Every finding on record at Washington Soldiers Home

Based on interview and record review the facility failed to ensure freedom from abuse, during a resident-to-resident altercation, for 1 of 3 residents (Resident 2) reviewed for resident abuse. This failure placed the residents at risk for injury, psychological harm, diminished feelings of safety and security, and a decreased quality of life. Findings included. Review of the electronic health record on 05/19/2026 showed that Resident 2 admitted to the facility on [DATE], and had diagnoses to include dementia/cognitive decline, stroke with left-sided weakness. Resident 2 was able to make need known, and required minimal to moderate assistance with activities of daily living. Review of the facility incident report dated 05/06/2026 showed that Resident 2 was in the dining room and had moved another resident's (Resident 1) name plate to a different location in the dining room as a joke. When Resident 1 entered the dining room, they sat at the new assigned seat, but staff tried to advocate for Resident 1 and told Resident 2 that they needed to move the name plates back to their assigned places. Resident 2 responded by saying that Resident 1 could, just be a man. At that point Resident 1 physically attacked Resident 2 by grabbing Resident 2's neck from behind and placing them in a headlock. Staff were able to intervene and separate Residents 1 and 2 without injury to either resident. During interview on 05/19/2026 at 11:40 AM Resident 2 stated that they wanted to sit closer to a friend in the dining room, so they moved Resident 1's name tag to a different place, and that didn't go over too well. Resident 2 stated, Resident 1 assaulted me. Physcially. Put me in a head lock. Resident 2 went on to say that it did not cause any injury or pain, and that there wasn't enough force behind it to really do any damage. During interview on 05/19/2026 at 11:54 AM Resident 1 stated that Resident 2 moved their place to another table and attacked their manhood, so they felt offended and attacked Resident 2. Resident 1 demonstrated crooking their arm as if having someone in a headlock and stated, I tried to break [Resident 2's] neck. During interview on 05/19/2026 at 1:30 PM Staff C, Quality Assurance Nurse, stated after the facility investigation was conducted, they did not feel that abuse had occurred since Resident 2 did not feel that they had been abused, and no one had gotten hurt. During interview on 05/19/2026 at 2:00 PM Staff A, Administrator, and Staff B, Director of Nursing, stated that they would not have concluded that there was failed facility practice because there was not anything that the staff could have done differently, and no one could have foreseen the altercation, but stated understanding of the expectation that residents be free from abuse. WAC Reference 399-97-0640(1).

Based on interview and record review, the facility failed to address identified risk factors for the development of pressure ulcers and implement preventative interventions timely for 1 of 4 sampled residents (Resident 3) reviewed for pressure related wounds. Resident 3 experienced harm when they developed two facility acquired pressure injuries after identified pressure prevention strategies, air mattress and heel protection boots, were not implemented timely as recommended. This failure placed residents at risk of development for pressure injury, medical complications, and diminished quality of life.Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) describes/defines a suspected deep tissue injury as: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury can result from prolonged pressure and may either resolve or develop into further tissue loss. Review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated March 2014, showed The nursing staff and Attending Physician/Wound Care Provider will assess and document an individual's significant risk factors for developing pressure sores and identify factors contributing or predisposing residents to skin breakdown. Review of the electronic health record (EHR) showed Resident 3 readmitted to the facility on [DATE] following a hip surgery with diagnoses that included high blood pressure, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 3 was able to make their needs known. Review of the July 2025 incident log showed Resident 3 fell out of their wheelchair and fractured their left hip which required surgery. Review of a progress note dated 07/28/2025 showed Resident 3 readmitted from the hospital with complaints of pain at the surgical site upon movement. Review of the Significant Change Minimum Data Set (an assessment tool) dated 08/04/2025 showed Resident 3 was at risk for pressure ulcer/injuries and did not have any unhealed pressure ulcer/ injuries at the time of re-admittance. Review of a progress note dated 08/01/2025 from the wound nurse showed a recommendation for a low air loss or alternating pressure air mattress and bilateral heel lift boots on at all times for skin integrity/prevention. Review of a progress note, dated 08/04/2025, showed Staff J, Registered Nurse/Resident Care Manager (RN/RCM), Followed up on the request to have a specialty mattress installed related to left hip fracture and non-movement and Custodial supervisor confirms that they are aware of the request and are waiting for proper support as the resident is being resistive and combative about trying to move them to install specialty mattress to prevent skin breakdown. Will continue to monitor and follow up. Review of a progress noted dated 8/13/2025 showed during routine care staff observed Resident 3 had an open sore on the left buttock approximately 1.6 centimeters (cm) x 2.5 cm and a right heel diabetic foot ulcer (DFU) approximately 1.5 cm x 1.5 cm. The progress note showed, Resident has stayed in bed after surgery. Review of a progress note, dated 08/14/2025, showed Resident 3 was enrolled with an outside wound provider for wound #1 left heel (Deep Tissue Pressure Injury) & wound #2 sacrum (lower back) unstageable pressure injury. Review of a progress note, dated 08/15/2025, showed Resident 3's power of attorney (legal representative) was notified of alternating air mattress in place and boots to prevent skin breakdown. Review of the August 2025 treatment administration record (TAR) showed alternating air mattress with a start date of 08/15/2025 and heel lift boots with a start date of 08/14/2025. During an interview on 08/27/2025 at 2:36 PM, Staff J, Registered Nurse/Resident Care Manager (RN/RCM), stated staff should have consistently followed up on the status of the alternating air mattress and the heel lift boots for Resident 3. During an interview on 08/29/2025 at 11:52 AM, Staff B, Director of Nursing Services (DNS), stated staff should have reapproached Resident 3 about implementation of the alternating air mattress and documented the outcome. Staff B stated when a resident refused care or preventative measures the expectation was for staff to document, educate the resident, and contact the provider. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure podiatry (the treatment of feet and their ailments) care and services were provided timely to avoid podiatric complications in residents with diabetes (elevated blood sugar) for 1 of 3 sampled residents (Resident 39) reviewed for foot care. Resident 39 experienced harm when they developed an avoidable foot wound and pain due to wearing ill-fitting shoes that prevented the resident from participating in therapy resulting in a decrease in strength from baseline and a slight functional decline when there was a delay in scheduling a podiatric shoe fitting. This failure placed residents at risk of discomfort, reduced ambulation and reduced participation in activities of daily life. Findings included . Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses that included quadriplegia (medical condition characterized by the complete or partial loss of motor function in all four limbs [arms and legs]), diabetes, and kidney disease (impaired kidney function). Resident 39 was able to make needs known. During an interview on 08/21/2025 at 10:01 AM, Resident 39 stated, They never get things done here. I've been waiting on new shoes for over a month now. Resident 39 stated their current shoes were not wide enough and caused a painful blister on their foot. Resident 39 stated they had not been able to participate in restorative or other activities because they did not have any shoes. Review of a progress note, dated 07/15/2025, showed during routine care Resident 39 was noted with a tender diabetic foot ulcer (DFU) on the bottom of the right foot/sole approximately 1.8 centimeters (cm) x 2.7 cm. Resident 39 stated their shoes were tight. Review of the EHR showed Resident 39 was enrolled with an outside wound provider on 07/16/2025. During an interview on 08/27/2025 at 9:30 AM, Staff J, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 39 informed them that their shoes were not wide enough and requested a podiatry appointment in June 2025. Staff J stated they did not have any information on the status of the appointment. During an interview on 08/29/2025 at 9:22 AM, Staff K, Facility Truck Driver, stated the podiatry referral went in on 07/01/2025 and was approved on 07/02/2025. Staff K stated they did not follow up with scheduling the appointment until 08/27/2025, 56 days later. Review of Resident 39's Resident attended/participated in Restorative Therapy Task for August 2025 showed Not available was marked daily from 08/07/2025-08/28/2025. No documentation for participation was located for 08/01/2025-08/06/2025. Review of the PT evaluation, dated 08/29/2025, showed Resident 39's transfer prior level of functioning was Total A (76-99% assistance) on 06/26/2025 and was assessed to be Dependent (100% assistance) on 08/29/2025. During an interview on 08/29/2025 at 10:57 AM, Staff O, Director of Rehabilitation Services, stated Resident 39's 08/29/2025 physical therapy evaluation showed a decrease in strength and had slight functional decline since discharge from Physical Therapy. Staff O stated they were surprised to hear Resident 39 had not been participating in the restorative program as exercise was something they enjoyed and was previously self-motivated. Staff O stated Resident 39 stated they were hopeful and willing to participate in therapy. During an interview on 08/29/2025 at 11:44 AM, Staff B, Director of Nursing Services, stated Resident 39's podiatry appointment was needed to get a fitting for shoes, and the expectation was for staff to follow up on appointments that needed to be scheduled for residents during the weekly transportation meeting. Refer to F688 for additional information.Reference WAC 388-97 -1060 (3)(j)(viii).

Based on interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) informed consents accurately completed prior to administering the medication for 1 of 5 sampled residents (Resident 8) reviewed for unnecessary medication use. This failure placed the resident and/or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medications and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 8 readmitted to the facility on [DATE] and was able to make needs known. The quarterly minimum data set (MDS, assessment tool) dated 08/06/2025 showed Resident 8 had diagnoses to include schizoaffective disorder (a mental health condition that affects a person's ability to think, feel, and behave clearly), bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs), anxiety disorder, depression, psychotic disorder (a mental disorder characterized by a disconnection from reality), and post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event). Review of the medication administration record (MAR) dated August 2025 from 08/01/2025 - 08/22/2025 showed Resident 8 received Aripiprazole (an antipsychotic medication) 20 milligrams (mg) once a day for schizoaffective disorder with hallucination and received quetiapine fumarate (an antipsychotic medication) 50 mg in the morning and 100 mg at bedtime for schizoaffective disorder. Review of Resident 8's consent for Aripiprazole, dated 03/18/2025, showed the medication dosage was for 15 mg by mouth, one time a day for schizoaffective disorder, bipolar type. However, the current provider order was for 20 mg via a gastrostomy tube (G-tube, a tube placed directly into the stomach to deliver nutrition, fluid, and medications) one time a day. Review of Resident 8's consent for quetiapine fumarate, dated 03/18/2025, showed the medication was for 100 mg via a G-tube at bedtime for schizoaffective disorder, bipolar type. However, it did not include the current order for 50 mg via a G-tube, once a day in the morning. During an interview on 08/25/2025 at 12:09 PM, Staff C, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 8's informed consents for Aripiprazole, dated 03/18/2025, dose and route was different from the current providers medication order. Staff C stated Resident 8's informed consents for quetiapine fumarate, dated 03/18/2025, was missing the morning dosage of 50 mg and it should have been included in the informed consent. Staff C stated this did not meet expectations. During an interview on 08/25/2025 at 12:46 PM, Staff B, Director of Nursing Services, stated Resident 8's informed consent for Aripiprazole, dated 03/18/2025, did not meet expectations because it was inaccurate for the current medication orders for dosage and route. Staff B stated Resident 8's informed consent for quetiapine fumarate, dated 03/18/2025, did not meet expectations because the dosage of 50 mg to be provided in the morning was missing. Reference WAC 388-97-0260

Based on observation, interview, and record review, the facility failed to ensure personal privacy was protected for 1 of 3 sampled residents (Resident 50) when reviewed for resident rights. This failure placed the resident at risk for embarrassment, a violation of their privacy, and a diminished quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 50 admitted to the facility on [DATE] with diagnoses that included high blood pressure, diabetes (too much sugar in the blood) and dementia (a decline in mental ability that interferes with daily life). Resident 50 was able to make needs known. Observation on 08/22/2025 at 9:27 AM showed a Monitoring in Progress sign on the exterior of Resident 50's room door. Review of Resident 50's EHR showed no documentation of consent to the recording device in their room. During an interview on 08/25/2025 at 10:57 AM, Staff J, Registered Nurse/Resident Care Manager (RN/RCM), stated Resident 50's roommate used an [NAME] (a smart device capable of playing music or recording). Staff J stated all residents who resided in the room with a recording device should have consent in the EHR, and Staff J was unable to locate a consent for Resident 50. During an interview on 08/29/2025 at 11:35 AM, Staff B, Director of Nursing Services, stated the expectation was for a consent to be signed by the resident or resident representative prior to the use of the recording device. Reference WAC 388-97-0360, 0500(1)

