to promote wound healing. The facility failed to ensure Resident #1's pressure ulcer did not progress and/or that he received emergent care and services as necessary. This failed practice resulted in actual harm to the resident as his pressure ulcer worsened resulting in bone infection and probable amputation. Findings include: Resident #1: admitted to the facility with [DIAGNOSES REDACTED]. Review of Progress Notes dated 7/16/13 revealed the resident developed a Stage II (partial thickness skin loss - superficial in nature) open area to the lateral side of the left heel measuring 0.2 by 0.2 inches, no depth, with a pink wound bed. Despite four different treatments being prescribed by the physician between 7/16-8/1/13 the wound had worsened as evidenced by an increase in size to 0.68 by 0.4 inches with a depth of 0.12 inches with scant drainage. On 8/1/13 a culture was obtained of the above wound drainage with the results obtained on 8/5/13 noting a bacterial infection that was highly resistant to many antibiotics. Documentation stated the physician was notified by a Licensed Nurse and "awaiting any new orders." On 8/8/13 the resident's body temperature was elevated at 99.8 degrees and Tylenol with cooling measures were instituted. In addition, there was a small to moderate amount of bloody drainage present on the dressing to the left heel. Despite the resident's wound infection and elevated body temperature there was no further attempt to notify the physician until 8/9/13 (four days later) at which time he was faxed relative to the lab results noting an infection. The physician ordered antibiotic therapy on 8/9 and the first dose was administered on 8/10/13. Documentation between 8/9-12/13 noted the wound had increased in size to 0.8 by 0.4 inches, depth of 0.08 inches with large amounts of reddish-yellow drainage with a foul odor and a small amount of dead tissue present. On 8/17/13 the nursing assessment revealed there was a copious amount of tan drainage, wound edges were hard and pale with redness around the wound. A repeat wound culture was obtained on 8/22/13 with results noting the same bacterial infection as previously treated on 8/10/13. Antibiotic therapy was again prescribed by the physician of 8/25/13. On 8/26/13 at 8:00 a.m. a nursing assessment by Staff Licensed Nurse A, revealed the left heel wound appeared to be "resolving" as wound filling in with new tissue. The resident's family member requested a referral to the wound clinic. A second nursing assessment later that day at 7:00 p.m. stated there continued to be tan drainage and a dark color appeared to be around the edges of the wound. A nursing assessment dated [DATE] stated left heel wound appeared to be "resolving slowly". Review of the physician assessment at the wound clinic dated 9/3/13 noted the pressure ulcer was a Stage IV (full thickness skin loss with extensive destruction), size measuring 0.6 by 0.4 inches with a depth of 0.48 inches, "very deep, all the way into the bone." There was dead tissue within the bed of the wound and also bone exposed to the wound with dark gray in color. New treatment orders were prescribed and bone pathology was sent to rule out bone infection. On 9/9/13 a bone infection was confirmed. Review of the physician assessment at the wound clinic on 9/10/13 noted amputation was being considered as a treatment option due to the severity of the wound. A telephone interview on 9/18/13 at 2:10 p.m. with the Wound Clinic physician revealed the facility did not seek appropriate medical attention to determine the cause of the wound and why it was still there when it continued to not improve. Interviewed on 9/18/13 at 3:00 p.m. Staff A, Resident Care Manager, reported he was unaware the wound was as deep as it was; "the wound clinic was able to debride it." An interview on 9/16/13 at 12:14 p.m. with the above resident's family member revealed staff had informed her the resident's wound was improving; however, when she observed it on 8/24/13 the wound was purple/black in color with pus type drainage. Due to her concerns relative to the condition of the wound she requested a referral to the wound clinic that following Monday (8/26/13). Although the facility was attentive to wound treatments and sought changes in wound treatment it worsened and/or did not improve. Staff assessments and documentation failed to accurately reflect the wound condition as evidenced by "resolving" and failed to seek further medical attention for the resident.

Based on observation, record review, and interview, the facility failed to provide necessary supervision to: A) to ensure resident care was provided in accordance with the plan of care, including the use of necessary equipment to maintain resident safety; deficient practice was identified for 1 of 4 sampled residents (#1) with injuries sustained during staff handling. Resident #1 did not have bilateral leg rests/foot pedals in place on her wheelchair despite a directive for their use. As Staff Member A, a nursing assistant (NA), pushed Resident #1's wheelchair the resident's foot fell down and was twisted under the wheelchair resulting in a right foot fracture. Additionally, the facility failed to supervise to: B) prevent recurrence of resident to resident aggression for 2 of 4 sampled residents (#10 & #12 ) involved in resident to resident altercations and C) discover a resident was missing and initiate the policy to search/locate the resident for 1 of 2 sampled residents (#5) with elopements. Failure to adequately supervise the residents placed them and/or others at risk for injury or harm. Findings include: A. Prevent unnecessary injury and pain Resident #1: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED].#1 used a wheelchair for transportation and staff was to take her to all destinations as she no longer walked. "Make sure my leg rests (sic) are on my wheelchair & I am completely back in the seat." A 6/21/13 nursing entry, by Staff Member C, an evening shift LN, documented that at 6:00 p.m. the resident was "found to have a very painful ankle, foot & toes of the right lower extremity upon movement." The resident's entire foot was swollen and her great toe was dark purple. Results of the 6/21/13 x-ray revealed a possible acute displaced fracture of the navicular (a bone in the foot), diffuse swelling in the right lower leg and ankle, and osteopenia (a lack of bone). Further CT scanning was recommended. A 6/21/13 physician's orders [REDACTED]. According to the 6/23/13 facility investigative review/conclusion of the 6/21/13 occurrence, after lunch a NA (Staff Member A) was pushing Resident #1 in her wheelchair and the resident's (right) foot got caught and bent back under the wheelchair. At the time, the resident only had one foot pedal in place on her wheelchair. According to the Staff Member A the other foot pedal could not be found. Another nursing assistant (Staff Member D) was following behind and reported Staff Member A was going a little too fast and the wheelchair was not tilted back. The Case Manager (LN) was not notified but the Medication LN (Staff Member B) was notified of the incident and pain medication was requested for the resident. At 6:00 p.m. the resident was found to have a very painful ankle foot and toes. An additional pain medication was requested from the physician. The wheelchair was replaced. Review of the June 2013 medication administration record (MAR) revealed the resident was provided Tylenol for foot pain on 6/21/13, 6/23/13, and on 6/25/13. The June 2013 MAR also documented on 6/26/13 at 4:45 p.m. the resident was experiencing 10 out of 10 right foot pain (ten being the highest rating), she was crying, and received another type of pain medication. The resident also received pain medication on 7/01/13 per the July 2013 MAR. On 6/28/13 a follow-up x-ray was obtained of Resident #1's right foot. A (bone) chip was noted in the right foot. It was difficult to determine whether the chip had come from the navicular bone or the adjacent bone. Soft tissue swelling was evident. A resident observation on 8/28/13 at approximately 12:15 p.m. noted the resident was seated in the dining room in her wheelchair with two leg rests in place. When interviewed on 8/30/13 at approximately 12:20 p.m., Staff Member F, a NA who frequently cared for Resident #1, recalled that one of the leg rests on the wheelchair wouldn't lock properly and would swing to the side but he continued to place the leg rest. Staff Member F recalled about a week before the incident, the problem with the wheelchair leg rest had been reported and they were awaiting repair. Staff continued to use the wheelchair despite the problem with the leg rest/foot pedal. Staff Member A, a NA, interviewed on 8/30/13 at approximately 11:25 a.m. stated she did not typically work with the resident. On 6/21/13 at approximately 1:30 p.m. she moved the resident from the dining room. The resident did not have one of the foot pedals (leg rest). She stated there had just been one foot pedal for a while. Reportedly, on 6/21/13 somehow Resident #1's foot went underneath the wheelchair and bent back as she was transporting the resident. The resident screamed out. Staff Member A wheeled the resident to her bedroom and left her for another caregiver(s) to assist her into bed. On 8/28/13 at approximately 2:45 p.m. Staff Member D, a NA, stated on 6/21/13 she was behind Staff Member A as she exited the dining with Resident #1. She observed that Resident #1 was upright in her wheelchair moving fast. Staff Member D heard the resident scream out and saw her leg go back (under the wheelchair). Staff Member D was in the resident's room later to check on her and she noticed the resident was having pain in her leg with movement. REFER TO F-309. Despite ongoing problems with the wheelchair leg rest/foot pedal, facility staff continued to use the wheelchair. Failure to support the resident's leg/foot adequately placed the resident at risk for injury and on 6/21/13 the injury occurred. B. Resident to resident altercations: Resident #10: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to the plan of care, the resident frequently walked without staff assistance to the point of fatigue. A social service assessment, dated 7/09/13, noted the resident responded to internal stimuli (hallucinations or irrational thoughts) a majority of the day and occasionally demonstrated aggressive behaviors. He was noted to be moderately impaired for decision making. Review of facility investigative documentation noted the