Based on observation, interview, and record review, the facility failed to maintain a sanitary and homelike environment for 1 of 4 halls (100 hall) when reviewed for environment. Failure to ensure Resident 19's wheelchair left armrest was in good repair placed the resident at risk for unsanitary conditions and a diminished quality of life.Findings included. Review of the electronic health records (EHR) showed the Resident 19 admitted to the facility on [DATE] with diagnoses to include stroke (blood supply to a part of the brain is suddenly cut off), hemiplegia (total or partial inability to move one side of the body) affecting the right side of the body, and utilized a wheelchair for mobility. Resident 19 was able to make needs known. Multiple observations on 08/21/2025 at 12:27 PM, 08/22/2025 at 12:48 PM, 08/25/2025 at 10:03 AM, 08/26/2025 at 10:56 AM, and 08/27/2025 at 12:54 PM showed Resident 19's wheelchair left armrest's black vinyl covering missing/torn off towards the back of the armrest with exposed cream material/padding. It was not a cleanable surface or a homelike environment. During an interview on 08/21/2025 at 12:27 PM, Resident 19 stated the left armrest of their wheelchair with exposed padding started out small and got bigger. Resident 19 stated the left armrest had been that way for about 10 months or so and staff were aware. During an interview on 08/27/2025 at 12:56 AM, Staff B, Director of Nursing Services, stated Resident 19's wheelchair left armrest was peeling and missing black [NAME] with exposed padding underneath. Staff B stated this was not a cleanable surface and did not meet expectations. Resident 19 told Staff B they had been provided with an armrest a while ago, but it was the wrong kind and had told staff they wanted it replaced with the one they had with an attached cup holder. Staff B was able to locate a document that showed an armrest was replaced on 02/13/2025 for Resident 19; however, no other documentation was found after that date. During an interview on 08/27/2025 at 1:54 PM, Staff A, Administrator, stated Resident 19's wheelchair left armrest condition with exposed substructure cloth which was not addressed prior to now did not meet their expectations. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 93 and 5) when reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.Findings included . Resident 93 Review of the electronic health record (EHR) showed Resident 93 admitted to the facility on [DATE] with diagnoses that included chronic pain, anxiety (emotional state characterized by feelings of fear or worry) and diabetes (too much sugar in the blood). Resident 50 was able to make needs known. Review of Resident 93's EHR showed hospitalization on 06/01/2025 and there was no documentation the resident or resident representative was provided with written copies of the bed hold notice or transfer form. During an interview on 08/26/2025 at 1:30 PM, Staff B, Director of Nursing Services (DNS), stated residents were provided with written copies of the bed hold and transfer form upon request. During an interview on 08/26/2025 at 3:20 PM, Staff A, Administrator, stated the expectation was for bed hold and transfer forms to be provided to residents when transferred to the hospital. Resident 5 Review of the EHR showed Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes, depression, heart failure and Charcot's joint (progressive musculoskeletal condition that causes joint instability and destruction in foot and ankle). Resident 5 was able to make needs known. During an observation and interview on 08/27/2025 at 10:06 AM, Resident 5 sat in their wheelchair in the room and stated they were in the hospital for six days and did not know about a bed hold. Review of the EHR showed Resident 5 had a signed bed hold form for leave on pass with family in August 2025, but no signed form for bed hold when they were in the hospital in June 2025. Review of progress notes showed Resident 5's spouse was notified about hospitalization, but there was no documentation about a bed hold, either verbally or in writing. Reference WAC 388-97-0120(4)

Based on interview and record review, the facility failed to ensure the minimum data set (MDS, an assessment tool) accurately reflected the status for 3 of 19 sampled residents (Residents 6, 5, and 1) when reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care needs, inaccurate medical record information, and a diminished quality of life. Findings included .Resident 1 Review of the electronic health record (EHR) showed Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction (paralysis that affects only one side of the body after blood flow to the brain was interrupted), heart failure, dysphagia (difficulty swallowing food or liquids) and dementia (thinking and social symptoms that interferes with daily functioning). Resident 1 was able to communicate their needs. During an observation and interview on 08/21/2025 at 12:24 PM, Resident 1 sat on their bed with an uneaten lunch tray in front of them. Resident 1 stated they did not have an appetite, had lost weight, and were shrinking away. Review of the significant change MDS, dated [DATE], showed Resident 1 was on a prescribed weight loss program. Review of the providers' orders showed Resident 1 had Prostat (nutritional supplement) for decreased muscle mass, dated 08/01/2025, and high calorie shake three times a day for weight loss, dated 07/21/2025. Review of the care plan dated, 02/06/2024, showed Resident 1 had potential for weight loss and multiple interventions to maintain weight. There were no instructions about a planned weight loss. Resident 5 Review of the EHR showed Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes mellites (too much sugar in blood), depression, heart failure and Charcot's joint (progressive musculoskeletal condition that causes joint instability and destruction in foot and ankle). Resident 5 was able to make needs known. During an interview on 08/27/2025 at 10:50 AM, Resident 5 stated they lost a lot of weight because they could not eat the food provided by the facility and they were drinking four shakes a day to help with weight gain. Review of the quarterly MDS, dated [DATE], showed Resident 5 was on prescribed weight loss program. Review of providers' orders showed Resident 5 was ordered Glucerna (supplemental shake) three times a day, dated 07/21/2025. Review of care plan, dated 03/21/2025, showed Resident 5 has a nutritional problem. There were no instructions about a planned weight loss. During an interview on 08/29/2025 at 8:56 AM, Staff B, Director of Nursing Services, stated the MDS on Residents 1 and 5 were coded in error, and the assessments did not meet expectations. Resident 6 Review of the EHR showed Resident 6 readmitted to the facility on [DATE] with diagnoses to include depression and post-traumatic stress disorder (difficulty recovering after experiencing or witnessing a terrifying event). Resident 6 was able to communicate needs. Review of the level I Preadmission Screening and Resident Review (PASSAR, a mental health screening tool), dated 01/07/2025, showed Resident 6 required a level II evaluation referral for serious mental illness. Review of the level II PASSAR Initial Psychiatric Evaluation Summary, dated 02/13/2025, showed Resident 6 was referred on 01/08/2025 and the evaluation was completed on 02/13/2025. Review of Resident 6's admission MDS, dated [DATE], showed section A1500 was coded No for being considered for the level II PASSAR process for having a serious mental illness and/or intellectual disability or a related condition. During an interview on 08/26/2025 at 11:01 AM, Staff G, Registered Nurse/MDS Coordinator (RN/MDSC), stated Resident 6's admission MDS dated [DATE] section A1500 should have been coded Yes and the MDS needed to be modified. During an interview on 08/26/2025 at 11:16 AM, Staff B, Director of Nursing Services, stated their expectation was that nurses followed the guidelines of the Resident Assessment Instrument Manual (detailed instructions on using the MDS assessment form along with care area assessments to develop a comprehensive plan that tracks resident status and aims to improve their well-being) when completing the MDS. Staff B stated Resident 6's admission MDS, dated [DATE], section A1500 was coded No and should have been coded Yes and needed to be modified. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to screen for mental health services on admission for 1 of 7 sampled residents (Resident 30) when reviewed for Pre-admission Screening and Resident Review (PASSAR, a mental health services screening tool). This failure placed the resident at risk for lack of mental health support, increase in adverse behaviors, decrease in mood, and diminished quality of life. Findings included.Review of the electronic health record showed Resident 30 admitted to the facility on [DATE] with diagnoses to include anxiety disorder, diabetes, and chronic kidney disease. The resident was able to make needs known. Review of the PASSAR level one, dated 05/09/2025, showed the Resident 30 required a level two PASSAR assessment. Review of the care plan, initiated 04/18/2025, showed Resident 30 had a level one PASSAR and a level two PASSAR was requested on 05/09/2025. During an interview on 08/27/2025 at 11:51 AM, Staff M, Social Worker, stated residents who admitted from the community would be considered a respite stay and the PASSAR would be completed within the first month of admission to the facility. Staff M stated Resident 30 admitted to the facility on [DATE] without a PASSAR and their PASSAR level one was completed on 05/09/2025. During an interview on 08/27/2025 at 1:46 PM, Staff N, Admissions, stated residents who admitted from the community would not have a level one PASSAR completed before admitting to the facility and the facility social workers would complete the PASSAR level one if it was determined the resident would stay at the facility greater than 30 days. Staff N stated the provider did not determine if the PASSAR level one should be completed or not due to a hospital exempted stay. During an interview on 08/27/2025 at 1:59 PM, Staff A, Administrator, stated the PASSAR level one should be completed prior to admission. Reference WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure license nurses followed orders for applying a splint (device used to immobilize or stabilize a joint or protected body part) and prevalon boots (boots used to relieve pressure on heels) for 1 of 3 sampled residents (Resident 1) when reviewed for positioning. This failure placed the resident at risk for worsening mobility, medical complications, and diminished quality of life.Finding Included.Review of the EHR showed Resident 1 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction (paralysis that affects only one side of the body after blood flow to the brain was interrupted), heart failure, dysphagia (difficulty swallowing food or liquids) and dementia (thinking and social symptoms that interfered with daily functioning). Resident 1 was able to communicate their needs. Observation on 08/21/2025 at 11:28 AM showed Resident 1 laid in bed with no boots or splint on. There was a splint on their nightstand. Observation and interview on 08/22/2025 at 11:26 AM showed Resident 1 had no splint or boots on in bed and Resident 1 stated the staff placed the right-hand splint on them a couple of days ago. Observations on 08/25/2025 at 1:03 PM and 08/26/2025 at 9:09 AM showed Resident 1 did not use their splint or boots. Review of the care plan showed Resident 1 had interventions for right wrist extension splint, dated 04/02/2025, and prevalon boots, dated 04/04/2025. Review of the provider's orders showed Resident 1 had order for Apply right wrist extension splint to right wrist, dated 04/02/2025 and prevalon heel lift boot (or equivalent) to bilateral [both sides] feet/lower legs while in bed, dated 04/02/2025. Review of the treatment administration record for August 2025 showed licensed nurses had initialed the splint and boots were on during the same timeframe of observations on the dates of 08/21/2025, 08/22/2025, and 08/25/2025. During an interview on 08/26/2025 at 9:53 AM, Staff F, Registered Nurse, stated Resident 1 refused the splint in the morning, and the documentation should reflect that. During an interview on 08/29/2025 at 8:56 AM, Staff B, Director of Nursing Services, stated the expectation was for licensed nurses to follow orders and document accurately. Documentation for Resident 1 splint and boots did not meet expectations. Reference WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure residents received treatment and services to increase and/or prevent further decline for 1 of 3 sampled residents (Resident 39) reviewed for limited range of motion (ROM). This failure placed residents at risk for a functional decline, increased dependence on staff, and diminished quality of life.Findings included . Review of the electronic health record (EHR) showed Resident 39 admitted to the facility on [DATE] with diagnoses that included quadriplegia (medical condition characterized by the complete or partial loss of motor function in all four limbs [arms and legs]), diabetes (too much sugar in the blood), and kidney disease (impaired kidney function). Resident 39 was able to make needs known. During an interview on 08/21/2025 at 10:01 AM, Resident 39 stated they had not participated in restorative because they had been waiting for wider shoes to be ordered. Resident 39 stated they felt increased weakness in their legs and could not recall the last time they participated in restorative. Review of Resident 39's 06/26/2025 Physical Therapy (PT) Discharge Summary showed the therapist documented Discharge Recommendations; Restorative Nursing Program for maintenance/build strength. Review of Resident 39's care plan, initiated 05/27/2025, showed the following Nursing Restorative Programs. Level 2 Lower extremity program with 3 pound weights. Vertical/Horizontal bar sit-to stand. Progress as tolerates. Encourage 6 times a week. Chart when participates. Initiated 06/26/2025 Modified Upper extremity program, rickshaw #25. Progress as tolerates. Encourage 6 times a week. Chart when participates. Initiated 07/16/2025 Sci-fit bike 15-20 minutes. Progress as tolerates. Encourage 6 times a week. Chart when participates. Initiated 06/26/2025 Trunk reaching exercises on each side. Progress as tolerated. Encourage 6 times a week. Chart when participates. Initiated 08/01/2025. Review of Resident 39's care plan, initiated on 05/27/2025, showed to Document any care refused by resident, reason for refusal and notify licensed nurse. Review of Resident 39's Resident attended/participated in Restorative Therapy Task for August 2025 showed Not available was marked daily from 08/07/2025-08/28/2025. No documentation for participation was located for 08/01/2025-08/06/2025. During an interview on 08/27/2025 at 8:24 AM, Staff L, Nursing Assistant (NA), stated they did not know why Resident 39 had not been participating in the restorative program. Resident 39 reported to Staff L that they had lost all their strength due to lack of participation in the restorative program and did not know if or when they would participate again. Staff L stated Resident 39 was supposed to be encouraged to participate six time per week but was offered the program approximately three times per week since they had stopped participating. Staff L stated they staffed residents who were not participating weekly but was unable to provide any further information on Resident 39's status with restorative. Review of the PT evaluation, dated 08/29/2025, showed Resident 39's transfer prior level of functioning was Total A (76-99% assistance) on 06/26/2025 and was assessed to be Dependent (100% assistance) on 08/29/2025. During an interview on 08/29/2025 at 10:57 AM, Staff O, Director of Rehabilitation Services, stated Resident 39's 08/29/2025 physical therapy evaluation showed a decrease in strength and had slight functional decline since discharge from Physical Therapy. Staff O stated they were surprised to hear Resident 39 had not been participating in the restorative program as exercise was something they enjoyed and was previously self-motivated. Staff O stated Resident 39 stated they were hopeful and willing to participate in therapy. During an interview on 08/29/2025 at 11:44 AM, Staff B, Director of Nursing Services, stated when Resident 39 expressed to Staff L that they lost their strength, a referral should have been made to physical therapy for evaluation. Staff B stated the lack of documentation, communication, and referral did not meet their expectations. Reference WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to monitor and accurately document fluid restrictions or failed to follow up on a speech therapy referral for 2 of 6 sampled residents (Residents 2 and 3) when reviewed for nutrition and/or dialysis.These failures placed residents at potential risk for medical complications and a diminished quality of life. Findings included.Resident 2 Review of the electronic health records (EHR) showed Resident 2 readmitted to the facility on [DATE] with diagnoses to include kidney failure with dependence on dialysis (the process of removing waste products and excess fluid from the blood due to kidney failure), diabetes (too much sugar in the blood), and heart failure. Resident 2 was able to make needs known. During an interview and observation on 08/25/2025 at 1:01 PM, Resident 2 stated they used to be on a fluid restriction but was no longer on a fluid restriction. There was a sign on the wall that showed, No Water Pitcher Fluid Restriction and Resident 2 stated it was an old sign. Resident 2 did not have a water pitcher in the room. Review of the current provider diet order, dated 03/31/2025, showed Resident 2 was prescribed a regular diet with regular texture and thin fluid consistency. It showed Resident 2 was to have smaller portions of starches and vegetables and had a fluid restriction of 1000 milliliters (ml) per 24 hours. The kitchen was to provide 200 ml each meal and nursing was to provide 150 ml during the day and evening shifts and 100 ml during the night shift, and to exclude Boost supplement from the restriction. Review of the current provider order, dated 07/29/2025, showed Resident 2 was prescribed a fluid restriction of 1000 ml in a 24-hour period. The dietary department was to provide 760 ml; breakfast = 280 ml, lunch = 240 ml, and dinner = 240 ml. Nursing was to provide 240 ml; each shift = 80 ml, and to document the amount of all fluids consumed during each shift in ml. This order did not match the fluid restrictions documented in the current dietary order. Review of Resident 2's Kardex (directions and information to provide care), dated 08/27/2025, showed, Fluid Restriction 1000 ml/day. 760ml - DIETARY - (280ml breakfast) - (240ml lunch)- (240ml dinner). 240ml - NURSING -(80ml/shift). It showed to document the amount of all fluids consumed during shift in ml. This matched the current fluid restriction order. Review of Resident 2's EHR in Tasks for Nutrition: amount eaten from 07/29/2025 – 08/26/2025 regarding the follow up question response to How much did the resident drink? (in mls?) showed the resident was provided over 760 ml on the following dates: 07/30/2025 = 1,200 ml, 08/03/2025 = 960 ml, 08/04/2025 = 793 ml, 08/13/2025 = 960 ml, 08/17/2025 = 900 ml, 08/19/2025 = 960 ml, 08/23/2025 = 880 ml, and 08/25/2025 = 880 ml. Review of the July and August 2025 medication administration records (MAR) from 07/29/2025 – 08/26/2025 showed the total amount of fluids documented in ml were lower when compared to what was documented in Tasks for 20 out of 29 dates. During an interview on 08/29/2025 at 10:49 AM, Staff D, Food Service Supervisor (FSS), stated their system showed Resident 2 was on a regular diet, regular texture, thin liquids, and a fluid restriction of 1000 ml per 24 hours. Resident 2's diet order showed the kitchen was to provide 200 ml each meal and nursing was to provide 150 ml on day and evening shift and 100 ml on the night shift. Staff D stated the dietary order and fluid restriction orders should match and the dietary department relied on nursing and/or speech therapy to communicate any changes related to a resident's diet and fluid restrictions by using a dietary communication form. During an interview on 08/29/2025 at 11:18 AM, Staff H, Nursing Assistant (NA), stated a resident's Kardex informed them who was on fluid restrictions, and they could also ask the nurse if they were not sure. Staff H stated the nursing assistants documented what fluids the residents drank in the computer system during meals and would have to ask the nurse first if the resident could have extra fluids before being able to provide. Staff H stated Resident 2 was on fluid restrictions and had a sign posted on the wall in their room. During an interview on 08/29/2025 at 11:25 AM, Staff C, Registered Nurse/Resident Care Manager (RN/RCM), stated when Resident 2's fluid restriction order dated 07/29/2025 was obtained their dietary order dated 03/31/2025 should have been updated/revised to reflect the current fluid restriction order. Staff C stated the aids/nursing assistants documented what fluids they gave to the residents in the computer system in tasks and nurses documented in the MAR. Staff C stated Resident 2's EHR tasks for amount of fluids consumed at meals compared to their July and August 2025 MAR fluids consumed showed the aids provided over the parameters for fluid restrictions and the MARs showed lower amounts consumed the majority of the time and this did not meet expectations. During an interview on 08/29/2025 at 11:56 AM, Staff B, Director of Nursing Services (DNS), stated residents on fluid restriction were to have all fluids consumed including during meals, during the shift, and documented by the licensed nurses in the MAR. Staff B stated the nursing assistants documented what fluids they provide and were consumed in the computer system (in tasks). Staff B stated Resident 2's dietary order should have been updated with the fluid restriction order, dated 07/29/2025, when it was obtained. Staff B stated what was documented in the computer system by the aids did not look like it was included in Resident 2's July and August 2025 MARs and this did not meet expectations. Resident 3 Review of the EHR showed Resident 3 readmitted to the facility on [DATE] following a hip surgery with diagnoses that included high blood pressure, diabetes, and dementia (a decline in mental ability that interferes with daily life). Resident 3 was able to make needs known. Review of Resident 3's progress note, dated 08/06/2025 at 9:55 PM, showed Resident 3 was starting to have a problem with a regular texture diet and could not eat. Resident 3 was given a supplement to drink, and staff referred to speech therapy for an evaluation to be completed. During an interview on 08/27/2025 at 2:36 PM, Staff J, RN/RCM, stated there had been no follow up on Resident 3's speech referral. During an interview on 08/29/2025 at 11:35 AM, Staff B, DNS, stated the expectation was referrals were followed up on and completed timely. Staff B stated if there was immediate concern related to the texture of a resident's diet nursing staff had the ability to assess the resident and downgrade the diet if necessary, in the interim. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Residents 8) when reviewed for unnecessary medication use. This failure placed the resident at potential risk for medical complications and a decreased quality of life.:Findings included . Review of the electronic health record (EHR) showed Resident 8 readmitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the blood), schizoaffective disorder (a mental health condition that affects a person's ability to think, feel, and behave clearly), and depression. Resident 8 was able to make needs known. Review of the form titled, Pharmacist Report of Irregularity, dated 06/09/2025 showed the pharmacist recommended Resident 8 be offered the shingles vaccination (a series of two shots that protects against shingles, a painful rash). The form's Facility Response section was left blank and did not show a clinical justification and/or rationale for not following the pharmacist recommendation. Review of the form titled, Pharmacist Report of Irregularity, dated 06/09/2025 showed the pharmacist recommended Resident 8 be offered the Respiratory Syncytial Virus (RSV, a severe respiratory illness) vaccination (used to prevent RSV infection). The form's Facility Response section was left blank and did not show a clinical justification and/or rationale for not following the pharmacist recommendation. Review of a progress note, dated 07/08/2025, showed the facility contacted Resident 8's power of attorney (POA, legal authority to act for another person's behalf) to obtain consent for the shingles and the RSV vaccination. The POA stated it was up to Resident 8 to decide, and staff should ask Resident 8 for their consent. There was no other documentation found in the EHR related to the pharmacist's recommendations. During an interview on 08/25/2025 at 11:40 AM, Staff C, Registered Nurse/Resident Care Manager, stated they tried to follow up on any pharmacist's recommendations within a week depending on the recommendation. Staff C stated they would contact the provider to see if they agreed or disagreed with the pharmacist's recommendations. Staff C stated there was a progress note dated 07/08/2025 that showed Resident 8's POA stated to ask Resident 8 if they wanted the vaccinations and they did not see any other progress note related to any follow up at this time. Staff C stated Resident 8 did not have documentation to show they had received the vaccinations, and the 06/09/2025 pharmacist's vaccination recommendations should have been followed up on by now and this did not meet expectations. During an interview on 08/25/2025 at 12:34 PM, Staff B, Director of Nursing Services, stated Resident 8's 06/09/2025 pharmacist's recommendations for shingles and RSV vaccinations should have been followed up on prior to now and this did not meet their expectations. Reference WAC 388-97-1300(4)(c)