resident had been involved in multiple resident to resident altercations typically without any provocation. According to an 8/01/13 nursing entry and facility investigative documentation, Resident #10 approached Resident #11 in the dining room stating he thought she had stolen a tool from him. Resident #10 struck Resident #11 in the face twice causing a red mark on her cheek and a small cut on the inside of her lip. Resident #10 received additional medication and remained in his room thereafter. Per an 8/15/13 7:00 a.m. nursing entry Resident #10 had pushed another resident (Resident #9) hard enough for her to lose her balance and fall on the floor. Resident #10 was redirected to his bedroom and given extra medication to address his agitation as well as his routine medications. The resident did not stay in his room. An 8/15/13 7:30 a.m. nursing entry documented Resident #10 entered the dining room and pushed another resident (Resident #12) hard enough for her to fall to the floor. The investigative document noted Resident #12 sustained an abrasion near her left eye/cheek and a right knee abrasion. One on one supervision was initiated after the second incident. Resident #10 was sent to the hospital for a psychiatric evaluation. Observation of Resident #10 on 8/28/13 at 1:35 p.m. noted he was walking up and down the hallway with a blank expression on his face and did not respond verbally when addressed. When interviewed on 8/30/13 at approximately 4:45 p.m. Administrative Staff Member E stated there had been no enhanced supervision for Resident #10 following his first episode of aggression on 8/15/13. He was sent to the hospital after the second incident. Despite facility knowledge of Resident #10's demonstrated aggressive behaviors toward Resident #9 on 8/15/13, and other occasions, there was no evidence of enhanced staff supervision to protect other residents. Resident #10 pushed another resident resulting in some superficial injuries and distress for Resident #12. C: Elopement: Resident #5: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident was on a fluid restriction. He received multiple psychoactive medications for management of his mental health issues. A social service assessment, dated 6/20/13, documented the resident's decision making was moderately impaired and his judgment and insight were very poor with an illogical flow of ideas and delusions. The resident's plan of care noted he transferred and ambulated independently at times and at other times he required assistance with walking and even used a wheelchair on occasion. The plan of care also documented, "I need help w/ (with) key pads & do not use my call light." According to a nursing entry on 7/04/13 at 11:00 p.m., the resident left the building without permission. Another facility resident was on an outing and when he returned he stated Resident #5 was at a local grocery store bumming cigarettes. Staff drove to the grocery store and picked up Resident #5. Upon his return Resident #5 was intoxicated and stated he had a 24 ounce Old English (beer) and a cigarette. The facility investigation, dated 7/04/13, identified the resident was last seen by staff at 7:30 p.m. when he received a snack. No one saw him leave the building and staff were unaware he was missing. The resident was returned to the building at 10:30 p.m. (3 hours later) after staff were notified by another resident. No injuries were identified. The resident went to bed but didn't stay there very long. Resident #5 got up and became verbally and physically aggressive with a LN. One on one staff supervision was then initiated. The resident asked another resident to assist him over the facility fence. The mental health professionals were contacted and the resident was sent to the hospital for an evaluation. Observations on 8/28/13 at approximately 3:10 p.m. revealed Resident #5 interrupted a conversation with the Investigator and Staff Member B multiple times requesting assistance to ensure he was able to see the psychiatrist due to concerns about his medications and possible side effects. Despite a suggestion about who to talk with, he continued to reapproach Staff Member B with the same request. On 8/28/13 at approximately 3:55 p.m., Staff Member G, an evening shift Nursing Assistant (NA) stated that on 7/04/13 she and Staff Member H, a NA, teamed together to care for a group of assigned residents including Resident #5. Staff Member G recalled seeing Resident #5 sometime between 7:00 p.m.-7:30 p.m. at the smoke break but did not see him after that. Typically, the resident walked around, played cards, went outside, or went to the lobby but was generally in bed around 9:00 p.m. The resident was pretty independent but needed caregiver assistance to remove his leg wraps in the evening. When interviewed on 8/28/13 at approximately 4:00 p.m., Staff Member H recalled the resident was talking about beer in the dining room on 7/04/13 but she didn't think anything about it. They were very busy caring for other residents that evening and heard about the resident's elopement the next day after returning to work. On 8/28/13 at approximately 11:30 a.m. Staff Member E stated staff were supposed to check on residents every two hours. Resident #5 was last seen three hours earlier on 7/04/13 and staff were unaware he was missing. On 7/04/13 Resident #5 exited the building without staff knowledge. Although the resident was relatively independent with his activities of daily living, he required staff assistance during the evening shift for removal of leg wraps and for medication administration at bedtime. Caregivers failed to check on his whereabouts/provide supervision and were unaware he was missing. Meanwhile, the resident was in the community for approximately three hours (much of the time in the dark) panhandling and drinking alcohol, an activity that posed some risks with his psychoactive medications and his health conditions. Resident #5 required supervision within a structured environment due to mental health conditions and associated behaviors.

Based on observation, record review, and interview, the facility failed to provide sufficient supervision to prevent accidents for 1 of 4 sampled residents (#1) reviewed for falls and associated injuries. Resident #1 was given a medication with sedating side effects, was noted to have difficulty walking, and then fell twice sustaining injuries. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to a physician's history and physical, the resident was hosptalized on [DATE] because of increased aggressive behaviors. The resident was re-admitted on [DATE]. The 2/02/12 admission nursing entry documented the resident walked in the hallway without any behavioral problems. He recalled where his room was, entered his room, and rearranged his personal items. Physician orders, dated 2/02/12, included orders to address agitation: Haldol (an anti-psychotic medication) 5 milligrams (mg) orally every four hours as needed, Ativan (an anti-anxiety medication) 4 mg every four hours as needed, and Cogentin 1 mg every four hours as needed. The 2/04/12 nursing entry documented the resident was pocketing food (holding food in the side of his mouth), then drooling most of it out of his mouth as he wandered the unit with a "shuffle gait". Pureed food was provided and the resident was assisted with feeding. On 2/05/12 and 2/06/12 the resident reportedly walked throughout the facility. The 2/07/12 nursing entry documented that at 7:00 a.m. the resident kept coming into a ladies' room repeatedly while they were being dressed. He was not redirectable. The resident received the as needed Ativan and Cogentin. "Resident was then too sleepy to eat breakfast" and was sleeping on his bed at 10:10 a.m. The February 2012 medication administration record (MAR) recorded the resident had "undirectable behaviors" on 2/07/12 and received Ativan 4 mg (for behaviors) and Cogentin 1 mg for increased drooling, both at 9:00 a.m. The psychiatrist visited and wrote an order on 2/07/12 at 9:25 a.m. to decrease the Ativan to 2 mg every four hours as need for agitation and increase the Cogentin to 1 mg twice daily. According to the 2/07/12 nursing entry and facility investigative documents, the resident was seated in the dining room (for lunch) at 12:20 p.m. He got up from the chair, tried to walk forward holding onto an overbed table, fell forward, landed on his knees, and bumped his head on the back of another resident's wheelchair sustaining a 1 by 1 centimeter (cm) skinned spot on the top of his head and a 1 1/2 by 1 cm red area on his forehead. The open area on his head was treated with first aid. A 2/07/12 6:45 p.m. nursing entry documented that staff found the resident sitting on the floor next to the dining room. There was a 1 1/2 inch laceration on the back of his head. Staff were unable to control the bleeding or approximate the wound (get the edges to come together). The resident was sent to the ER and returned to the facility with 7 staples on the back of his head and one on the top laceration (from earlier in the day). There were daily treatments ordered. When interviewed on 2/08/12 at approximately 1:30 p.m., Staff Member B, the Investigative Nurse, stated the Ativan "probably contributed to the falls". Observations on 3/08/12 at approximately 2:06 p.m. and at 3:00 p.m. revealed the resident was lying across the foot of his bed. There was no notable head laceration at that time. Later the resident was walking around the unit. On 3/08/12 at approximately 3:10 p.m. Staff Member A, the Licensed Nurse (LN) on-duty during the evening shift on 2/07/12, stated "He was so wobbly that afternoon". He was basically a "one-on-one" but no specific staff member was assigned to watch him. Staff were in the dining room passing trays. He got up and "sneaked out". "All (the staff members) were just as much at fault." The LN reported the resident was seated against the north wall of the dining room at a bedside table (half the way across the dining room). She also identified where he was found, across the hallway outside the dining room. Observations revealed that the resident would have had to walk across the dining room, down the narrower exit corridor in the dining room , and across the hallway where he appeared to fall against the handrail (per report of blood on the handrail). Despite knowledge of the resident receiving a large dose of Ativan with sedation lasting into the evening, staff failed to provide sufficient supervision to prevent two falls with resulting lacerations and staples to his head.