Based on observation, interview, and record review, the facility failed to schedule a follow up dental appointment and provide prompt dental services for 1 of 3 sampled residents (Resident 19) when reviewed for dental. This failure placed the resident at risk for continued dental problems and a diminished quality of life. Findings included. Review of the electronic health records (EHR) showed the Resident 19 admitted to the facility on [DATE] with diagnoses to include stroke (blood supply to a part of the brain is suddenly cut off), hemiplegia (total or partial inability to move one side of the body) affecting the right side of the body, and diabetes (too much sugar in the blood). Resident 19 was able to make needs known. During an interview and observation on 08/21/2025 at 12:42 PM, Resident 19 stated they had oral pain at times in their left upper back molar and told staff three or four weeks ago that they wanted to see a dentist to have the tooth pulled out. Resident 19 stated they still had not seen a dentist. Resident 19 had missing upper and lower teeth. Review of the focused care plan, initiated on 07/01/2020, showed Resident 19 had an oral/dental health problem related to natural teeth, cracked/broken tooth/teeth/fillings, heavy build up and needed encouragement for daily brushing. It showed an intervention initiated on 07/01/2020 to coordinate arrangements for dental care and transportation as needed. Review of the Patient Information Exchange form dated 04/22/2025 for Resident 19's dental appointment on 04/22/2025 showed Observation, Evaluation & Recommendations, included tooth number 15 was on a root canal watch (identified issue, that could lead to a root canal, a dental procedure that treats infected or inflamed tooth pulp/nerve and blood vessels of the soft tissue). It showed tooth number 15 needed a built-up/crown (materials to rebuild the damaged portion of the tooth), and silver diamine fluoride (SDF, an antimicrobial liquid used to treat cavities) to be placed everywhere. Review of a progress note dated 04/22/2025 showed, Resident went to Dental appointment this morning, a note stated [Resident 19] will need buildup crown for #15, however [Resident 19], must pay from [their] own pocket due to not being covered by the insurance. Resident said that [they] will not do it. During a follow-up interview on 08/26/2025 at 1:13 PM Resident 19 stated that after their dental appointment in April 2025 they had told staff they did not want to pay for a root canal, and they just wanted the tooth pulled out to prevent further occasional oral pain. Review of the progress note dated 08/07/2025 showed Resident 19 was on alert for reports of pain of the left upper molar at times. During an interview on 08/26/2025 at 1:42 PM, Staff C, Registered Nurse/Resident Care Manager, stated when Resident 19 complained of tooth pain they should have been assessed, provider notified, and a dental appointment scheduled to have the tooth pulled to prevent further oral pain. Staff C stated this should have been addressed prior to now. During an interview on 08/26/2025 at 2:50 PM, Staff B, Director of Nursing Services, stated Resident 19 needed to have an oral assessment, provider notified, and a dental appointment scheduled to have the tooth extracted. Staff B stated Resident 19's dental issues were not addressed timely and did not meet their expectations. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to post the actual hours worked in the nursing staffing postings for 5 of 5 observed days during the survey period (08/21/2025, 08/22/2025, 08/25/2025, 08/26/2025, and 08/27/2025) when reviewed for nursing staff postings. This failure prevented the residents, family members, and visitors from exercising their rights to know the actual numbers of available nursing staff in the facility. Findings included . Observations on 08/21/2025 at 9:48 AM, 08/22/2025 at 10:36 AM, 08/25/2025 at 1:47 PM, 08/26/2025 at 2:00 PM, and 08/27/2025 at 9:30 AM of the nursing staffing postings showed, Number of hours; however, did not indicate if those hours were actual or scheduled hours documented for each discipline on each shift. During an interview on 08/27/2025 at 11:09 AM, Staff E, Administrative Assistant 3 (AA3), stated the night nurse made up the nursing staff postings and posted them daily. Staff E stated the postings showed scheduled hours worked for each discipline on each shift and not the actual hours worked. During an interview on 08/27/2025 at 12:08 PM, Staff B, Director of Nursing Services, stated the scheduled hours worked were what was being posted for the nursing staffing postings; however, they should have also reflected the actual hours worked. Staff B stated this did not meet expectations and the form needed to be updated to reflect/include actual hours worked for each discipline. No Associated WAC

Based on interview and record review, the facility failed to identify an allegation of neglect and failed to report the allegation to the state agency with the required timeframe for 1 of 3 sampled residents (Resident 1) reviewed for reporting alleged violations. These failures placed the resident at risk for ongoing abuse/neglect, unmet needs and a decreased quality of life. Findings included . Review of the facility operating procedure titled, Abuse and Neglect, dated December 18, 2024, showed that neglect is an act or omission that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health, and can also mean a failure to provide a resident with the goods and services necessary to avoid physical harm. The operating procedure further showed that employees witnessing or having cause to suspect that abuse or neglect has occurred must report the concern to a licensed nurse and report it to the State Agency hotline. Review of the electronic medical record (EMR) showed Resident 1 admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls). The medical record showed Resident 1 had a history of heart attack and placement of a coronary stent (a small tube that is placed inside an artery of the heart to keep it open, preventing narrowing and blockage, and allowing blood flow). Review of the facility incident report and investigation, dated 03/27/2025 and 03/28/2025, showed on 03/24/2025 Resident 1 had reported to facility staff about an incident occuring on 03/08/2025, around 2:00-3:00 AM, that they had been experiencing chest pain and reported it to staff three times, and staff did not do anything in response until several hours later. During interview on 04/08/2025 at 12:21 PM, Resident 1 stated that in the early morning of 03/08/2025 they felt like they were dying, and that they could not breathe. Resident 1 stated they went to the nurse about it, concerned because they had heart attacks in the past, and was told they were fine; they were just having a panic attack. Resident 1 further stated they were finally sent to the hospital about four hours later. Resident 1 stated that they did not have another heart attack, but they did have pneumonia (infection causing inflammation and fluid buildup in the air sacs of the lungs, making it difficult to breathe). Review of a hospital discharge summary, dated 03/18/2025, showed that Resident 1 had a hospital stay from 03/08/2025 to 03/18/2025 and was treated for pneumonia. Review of a grievance form, dated 03/24/2025, written by facility staff, showed that Resident 1 reported to staff that they had gone to their nurse, on the morning of 03/08/2025, and said that they were having chest pain and could not breathe. The grievance form showed Resident 1 informed staff they couldn't breathe, and felt a lot of pressure on their chest, but staff did not call the doctor. They felt like they were going to die waiting for someone to actually listen to their plead of not being able to breathe. The grievance noted the staff member receiving this complaint reported it to their supervisor. Review of the online State Agency reporting confirmation, dated 03/27/2025 at 1:58 PM, showed that the facility reported Resident 1's allegation of neglect to the State Agency. The facility reported the allegation to the State Agency three days after the resident voiced the allegation to facility staff. During interview on 04/08/2025 at 1:26 PM, Staff A, Director of Nursing Services (DNS), stated that it was their expectation that the staff who received Resident 1's allegation of neglect would have immediately reported the allegation to a nurse and to the State Agency. Staff A, DNS, stated that it was not acceptable to wait three days to report an allegation of neglect to the State Agency. Reference WAC 388-97-0640 (5)(a)

Based on observation and interview, the facility failed to provide food at an appetizing temperature for 1 of 1 tray line when reviewed for Kitchen Services. This failure placed residents at risk of lower nutritional intake, potential weight loss, and a diminished quality of life. Findings included . On 07/15/2024 at 12:42 PM, Resident 71 stated Some of the food sucks because the meat is overcooked. On 07/15/2024 at 12:58 PM, Resident 37 stated, The food does not taste good here. On 07/15/2024 at 12:23 PM Resident 78 stated, The food is not very flavorful and could use some improvement. The chicken and other meat are over cooked and dry. Review of the lunch menu for 07/17/2024 showed the Regular diets would receive Italian Meatloaf, Lemon Herb Orzo, Garlic Bread, Roasted Asparagus and Marbled Cheesecake. The protein alternative was Tilapia. Observation on 07/17/2024 at 11:49 AM during lunch tray service showed Staff L, Food Service Worker Lead, plating meatloaf on resident trays and adding gravy to only select trays. Staff L said they were adding gravy to the meatloaf slices that looked dried out. Review of the lunch menu for 07/17/2024 showed gravy was not on the menu for those receiving Regular diets. During an interview on 07/17/2024 at 1:03 PM, when requested to take the temperature of a test food tray, Staff L, Food Service Worker Lead stated the orzo was 135 degrees Fahrenheit (F), the asparagus was 135 degrees F, the meatloaf was 136 degrees F, and the Tilapia was 125 degrees F. When asked if these temperatures were hot enough, Staff L, said No, the fish was not up to temperature. During an interview on 07/18/2024 at 9:03 AM, Staff M, Dietary Manager, said only altered texture diets should have received gravy and if a menu item was dried out it should not have been served. Staff M said the Tilapia temperature did not meet their expectation. Reference WAC 388-97-1100 (1), (2)

Based on observation, interview and record review the facility failed to ensure 22 of 90 sampled residents (Residents 2, 8, 13, 14, 18, 23, 30, 34, 37, 40, 48, 59, 60, 62, 64, 71, 73, 74, 82, 85, 86 and 140) received physician ordered therapeutic diets or portion sizes. This failure placed residents at risk for medical complications, nutritional deficits and a decreased quality of life. Findings included . <Therapeutic Diets> Review of lunch menu for 07/17/2024 showed the Regular diets would receive Italian Meatloaf, Lemon Herb Orzo, Garlic Bread, Roasted Asparagus and Marbled Cheesecake. Review of the lunch extension menu showed Easy to Chew, Soft and Bite Sized and Puree diets were to receive a wheat roll instead of garlic bread. Observation of the lunch tray preparation service on 07/17/2024 between 11:13 AM and 11:52 AM showed Staff L, Food Service Worker Lead, serving garlic bread to residents on Easy to chew, Soft and bite sized and Puree diets. Observation of the steam table during tray service showed no wheat rolls. During an interview on 07/17/2024 at 11:49 AM, Staff L said the main kitchen had only prepared garlic bread and garlic bread sticks. Staff L said they were unsure why wheat dinner rolls were not prepared. <Portion Sizes> Observation on 07/17/2024 at 11:31 AM showed the tray card for Resident 60 indicated Large Portion. Staff L provided one and a half portions of meatloaf and portion sizes consistent with the regular diet for the starch, vegetable and dessert. Observation on 07/17/2024 at 11:31 AM showed the tray card for Resident 48 indicated Double Protein. Staff L provided the portion sizes consistent with the regular diet (1 slice). During observation and interview on 07/17/2024 at 11:45 AM, Staff N, Food Service Supervisor reviewed Resident 48's tray card and said two slices of meatloaf should have been provided. Staff N requested Staff L plate an additional slice of meatloaf. During an interview on 07/18/2024 at 9:03 AM Staff M, Dietary Manager said tray cards that indicate Large Portion should have been provided one and a half portions of protein and starch. Staff M was unable to provide an explanation why the cook did not prepare wheat rolls; however, stated the expectation was that extension menus and tray cards were followed. Staff M said wheat rolls should have been provided as ordered or the dietician should have been notified to determine if an alternative could have been substituted. Reference: (WAC) 388-97-1200(1)

Based on observation, interview, and record review, the facility failed to ensure an incident of potential abuse, such as misappropriation of personal property, was identified as such and reported to law enforcement and the State Survey Agency as required for 1 of 4 sampled residents (Resident 37) reviewed for abuse. Failure to report allegation/incident of abuse placed the resident at risk for additional abuse and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines titled, The Purple Book, dated October 2015, showed the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator of the facility and to other officials in accordance with State law .including to the State survey and certification agency. Resident 37 readmitted to the facility on [DATE] and was able to make needs known. During an interview and observation on 07/17/2024 at 10:12 AM, Resident 37 stated staff were aware that they had personal items stolen before and that was why they had keys for the locks on their nightstand and closet. Resident 37 had six keys hanging from a lanyard around their neck. Review of Resident 37's Grievance form dated 06/10/2024 showed on 06/08/2024 Resident 37 had a concern that people were stealing their things, and they were extremely upset over not having a lock on their closet door. This was causing them emotional distress to the point of crying. It showed, Steps taken to investigate the grievance: Resident without a lock on closet. It showed that locks were installed on closets as per resident request on 06/12/2024 and Resident 37 was notified on 06/12/2024. This grievance did not address the concern of stolen items or of reporting allegations of misappropriation of personal property. Review of the facility's incident reporting log from February 2024 through July 12, 2024, showed no incidents logged for Resident 37's allegation of stolen items. During an interview on 07/18/2024 at 8:21 AM, after reviewing Resident 37's grievance form dated 06/10/2024, Staff B, Director of Nursing Services, stated the police and State Agency should have been notified and that did not happen. During an interview on 07/18/2024 at 8:41 AM, after reviewing Resident 37's grievance form dated 06/10/2024, Staff A, Administrator, stated it did not meet expectations and staff needed to follow the guidelines in the Purple Book. Staff A stated the police and abuse hotline should have been called. Reference WAC 388-97-0640(5)(a)(6)(a)(c)

Based on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if a resident had a healthcare advance directive (AD) for 1 of 17 sampled residents (Residents 78) reviewed for AD. This failure placed the resident at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences. Findings included . An AD is a written instruction, such as a living will or durable power of attorney [DPOA] for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Resident 78 admitted to the facility on [DATE] and was able to make needs known. Review of Resident 78's electronic healthcare record (EHR) on 07/15/2024 showed that the resident had a DPOA for financial; however, there was no documentation of an AD for healthcare. During an interview on 07/17/2024 at 10:38 AM, Resident 78 stated they thought their sister was their DPOA for healthcare but if not, they wanted their sister to be their DPOA for healthcare. Review of Resident 78's advanced directive care plan, revision dated 03/13/2024, showed that Resident 78 had a DPOA for Financial only. During an interview on 07/17/2024 at 1:39 PM, Staff H, Psychiatric Social Worker, stated that they were unable to locate documentation in the EHR that Resident 78 was offered AD information for healthcare or that it had been reviewed and it should have been. Staff H stated they were unable to locate a healthcare AD for Resident 78. During an interview on 07/17/2024 at 2:02 PM Staff A, Administrator, stated that AD information was to be offered to residents, obtained, and reviewed upon admission, and on a quarterly basis, and the documentation should be in the resident's EHR. Staff A stated that it did not meet expectations that they were unable to locate Resident 78's AD for healthcare. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b)