Based on observation, record review, and interview, the facility failed to ensure necessary care and services were provided to maintain the highest level of physical well-being for 1 of 3 sampled residents (#1). Resident #1 experienced harm, a severe erosion of his penis, related to unrelieved pressure in conjunction with the use of a urinary catheter. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The initial nursing assessment did not document any abnormal findings on the resident's penis. The plan of care documented the resident was to receive catheter care at the facility including washing his perineal area every evening and emptying the catheter bag every shift. The resident also wore disposable briefs. He did not wish to be awakened at night to use the bathroom. The resident was sent to the urology clinic for monthly catheter changes. A 7/23/10 note from the urology clinic documented the resident's catheter had been changed and he was to return to the clinic in one month. In addition, the note stated, "Please don't let (the resident) sit on catheter it is causing urethral erosion and bleeding". A corresponding physician's orders [REDACTED]. There was no facility assessment identifying: the onset of the erosion of the penis, measurements, possible contributing factors, and alternative approaches to promote healing and to prevent further injury. Despite the directives from the urology clinic, the directives were not added to the Physician order [REDACTED]. The 9/2010 flow sheet stated, "Avoid sitting/lying on R/C (catheter) tubing r/t (related to) penile (penis) erosion". Licensed Nurses (LNs) were to sign every shift. The care plan was updated for the Nursing Assistants (NAs) to make sure the catheter was not under his leg and not to let the resident sit on the catheter as it was causing urethral erosion. There was no date when the intervention was added. The resident's catheter was changed in the urology clinic on 10/21/10. It was noted that a urine specimen was sent for a culture and antibiotics were ordered. The resident had a hospitalization and returned to the facility on [DATE]. The admission nursing assessment by LN#1 documented no abnormal findings related to the resident's genitalia. However, the plan of care documented, "Make sure catheter is not under leg and do not let Res. (resident) sit on it. It is causing urethral erosion." A 2/24/11 quarterly assessment by LN #1 also documented staff were to ensure the resident did not sit on the catheter, "this is causing erosion of his penis". Despite the mention of the penis erosion, there was no actual assessment of the size, any changes, or to evaluate the effectiveness of their interventions. A 3/38/11 (sic) nursing progress note documented the resident was on an antibiotic. A&D ointment was being applied to his groin and buttocks where he was excoriated. The resident was complaining of severe pain when the area was washed. There was no assessment of the cause of the excoriation. The treatment continued without further assessment until the resident was admitted to the hospital on [DATE]. Review of the hospital ER records revealed findings that the catheter had eroded "through majority of distal penis inferiorly (the majority of the length of the penis on the underneath side)."Additionally, the ER nursing assessment documented that the urethra had eroded to the base of the penis. The area was very tender to touch. There was also redness to skin of the peri-area. Observation of Resident #1's genitals was conducted on 5/02/11 at approximately 1:20 p.m. The resident stated, "Be careful. You know how tender that is." The resident's penis was split and opened up from the tip to the base. The urethral tissue was exposed and healed over on the underneath surface of the penis. The catheter inserted at the base of the penis. LN #1 stated they had an order for [REDACTED]. Interviewed on 5/03/11 at approximately 2:30 p.m., a staff member who had changed the resident's catheter at the urology clinic recalled the erosion had happened over time. The staff member reported on a concern during the 7/23/10 visit. The catheter was tucked under the resident causing a pressure area/damage. On 10/21/10 he noted there was a lot of blood in the urethra. During the March 2011 (3/22/11) catheter change he stated the erosion was all the way to the base of the penis. Office documentation also noted the issues on those dates. On 5/05/11 at approximately 10:05 a.m., the Director of Nursing stated there was no wound on the resident's penis at the time of his 8/24/09 admission to the facility. The erosion had developed after he arrived at the facility.