Based on record review and interview, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of 1 of 3 residents (Resident #1) reviewed for incision care following surgery. The facility did not ensure Resident #1 had a physician treatment order for incision care upon readmission to the facility. The facility implemented treatment for [REDACTED]. The facility failed to ensure its weekly skin check policy that required removal of dressings to assess wounds was consistently followed. The facility also failed to notify the physician when potential signs and symptoms of incision infection were noted. Resident #1 suffered harm from delay of [DIAGNOSES REDACTED]. Findings included: Resident #1 was readmitted to the facility on [DATE] following surgical repair of a fractured femur. Review of the resident's Weekly Skin Check completed on admission showed the resident had two incisions with staples on the side of his right thigh: #1 Upper incision, 6.5 centimeters (cm) wide by .1 cm deep; #2 Lower incision 2.4 cm by 0.1 cm deep, both without drainage or odor. WEEKLY SKIN CHECKS Review of the facility's Policy Identifying Skin Issues and Weekly Tracking showed under procedure, Second bullet, Weekly by the Licensed Nurse, will conduct a thorough assessment by removing any dressing (unless contraindicated by MD orders) to inspect the resident's current skin condition. The LN should note and document abnormalities or impairment to skin integrity by documenting location, measurements and description of skin. Review of a Weekly Skin Check for Resident #1 dated 09/08/17 (one week after admission) showed documentation of Incision #1 described as surgical incision with dressing, dressing intact, no BT (breakthrough) drainage, see previous sheet for measurements; Incision #2, surgical incision with dressing, dressing intact, no BT (breakthrough) drainage, see previous sheet for measurements. There was no evidence the resident's dressings were removed to assess the incisions. Review of a Weekly Skin Check for Resident #1 dated 09/15/17 (two weeks after admission) showed on the body diagram documentation dressing intact pointing to the upper incision and staples pointing to the lower incision. There was no evidence the dressing on the upper incision was removed for assessment and no evidence of documentation of the condition of the incisions. On 09/29/17 at 11:30 AM, Staff C, Director of Nursing, DNS, reviewed the above skin check documents and stated that the dressings should have been removed to assess the incisions. During interview on 09/29/17 at 3:10 PM, Staff G, Registered Nurse, RN, Care Manager, stated that nurses should visualize the incision and that he did not agree with referring to a dressing as a skin check. ONGOING MONITORING Review of the resident's Treatment Administration Record (TAR) dated 09/2017 showed an order initialed by Staff E, Licensed Practical Nurse, (LPN) dated 09/01/17 Cleanse R (right) upper thigh incision with NACL (sodium chloride); pat dry; cover with Opsite dressings-cover staples with gauze prior to Opsite PRN (as needed) for soilage/displacement. The treatment was noted to be done PRN. Review of facility's Readmission orders [REDACTED] During interview on 09/29/17 at 11:10 AM, Staff H, Nurse Practitioner (NP) reviewed the treatment order dated 09/01/17. Staff H stated that she would not have accepted this order for a fresh post-operative resident. Staff H stated she would have asked the nurse to call and find out specifically what treatment should be done. Review of nursing progress notes dated 09/03/17 through 09/11/17 showed no evidence of assessment of Resident #1's incision. On 09/08/17 at 10:00 PM, staff documented the resident had a low grade temperature of 99.4 degrees. On 09/10/17 at 4:30 AM, nursing progress notes showed the incision area was still quite tender and resident had pain with movement. On 09/12/17, (ten days after previous dressing change) at 4:45 AM, Staff J, Registered Nurse, RN, changed the dressing and documented dressing on proximal (upper) incision with old drainage, foul odor, continues to be tender to touch. Review of the MD Reporting log dated 09/12/17 showed Staff J notified Staff O, Physician, about the foul odor. Physician response noted the resident's sutures would be removed at the orthopedic follow up appointment. There was no evidence of response to the report of foul odor from the wound drainage. On 09/13/17 at 10:00 PM, staff documented that the resident's dressing was changed with quarter-sized area of serous, brownish red drainage on old dressing, staples intact, incision line inflamed but no pus noted, no foul odor. On 09/18/17, night shift, nursing progress notes showed the dressing was changed with scant amount of serous drainage with no signs of infection. Hip area swollen /+[MEDICAL CONDITION]. Bluish purple border around incision. Review of nursing progress notes dated 09/18/17, day shift, showed Resident #1 went to an orthopedic follow up appointment and had staples removed from right femur. Resident was on alert for start of Keflex (antibiotic) 500 milligrams (mg) QID (four times a day) for 14 days for [MEDICAL CONDITION] (bacterial infection) of right femur. Resident #1's incision was treated based on an order that was not verified as a physician order. There was no evidence the resident's incision was visualized and assessed for ten days, including during weekly skin checks as required by facility policy. There was no evidence potential signs of infection including low grade temperature, inflammation and tenderness were reported to the physician prior to the orthopedic physician's [DIAGNOSES REDACTED].

Based on observation, record review and interview, the facility failed to provide care and services according to professional standards of practice for 1 of 3 residents (Resident #1) reviewed for incision care following surgery. The facility implemented treatment for [REDACTED]. The facility failed to adequately assess and monitor the resident's incision and failed to notify the physician of potential signs and symptoms of infection according to professional standards of practice. These failures resulted in harm for Resident #1 who required antibiotic therapy for an incision infection. Findings included: Refer to F309 physician's orders [REDACTED].>According to Smith and Duell, Clinical Nursing Skills, sixth edition, page 4, the responsibilities of the professional nurse involve administration of treatments per physician's orders [REDACTED].>Resident #1 was readmitted to the facility on [DATE] following surgical repair of a fractured femur. Review of the resident's Weekly Skin Check completed on admission showed the resident had two incisions with staples on the side of his right thigh as follows: #1 Upper incision, 6.5 centimeters (cm) wide by .1 cm deep; #2 Lower incision 2.4 cm by 0.1 cm deep, both without drainage or odor. Review of the resident's Treatment Administration Record (TAR) dated 09/2017 showed an order initialed by Staff E, Licensed Practical Nurse, (LPN) dated 09/01/17 Cleanse R (right) upper thigh incision with NACL (sodium chloride); pat dry; cover with Opsite dressings-cover staples with gauze prior to Opsite PRN (as needed) for soilage/displacement. The order was noted as PRN. Review of facility Readmission orders [REDACTED] During interview on 09/19/17 at 2:30 PM, Staff E stated that she was responsible for writing the treatment order dated 09/01/17 on the TAR; however, she did not recall where she got the order from. She stated that she reviewed the hospital discharge orders and also took a verbal report from a nurse at the hospital; she stated that it had to have come from either one of those sources. Staff E was not able to provide evidence of a physician order [REDACTED].>On 09/19/17 at 10:45 AM, Staff C, Director of Nursing, DNS, reviewed Resident #1's facility and hospital records. Staff C did not locate a physician's orders [REDACTED]. During interview on 09/29/17 at 11:10 AM, Staff H, Nurse Practitioner (NP) reviewed the treatment order dated 09/01/17. Staff H stated that she would not have accepted this order for a fresh post-operative resident. Staff H stated she would have asked the nurse to call and find out specifically what treatment should be done. WEEKLY SKIN CHECKS According to Lippincott Manual of Nursing Practice, Ninth Edition, Wound Management, Nursing Assessment, pages 130-131, the frequency of wound assessment is determined by the nature of the wound, degree of drainage and the facility protocol. Review of the facility's Policy Identifying Skin Issues and Weekly Tracking dated 05/30/17 showed under procedure, Second bullet, Weekly by the Licensed Nurse, will conduct a thorough assessment by removing any dressing (unless contraindicated by MD orders) to inspect the resident's current skin condition. The LN should note and document abnormalities or impairment to skin integrity by documenting location, measurements and description of skin. Review of a Weekly Skin Check for Resident #1 dated 09/08/17 (one week after admission) showed documentation of Incision #1 described as surgical incision with dressing, dressing intact, no BT (breakthrough) drainage, see previous sheet for measurements; Incision #2, surgical incision with dressing, dressing intact, no BT (breakthrough) drainage, see previous sheet for measurements. There was no evidence the resident's dressings were removed to assess the incisions. Review of a Weekly Skin Check for Resident #1 dated 09/15/17 showed on the body diagram documentation dressing intact pointing to the upper incision and staples pointing to the lower incision. There was no evidence the dressing on the upper incision was removed for assessment and no evidence of documentation of the condition of either incision. On 09/29/17 at 11:30 AM, Staff C, Director of Nursing, DNS, reviewed the above skin check documents and stated that the dressings should have been removed to assess the incisions. During interview on 09/29/17 at 3:10 PM, Staff G, Registered Nurse, RN, Care Manager, stated that nurses should visualize the incision and that he did not agree with referring to a dressing as a skin check. ONGOING MONITORING According to Lippincott Manual of Nursing Practice, Ninth Edition, Wound Management, Nursing Assessment, pages 130-131, showed documentation of the wound's status should occur at least every shift. Review of nursing progress notes dated 09/03/17 through 09/11/17 (nine days) showed no evidence of nursing assessment of Resident #1's incision. According to Lippincott Manual of Nursing Practice, Ninth Edition, Wound infection, page 122, Clinical Manifestations of wound infection included 1. Redness, excessive swelling, tenderness, warmth; 3. Pus or other discharge from the wound; 5. Foul smell from the wound. On 09/08/17 at 10:00 PM, staff documented the resident had a low grade temperature of 99.4 degrees. On 09/10/17 at 4:30 AM, nursing progress notes showed the incision area was still quite tender and resident had pain with movement. On 09/12/17, (10 days after previous dressing change) at 4:45 AM, Staff J, Registered Nurse, RN, changed the dressing and documented dressing on proximal (upper) incision with old drainage, foul odor, continues to be tender to touch. Review of the MD Reporting log dated 09/12/17 showed Staff J notified Staff O, Physician, about the foul odor. Physician response noted the resident's sutures would be removed at the orthopedic follow up appointment. There was no evidence of response to the report of foul odor from the wound drainage. On 09/13/17 at 10:00 PM, staff documented that the resident's dressing was changed with quarter-sized area of serous, brownish red drainage on old dressing, staples intact, incision line inflamed but no pus noted, no foul odor. On 09/18/17, night shift, nursing progress notes showed the dressing was changed with scant amount of serous drainage with no signs of infection. Hip area swollen /+[MEDICAL CONDITION]. Bluish purple border around incision. Review of nursing progress notes dated 09/18/17, day shift, showed Resident #1 went to an orthopedic follow up appointment and had staples removed from right femur. Resident was on alert for start of Keflex (antibiotic) 500 milligrams (mg) QID (four times a day) for 14 days for [MEDICAL CONDITION] (bacterial infection) of right femur. Resident #1's incision care was not consistently completed according to professional standards of practice. The resident's incision was treated based on an order that was not verified as a physician order. There was no evidence the resident's incision was visualized and assessed for nine days, including during weekly skin checks per facility protocol. There was no evidence potential signs of infection including low grade temperature, inflammation and tenderness were reported to the physician prior to the [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure staff, who were certified to provide CPR, (Cardio-Pulmonary Resuscitation) were available at all times to provide care until emergency medical services arrived for two of two Sampled Residents (#s 1 and 3) . This failure resulted in incorrect method used for cardiopulmonary resuscitation for Resident #1. Additionally, this failure placed residents, staff and visitors at potential risk for a delay in resuscitative efforts. Failure to ensure staff were available who were certified in providing CPR resulted in determination of Immediate Jeopardy on [DATE]. Immediate Jeopardy was removed on [DATE] with staff from all shifts being trained in a hands-on CPR class provided in the facility. Findings included . Record review of the facility policy titled CPR (Cardiopulmonary Resuscitation) dated [DATE], showed that if residents desire resuscitation efforts, staff will immediately initiate the resuscitation process. Only staff who have been trained in CPR/AED (Automated External Defibrillator - a device placed on a person's chest that monitors the heart's rhythm and can deliver a shock to restore normal rhythm if indicated) should participate. Additionally, the policy directs only staff members who have been trained on CPR and AED's should provide the emergency care. The facility policy reference, a textbook by the American Heart Association, Basic Life Support (BLS) for Healthcare Providers, was provided by the Staff Development Coordinator. During an interview on [DATE] at 3:30 PM, Staff H, Staff Development Nurse (SDN), stated that it was her understanding all of the licensed nurses at the facility should be certified in CPR. During an interview on [DATE] at 12:30 PM, Staff H, SDN, stated she was a certified instructor for CPR and provided the American Heart Association's Basic Life Support for Healthcare Providers textbook students received in class. Staff H stated that she taught a class to certify staff every month and any staff member could participate in the class. Staff H stated that she did not track which staff had a current CPR card, and which ones did not, but that staff were responsible for knowing when they need to have the required training. Record review of the book, American Heart Association, Basic Life Support (BLS) Provider Manual, dated 2015, page 19, showed a section titled Adult Chest Compressions. Included in the chest compressions section was sub-section, the importance of a firm surface, which informs the reader, in order to make the chest compressions effective enough to pump blood, place the victim on a firm surface, such as the floor or a backboard. The American Heart Association, Basic Life Support (BLS) Provider Manual, dated 2015, page 5, also showed if there was a trained resuer to perform rescue breaths, the breaths should be provided. RESIDENT #1 Review of Resident #1's record showed on [DATE] at 5:00 PM, the resident had a choking incident, which resulted in the resident becoming unresponsive and CPR was initiated. During an interview on [DATE] at 3:10 PM, Staff F, RN Supervisor, stated that he provided CPR during the incident. Staff F described the incident as Resident #1 sat in his wheelchair, began to choke, and then became unresponsive. Staff F, RN, also stated staff attempted the [MEDICATION NAME] Maneuver (an emergency procedure to clear a blocked airway). The [MEDICATION NAME] Maneuver was not successful and the resident became unresponsive. Staff F, RN, stated they then moved Resident #1 from his wheelchair and laid him on top his bed, then initiated CPR. Staff F stated Resident #1 had a regular soft type mattress and the backboard was not placed under the resident during CPR. Staff F stated the backboard was located on the crash cart. Staff F stated a different staff member retrieved the crash cart and returned to Resident #1's room with it, however, the backboard was not removed from the cart. Staff F stated he provided CPR for approximately 5 minutes until emergency medical services arrived. Record review showed there was no documentation in Resident #1's chart to support his pulse had been checked prior to initiating CPR. Observations on [DATE] at 3:40 PM, showed Resident #51's mattress on his bed. The mattress easily compressed, (moved up and down), when the surveyor pushed on it lightly with her hand. Observations on [DATE] at 7:00 PM, showed the crash cart had a firm backboard attached to the back of the emergency cart, readily available if needed. During an interview on [DATE] at 2:15 PM, Staff H, SDN, RN, stated the American Heart Association teaches, although it is acceptable for a lay person to not give mouth to mouth breathing, professional healthcare staff should provide breathing. Staff H stated the video shown during the training does indicate health care providers may provide chest compressions only, if there was no barrier device available, however, the healthcare professional was expected to provide rescue breathing once some type of barrier device arrived. Staff H stated each crash cart had a mouth piece on the top of it, and there were barrier devices to provide breaths through located throughout the facility. During an interview on [DATE] at 3:10 PM, Staff F, RN Supervisor, stated he did not provide breaths during CPR. Staff F stated he only provided Resident #1 with chest compressions. The facility failed to ensure nursing staff were trained in CPR. There was no evidence staff checked Resident #1's pulse prior to initiating CPR; staff failed to use a backboard during chest compressions, and failed to provide rescue breaths, even though the facility had supplies to assist with breathing. During an interview on [DATE] at 3:40 PM, Staff R, Human Resources, reviewed the job descriptions and qualifications for licensed nurse positions and stated CPR certification was not listed as a requirement or as necessary. Staff R stated CPR certification was not a qualification checked at the time of hiring new staff. During an interview on [DATE] at 4:30 PM, Staff H, SDC, RN, reviewed the list of staff with current CPR certification, and stated that she did not have evidence that Staff F had been trained in providing CPR. Additionally, Staff H reviewed the list of certified staff and stated there were only five licensed nurses listed. Of the five listed, all were assigned to work the day shift. There was no documentation to support any of the evening shift or night shift nurses that were scheduled for the remainder of the day, [DATE], were certified in CPR. RESIDENT #3 Review of Resident #3's record showed advanced directives dated [DATE], the resident wished to have CPR if found without a pulse and not breathing. Review of Resident #3's medical record showed a nursing note dated [DATE] at 3:40 AM, which described at 2:25 AM, Resident #3 was found without a pulse and not breathing. The note indicated CPR was initiated by Staff E, RN Supervisor. The note showed Staff E used an AED during the resuscitative effort. Staff E documented she continued CPR/AED until the paramedics arrived and pronounced Resident #3 dead at 2:56 AM. During an interview on [DATE] at 4:30 PM, Staff H, SDC, RN, reviewed the list of staff with current CPR certification, and stated that she did not have evidence Staff E had been trained in providing CPR or in the use of an AED. During an interview on [DATE] at 5:00 PM, Staff B, Interim Director of Nursing, DNS, stated that her expectation was for all licensed nursing staff to be certified in providing CPR. Staff B confirmed there was no evidence to support the facility had certified staff available at all times. Failure of staff to participate in required training placed residents at risk for ineffective resuscitative efforts, thus decreasing chances of survival. Failure of the facility to ensure there was CPR trained staff available at all times placed all residents, staff and visitors at potential risk of not having every possible effort made to save one's life. .

Based on observation, interview and record review facility administration failed to effectively use its resources to attain or maintain the highest practicable well-being of each resident. Administration did not demonstrate systems were in place to ensure resident safety and to prevent abuse; administer the building effectively to ensure an effective infection control program; nursing assessments were complete; and greivances resolution and medically related social services were provided. Failure to ensure compliance in Freedom from Abuse as referenced in F223 represented Immediate Jeopardy for Sampled Residents (#s 8, 17, 29 and 83) and resulted in harm for Resident (#s 8, 17 and 83). Failure to ensure compliance in Accident Prevention as referenced in F323 represented Immediate Jeopardies for Sampled Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) related to safety with smoking; and for Sampled Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98,102, 104, 106 and 108) for lack of supervision and system in place to ensure resident safety for those who wandered or were at risk for elopement and falls. This resulted in harm for Resident (#s 1, 26, 73, 98, and 102). Failure to ensure compliance resulted in harm for Resident #75 related to restraint use as referenced in F 221; harm for Resident (#s 8, 17 and 26) as referenced in F 225; harm for Resident (#s 8 and 17) as referenced in F 250 social services; and harm for Resident #25 related to significant weight loss as referenced in F 325. Facility failures resulted from lack of effective administration to ensure resident safety to prevent harm for multiple residents. Administration failed to ensure the facility was in compliance with the following regulatory requirements which affected quality of care and quality of life for all residents in the facility: Findings included . Substandard Care was identified in the following four areas: 42 CFR 483.12 Freedom from Abuse; 42 CFR 483.12(a)(3)(4)(c)(1)-(4) Investigate/report Allegations/Individuals 42 CFR 483.25(d)(1)(2) Accidents Prevention 42 CFR 483.40 (d) Behavioral Health Services 1) Refer to 42CFR 483.12 F223 Free from Abuse and Neglect. Each resident has the right to be free from abuse, neglect. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff and other residents. Failure to implement measures to prevent abuse resulted in harm for Resident (#s 8, 17 and 83) related to inappropriate touching. Immediate jeopardy was determined on 04/03/17 and removed on 04/04/17 following extensive staff training on abuse recognition and procedures for protecting, notifications and investigating. Additional measures were added for increased supervision of Resident #8 and Resident #17. 2) Refer to 42CFR 483.25(d) F323 Accidents. The facility did not provide an environment that was free from accident hazards over which the facility had control and did not provide adequate supervision to ensure safety with smoking or avoid preventable, avoidable accidents for Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) in the resident smoking area and for Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98,102, 104, 106 and 108) with risks for wandering and/or exited the building without staff knowledge and falls. Exiting the building without staff supervision resulted in harm for Resident (#s 26, 73, 98 and 102). Failures as referenced in F323 represented Immediate Jeopardies for Sampled Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) related to safety with smoking; and for Sampled Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98,102, 104, 106 and 108) for lack of supervision and system in place to ensure resident safety for those who wandered or were at risk for elopement and those with falls. This resulted in harm for Resident (#s 1, 26, 73, 98, and 102). Immediate Jeopardy was determined on 03/23/27 for lack of safety during smoking and removed on 03/27/17 with increased staff monitoring and supervision and addition of an emergency call system and improved lighting in the smoking area. Immediate Jeopardy was determined on 03/27/17 for safety related concerns for failure to supervise residents who left the facility or were at risk for elopement. The facility also failed to ensure they had a system in place to alert staff when residents exited the building and provided adequate supervisionto residents. Immediate Jeopardy was remove on 03/28/17 through activation of door alarm system; staff identification of residents at risk for elopement and increased staff monitoring and supervision of residents who wandered and continuous monitoring of exit doors and redirected exits and entrance through the main facility door. 3) Refer to 42CFR 83.12(c)(1) F225 Report/Investigate Abuse and Neglect. The facility failed to report alleged violations or conduct a thorough investigation of all alleged violations for Sampled Residents (#s 1, 8, 17, 19, 21, 26, 29, 52, 73, 75, 79, 98, 99 and 102). The facility did not report abuse, or thoroughly investigate incidents to determine measures were implemented to prevent further incidents which resulted in harm for Resident #8 and Resident #17. 4) Refer to 42CFR 483.40(d) F250 Social Services. Medically related social services were not provided to ensure behavior management and assistance to prevent incidents of inappropriate touching which resulted in harm for Resident #8 and Resident #17. Social services failed to ensure grievances were resolved for Sampled Residents (#s 30, 49, 64, 69, 79 and 92); and Sampled Resident #69 received assistance with a hearing device and implemented an effective behavior management program for Sampled Residents (#s 29, 49 and 75) and ensures Sampled Resident #1 received Pre-Admission and Screening. Administration failed to ensure compliance with additional following regulatory requirements: F156 - 483.10(d)(3)(g)(1)(4)(5)(13)(16)-(18) - Notice Of Rights, Rules, Services, Charges for failure to provide advance notification when Medicare covered services ended. F166 - 483.10(j)(2)-(4) - Right To Prompt Efforts To Resolve Grievances for Failure to ensure staff implemented and followed a system to provide prompt response and resolution for resident grievances. F170 - 483.10(g)(8)(i)(9)(i)-(iii)(h)(2) - Right To Privacy - Send/receive Unopened Mail for failure to ensure staff delivered mail to residents on Saturdays. F176 - 483.10(c)(7) - Resident Self-Administer Drugs If Deemed Safe for failure to ensure one resident was assessed and safe to take medications with him during appointments. F221 - 483.12(a)(1) - Free From Abuse/involuntary Seclusion for failure to assess and reassess the use of a seat belt restraint, obtain informed consent, and ensure the restraint was the least restrictive alternative prior to implementation. This failure resulted in psychological harm and restriction of movement for Resident #25 during repeated use of a belt in a wheel chair. F241 - 483.10(a)(1) - Dignity And Respect Of Individuality for failure to ensure dignity during assistance with eating and prevent physical intrusion and maintain resident privacy for two residents. F246 - 483.10(e)(3) - Reasonable Accommodation Of Needs/preferences for failure to ensure accommodation of need was addressed for one resident regarding uncomfortable room temperatures. F248 - 483.24(c)(1) - Activities Meet Interests/needs Of Each Resident for failure to ensure one resident with dementia received a meaningful activity program. F272 - 483.20(b)(1) - Comprehensive Assessments for failure to ensure all required Minimum Data Set Assessments were conducted according to required time frames for 37 residents. F273 - 483.20(b)(2)(i) - Comprehensive Assessment 14 Days After Admit for failure to ensure required Admission Minimum Data Set Assessments were conducted according to required time frames for two residents. F274 - 483.20(b)(2)(ii) - Comprehensive Assess After Significant Change for failure to ensure required Minimum Data Set Assessments were conducted following significant changes in conditions according to required time frames for five residents. F275 - 483.20(b)(2)(iii) - Comprehensive Assess At Least Every 12 Months for failure to ensure required Annual Minimum Data Set Assessments were conducted according to required time frames for 13 residents. F276 - 483.20(c) - Quarterly Assessment At Least Every 3 Months for failure to ensure required Quarterly Minimum Data Set Assessments were conducted according to required time frames for 15 residents. F279 - 483.20(d); 483.21(b)(1) Develop Comprehensive Care Plans for two residents with swallowing or hearing problems. F285 - 483.20(e)(k)(1)-(4) - Pasrr Requirements for failure to ensure one resident received a Pre-Admission Screening and Resident Review and referral for level II evaluation when indicated. F309 - 483.24, 483.25(k)(l) - Provide Care/services For Highest Well Being for failure to conduct neurological monitoring to identify potential head injuries following falls for seven residents. F313 - 483.25(a)(1)-(2) - Treatment/devices To Maintain Hearing/vision for failure to ensure one resident who was hard of hearing obtained and used an assistive hearing device. F323 - 483.25(d)(1)(2)(n)(1)-(3) - Free Of Accident Hazards/supervision/devices F325 - 483.25(g)(1)(3) - Maintain Nutrition Status Unless Unavoidable for failure to timely reassess and consistently implement interventions and assist with eating to prevent significant weight loss for one resident. F329 - 483.45(d)(e)(1)-(2) - Drug Regimen Is Free From Unnecessary for failure to ensure adequate indication for use, effective non-pharmacological interventions were provided and medications monitored for potential adverse effects for five residents. F332 - 483.45(f)(1) - Free Of Medication Error Rates Of 5% Or More for failure to ensure licensed staff maintained a medication error rate of less than 5%. F371 - 483.60(i)(1)-(3) - Food Procure, Store/prepare/serve - Sanitary for failure to ensure staff stored, prepared and served food in a sanitary manner in the kitchen and in two dining rooms. F387 - 483.30(c)(1)(2) - Frequency & Timeliness Of Physician Visit for failure to ensure physician medical visits occurred according to required intervals for 49 residents. F431 - 483.45(b)(2)(3)(g)-(h) - Drug Records, Label/store Drugs & Biologicals for failure to ensure medications were received and stored according to required pharmacy standards. F441 - 483.80(a)(1)-(4)(b)(e)(f) - Infection Control, Prevent Spread, Linens for failure to ensure staff followed handwashing as required and tracked and trended infections in the facility to prevent spread of infection. F498 - 483.35(c); 483.95(g)(1)- (4) - Nurse Aide Demonstrate Competency/care Needs for failure to ensure nursing aide staff received required dementia training. Failure to effectively administer the facility resulted in determination of Immediate Jeopardy on 03/27/17 and removed on 03/28/17 with additional provision of administrative oversight and implementation of interim administration.

Based on observation, interview, record review and policy review the facility failed to provide adequate supervision to ensure resident smoking safety; conduct comprehensive assessments that identified and analyzed all individual risk factors that impacted ability to smoke independently; failed to prevent potential or actual smoking injuries and provide a safe smoking environment with immediate access to a call system, fire extinguishers and fire blanket for eight of eight Sampled Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) who smoked. Failure to adequately supervise residents who were unsafe to smoke independently resulted in injury for Resident #19. The facility did not identify and address these safety concerns which placed all residents at risk for potential smoking related accidents and determined to be an Immediate Jeopardy on 03/23/27 for lack of safety during smoking and removed on 03/27/17 with increased staff monitoring and supervision and addition of an emergency call system and improved lighting in the smoking area. The facility also failed to provide a safe environment and ensure staff adequately supervised residents who wandered, or were aware and intervened when they exited the building for thirteen of fifteen Sampled Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98, 102, 104, 106 and 108) who had exit seeking behavior. These failures placed all vulnerable, cognitively impaired residents at risk for serious injury or death. Resident #1, Resident #73, Resident #98 and Resident #108 experienced harm when they sustained falls with injuries and/or were exposed to inclement weather. The facility failed to take appropriate corrective actions to prevent similar incidents, determined to be an Immediate Jeopardy on 03/27/17 for safety related concerns for failure to ensure they had a system in place to alert staff when residents exited the building and provided adequate supervision to them to prevent harm. The Immediate Jeopardy was removed on 03/28/17 through activation of door alarm system; staff identification of residents at risk for elopement and increased staff monitoring and supervision of residents who wandered and continuous monitoring of exit doors and redirected exits and entrance through the main facility door. The facility also failed to provide resident supervision and conduct thorough accident investigations to determine circumstances of resident falls and incidents and implement measures to prevent reoccurrence for eight of thirteen Sampled Residents (#s 17, 26, 29, 52, 75, 98, 99, and 102) reviewed for falls. These failures placed all residents at risk for continued falls with injuries. This resulted in harm for Resident #26 who experienced a fall with fracture. The facility also failed to ensure portable oxygen tanks were kept in a locked room; hazardous chemicals in room and in housekeeping carts were secured, and hot coffee in pots on burners were not within reach of residents with cognitive impairments and wandering behaviors. Findings included . Record review of the facility policy titled, Washington State Veteran's Home Smoking and Tobacco Procedure dated 11/30/16, stated the purpose included to put in place reasonable precautions to ensure the safety of all those who live, work and visit our facilities with an environment that limits the risks of fire or exposure totobacco products to the maximum extent possible. The procedure defined the following: Safe Smoker - A smoker assessed as possessing cognitive ability, judgment, manual dexterity, and mobility who is assessed as safe to smoke without supervision. Unsafe Smoker - A smoker assessed as lacking cognitive ability, judgment, manual dexterity, and mobility who is evaluated as a safety hazard to self and/or others with their smoking habits and determined to need supervision in order to smoke. The procedure showed all assessments must consider the cognitive ability, judgment, manual dexterity and mobility of the resident. The procedure also showed smoking would take place in designated smoking areas only. Record review of the form titled, Notice of Infraction, read: -Residents of the Washington Soldiers Home, who smoke, will be assessed for their ability to smoke safely and independently on the day of admission. -Smokers will be assessed as to their ability to smoke safely as needed depending on their change of condition. -Residents who violate smoking safety policies and procedures will be reassessed and the smoking status may be change to reflect the risk they pose to themselves or others. -In accordance with the Clean Air Act WSH staff will not be allowed to monitor residents that are deemed unsafe to smoke. SMOKING During observation on 03/22/17 at approximately 4:30 PM, a smoking shelter (smoke shack), with transparent siding, was visible from the assisted dining room and the hallway that lead to Wings 3 and 4. Three chairs were placed in front of the shack, partially blocked the view of residents sitting wheelchairs inside the shack. Approximately three chairs, a portable radio that sat on a table, and an overhead heater were also observed inside the shack. The shack had a door, made from heavy plastic translucent strips hung from the top to the bottom of the door to the ground. Two smoking receptacles were placed outside on the left side of the shack, two receptacles were located inside the smoke shack, and one was located by the chairs on the outside of the shack. There was no visible call system in the shelter for residents to alert staff in an emergency. During an interview on 03/23/17 at 9:04 AM, Resident #95 stated he was an independent smoker and had been approached by other residents for cigarettes, but declined to share. Resident #95 stated he kept his cigarettes and lighters in his pocket, and showed to verify. When asked what he would do if he fell in the smoking area, Resident #95 stated I would let someone out there with me know. If I was alone, I'm not sure. Maybe let someone know walking by the window. During observation on 03/23/17 9:52 AM, Resident #19, Resident #30 and Resident #103 sat in the smoke shack, in close range of each other. Upon entering the smoke shack, Resident #19 held an item in his right hand, and threw it down on the ground between his wheelchair and Resident #30's wheelchair. When this surveyor glanced at the ground, a half-smoked cigarette was found. When asked if all three residents were independent smokers, all three residents replied, Yes. Resident #19 lifted up his left hand that held the electronic cigarette and said, I smoke e-cigarettes. When asked what the rules were for cigarettes and lighters, all three residents stated that they kept them on themselves at all times, and didn't share them with anyone. All residents stated that they had been approached, but did not share. When asked how they notified staff for assistance or in an emergency, Resident #103 stated they looked out for each other. Resident #19 stated approximately three years ago, he had a seizure and fell out of his chair on the ground Resident #30 wheeled himself inside the facility and yelled help until staff responded. Resident #30 verified Resident #19's story. When asked how often staff came by to check on residents in the smoke shack, Resident #103 responded, Occasionally. Sometimes they can see you from the window when they walk down the hall. During an interview on 03/23/17 at 11:14 AM, Staff JJJ, Resident Care Manager, (RCM) and Staff R, Licensed Nurse (LN), stated that all residents who smoked, were assessed. In order to smoke, the residents had to be assessed as independent. The residents demonstrated how to safely light their own cigarettes, extinguish it, make sure they didn't burn their clothes, kept the pack of cigarettes in their pockets or locked up when not in use. To ensure safe smoking practices, the expectation for staff was to look at the smoke shack and the residents each time they walked by the windows in the hallway or dining room. When asked if there were any residents that had a history of [REDACTED]. Infractions served each time residents smoked unsafely. Staff JJJ stated that the facility was attempting to go non-smoking. Staff JJJ stated that Resident #103 readmitted after the smoking policy changed. Resident #103 agreed to be a non-smoker in order to be admitted . Staff JJJ stated that Resident #103 had been seen several times smoking, infractions were written several times, but he continued to smoke. Staff JJJ stated the resident stated he didn't care and he won't stop smoking. Staff JJJ stated that each time staff saw him smoke, they wrote an infraction. The surveyor informed Staff JJJ Resident #103 was recently seen outside smoking, and neither Staff JJJ nor Staff R were aware. Observation on 03/23/17 at 12:31 PM, Resident #30 actively smoked in the smoke shack alone. The resident had a long beard and wore a cowboy hat. Observation on 03/23/17 at 2:12 PM, Resident #19 sat alone in the smoke shack, smoking, while the fire drill alarms sounded. During an interview on 3/23/17 at 5:49 PM, when asked about e-cigarette smoking, Resident #19 said I have been out there late and I typically go to bed around 1:00 AM. The dining room (Crow's Nest) gets lock at 10:00 PM. Additionally, he offered that last month he had a seizure. During an interview on 03/23/17 at 7:27 PM, Resident #19 and Resident #30 stated that there were not enough lights surrounding the smoking area to judge the terrain (to walk from building to smoke shack), and not enough heat for cold days and nights. Both residents stated they had smoked alone and at night. Resident #30 stated that it was kind of scary in the smoking area at night. Resident #19 repeated the story about when he had a seizure outside and Resident #30 went for help. If it weren't for (Resident #30), I don't' know what I would have done. None of the residents observed wore smoking aprons while smoking. When asked if Resident #19 and Resident #30 were aware how to use the fire blanket, both residents stated they would use the directions on the front of the package. When asked if they knew how to use the fire extinguisher, both residents agreed and pointed to the extinguisher on the outside of the shack. The extinguisher was located on the outside of the shack, and not in an accessible location to residents who smoked inside the shack. Observation on 03/23/17 at 9:00 PM, lights from inside the building dimly illuminated the uneven concrete on the left side of the door that opened to the courtyard and smoke shack. Two dim light bulbs located in the extension of the roof on the right side of the door that entered the court yard to the smoke shack left a dark area on the ground that led to the smoke shack. A single, solar bulb inside the smoke shack occasionally flickered. RESIDENT #19 Resident #19 readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS, a required assessment tool,) dated 03/14/17, indicated the resident had moderate to severe cognitive impairments. A Smoking assessment dated [DATE] recorded a score of 6 that was corrected to 9. Scores of 8 or above in the smoking assessment identified residents were not safe to smoke unsupervised. An undated Care Directive showed goals important to the resident: enjoyed smoking with the other residents. The directive showed to supervise smoking with regular cigarettes, discontinued by the Staff D on 03/30/17 and could be independent with electronic cigarettes only. The directive indicated to notify LN if observed smoking in smoke shack. SAFE TO SMOKE E-CIGARETTES ONLY. Smoking Infraction Notices in Resident #19's record showed the following: -On 5/31/16 Resident #19 was observed providing smoking material to other residents. -On 7/27/16, Resident #19 was observed to have burn holes in his pants and was found sleeping in the smoke shack with a lit cigarette. Infraction notices showed on the dates of, 08/01/16, 08/10/16, 08/11/16 and 09/09/16, staff found Resident #19 smoking regular cigarettes instead of E-cigarettes. A smoking document dated October 7 (no year identified), Staff M, Social Services Assistant (SSA), witnessed Resident #19 in the smoking shelter receiving a cigarette from Resident #30, who lit the cigarette and began to smoke. An infraction notice dated 09/11/16, showed the resident was seen by an aide in the smoke shack smoking a brown cigarette. When staff approached Resident #19, he refused to give up his cigarettes and lighter. A nursing progress note dated 03/15/17, showed Resident #19 had a blister on the third finger of the right hand. The blister measured 1.1 cm x 0.9 cm. During an interview on 03/23/17 at 8:45 PM, when asked What happened, Staff NN, Licensed Nurse (LN) stated, I think he burned it (finger) with a cigarette. Observation on 03/23/17 at 8:55 PM, Resident #19 sat in his wheelchair in the smoking shack. When asked about his finger, the resident stated he did not want to discuss the incident and declined the surveyor's request to visualize the wound. The resident stated, It's healing. Record review of documents titled, Smoking Assessment, and Resident Smoking Agreement, dated 03/29/17 and 03/30/17, Resident #19 was assessed as A responsible, Independent E-cigarette user, due to repeated smoking infractions. On 03/30/17, Staff D updated the Care Directive to include the resident was placed on 15 minute checks when in the smoking shed to ensure was not using regular cigarettes. Observation on 03/23/17 at 9:52 AM, the surveyor observed Resident #19 throw a cigarette on the ground when approaching the smoke shack. Staff failed to provide ongoing supervision to ensure the resident smoked safely. The facility did not adjust level of supervision to ensure the safety of the resident while smoking, until surveyor observation and inquiries. On 04/03/17 at 3:52 PM, Staff D, Interim Director of Nursing (IDNS), stated that Resident #19 was placed on one to one observation at the smoking shack and had been asking other residents for smoking equipment. Staff D stated, He currently is out of his e-cigarettes. Staff D stated the resident wanted to use the e-cigarettes. When placed on 15 minute checks, Staff D stated that, the resident said he did not want to stay at this facility and would like to be transferred to another facility that would let him smoke. RESIDENT #30 Record review of a Quarterly MDS dated [DATE] showed Resident #30 readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed the resident was alert and oriented to person, place, time and situation, had mild short term memory loss, impaired balance, decreased endurance, pain and weakness. Record review of care plan dated 02/09/17 showed Resident #30's ability to complete activities of daily living fluctuated due to pain, alteration in mood or weakness. The care plan identified the resident as a fall risk with a history of falls and directed staff to notify the licensed nurse when the resident was observed nodding off. A Care Conference Summary dated 05/26/16 showed, (Resident #30) not safe with regular cigarettes. Exploring different types. Wants to be independent. Notes showed the resident was required to smoke e-cigarettes only. During observation on 03/23/17 at 9:52 AM, Resident #30 had a long, untrimmed beard, approximately two inches in length. The resident smoked a regular cigarette in the smoke shack and sat next to Resident #19, who threw a lit cigarette on the ground. Resident #30's medical record contained a document titled, Smoking Infraction, a smoking violation for providing a cigarette to Resident #19 on 10/07/16, who was required to only smoke e-cigarettes for safety reasons. Record review of a Smoking assessment dated [DATE], showed resident scored a three, which indicated a low risk/safe smoker, due to medication prescribed that may cause drowsiness. The smoking assessment did not identify and accurately reflect all risks to ensure safety while smoking that included previous history of smoking infractions or impact of diagnoses. On 03/24/17, Resident #30 was issued an additional Smoking Infraction for again providing a cigarette to Resident #19, an unsafe smoker. Resident #30 had a history of [REDACTED]. The facility did not conduct further assessments or implement interventions to prevent reoccurrence of infractions. RESIDENT #48 Record review of a Quarterly MDS dated [DATE] showed Resident #48 admitted to the facility with [DIAGNOSES REDACTED]. The resident exhibited short term memory loss, required assistance for dressing, hygiene, bathing, transfers, and a manual wheelchair for mobility. Review of a Care Plan dated 01/16/17, showed Resident #48 had a high risk for falls and sustained a fall on 01/17/17 in the bathroom. The care plan showed the resident's functional status may fluctuate due to dialysis and the resident was at risk for injuries related to impaired safety awareness and judgement. The care plan directed staff to provide cues to only propel short distances, and to not cross busy roads when outside. Review of an undated Care Directive showed Resident #48 smoked independently, and often smoked outside by the Commissary and Maintenance or Roosevelt smoking areas. During an interview on 03/23/17 at 7:20 PM, Staff FFF, Registered Nurse Supervisor (RN3) could not locate the resident's smoking assessment in the medical record. Observation on 04/05/17 at 8:31 AM, Resident #48 had a beard and propelled his wheelchair from the covered area located at the Barracks, across the street toward the nursing facility. The covered area led from the Barracks smoking area. No staff were seen at that time. Several minutes later, Staff F arrived and pushed Resident #48's wheelchair up the ramp back into the nursing facility. In an interview on 04/05/17 at 8:50 AM, Staff F, Registered Nurse, Investigative Nurse (RN-IN), stated Resident #48 just asked for a ride up the ramp, and was not aware and did not ask where the resident had been. When asked if Resident #48 smoked at the Barracks Assisted Living Smoke Shack, Staff F, RN-IN, stated that the resident used to live there, visited frequently and smoked there. When asked to clarify the designated smoking area for the nursing facility, Staff F, stated, the smoke shack out back. Staff R, Licensed Nurse (LN), also present stated that Resident #48 tootled around all the time. During the same interview, when asked if Resident #48 was a fall risk, Staff F, RN, stated no and had not fallen during the past two years. This contradicted the resident's care plan which showed the resident had a fall on 01/17/17, and was a fall risk. In an interview on 04/05/17 at 8:55 AM, Staff C, Interim Superintendent (IS), was informed of the above incident. Staff C stated that the only designated smoking area for the facility was the shack off of the Crow's Nest Dining Room. Additionally, Staff C stated that education would be needed for all individuals involved, including staff. Observation on 04/05/17 at 1:03 PM, Resident #48 self-propelled his wheelchair out the front door of the facility, crossed the street to the breezeway, and self-propelled down the sidewalk that ran behind the dining hall. The resident then crossed the street back to facility grounds, propelled up the side walk near the administrative office wing of the facility, back down to the street, across the street, and into the designated staff smoking structure. Resident #48 then removed a cigarette from his coat pocket, lit the cigarette, and began smoking. The resident then left the staff smoking structure, self-propelled his wheelchair with a cigarette in his mouth. The surveyor entered the front door of facility and alerted staff. Staff QQQ, Facility Plant Manager, greeted Resident #48, and attempted to redirect. During an interview on 04/05/17 at 2:20 PM, in response to the report, Staff TTT, Registered Nurse, Investigative Nurse for another facility (RN), stated that she observed Resident #48 with what appeared to be a burn hole in his pants. The facility did not provide evidence staff conducted a comprehensive assessment to determine if Resident #48 was safe to smoke unsupervised, although staff reported concerning behaviors of not smoking in designated smoking area. In interview on 04/05/17 at 4:30 PM, Staff E, Deputy Director (DD), stated Resident #48 was placed on one to one (1:1) after the incident. RESIDENT # 62 Resident #62 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of the resident's undated care directive listed Resident #62 as an independent smoker as of 06/27/14. The facility Alert Charting Record documented Resident #62 had a fall with a laceration charted 11/04/16. A fall assessment dated [DATE] identified the resident had a moderate risks for falls. Review of the nursing progress note showed staff communication identified the resident was less able to be independent with self-care and required more assistance. A smoking assessment dated [DATE] showed a score of 0, indicating a low risk-safe smoker. The assessment did not address if or how Resident #62's recent fall impacted safety considerations for smoking. Follow-up smoking assessments performed on 03/27/17, 03/29/17 and 03/30/17, concluded the resident could smoke independently. Documentation on the 03/29/17 and 03/30/17 smoking assessments recorded the resident's frustration with the ongoing assessment process and declined to sign the form. Staff documented Resident # 62 stated, I've done this four times already, I'm not doing anymore. On 3/23/17 at 2:38 PM Resident #62 approached this surveyor and started conversation about smoking. He voiced concerns regarding the possibility of making the building a non-smoking facility, stating they (residents) need a smoking site on campus, it is a human right. Resident #62 further stated, Two residents said they were told if caught smoking would have to leave. They took away assisted smoking last year. People have a right to smoke, some patches don't work. RESIDENT #93 Record review of 12/22/16 Quarterly MDS, showed Resident #93 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented, exhibited short term memory loss, required assistance for bed mobility, transfers, dressing, toileting, grooming and bathing. Record review of an undated care directive showed the resident was a fall risk, had communication deficits which required staff to anticipate needs, and needed additional time allowed to process information. The resident was at risk for falls due to use of psychotropic and narcotic medications, impaired cognition, required cues/supervision for safety, should not lean too far back or forward in his wheelchair, and to wear proper footwear. Resident #93 occasionally required the use of oxygen for respiratory distress. Record review of a smoking assessment dated [DATE], showed Resident #93 scored a 12, which indicated a high risk for injuries and was not determined safe to smoke independently. Record review of Smoking Infractions reports, showed Resident #93 had a history of [REDACTED].#93 purchased cigarettes from an unknown source, and had a history of resident to resident altercations. A smoking assessment dated [DATE], the resident scored a 7, which indicated he was an independent smoker, needed to be monitored for one week, then required reassessment. During an interview on 03/23/17 at 7:10 PM, Staff NN, a Licensed Nurse (LN), stated Resident #93 was not terribly compliant. Staff did not like it when he smoked, and did not smoke in the designated areas, despite reminders to stay in the smoke shack. Resident #93 was bad about borrowing smokes. Sometimes, staff found burn holes in his clothing, which he was then made a non-smoker. Staff NN stated that the smoking assessment indicated residents had to demonstrate they could light their own cigarette, safely dispose of the remains and use proper receptacle. Resident #93 was observed putting the lit cigarette butt in his pocket. Staff NN was not aware how often the smoking evaluations were reviewed. When there was an issue, the status was reviewed and changed if needed. The smoking assessment conducted on 03/23/17 did not address serious safety concerns such as finding burn holes in Resident #93's clothing and not consistently smoking in the designated smoking area. The assessment was not consistently scored or accurate, did not identify all potential risk factors including diagnoses, medications, and history, to ensure the resident was safe while smoking. RESIDENT #103 Record review of 01/13/17 Admission MDS, revealed Resident #103 was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed the resident was alert and oriented, had short term memory loss and required cues and supervision for safety. The MDS also showed Resident #103 required assistance for transfers, bed mobility, toileting and long distance mobility, was a high fall risk, and required use of a lift when fatigued. Record review of the front of Resident #103's medical chart, showed a note was taped to it stating, Give infraction each time seen smoking, per Staff A and Staff B. Record review of the February 2017 Medication Administration Record (MAR) showed Resident #103 received a prescribed antidepressant, and recently started a mood stabilizer. Additionally, the resident had an order for [REDACTED]. The patch was discontinued on 03/14/17 due to non-use. Record review of nursing progress notes dated 1/14/17, 02/26/17, 03/06/17, 03/07/17, 03/08/17, 03/09/17, and 03/13/17 documented Resident #103 had been observed smoking outside. Record review of document titled, Notice of Infraction- Smoking, dated 1/23/17, showed the resident was observed smoking in a non-designated smoking area. Review of Infractions dated 2/2/17, 2/7/17, 2/10/17, 2/14/17, 2/16/17, and 2/17/17, Resident #103 was observed smoking despite a non-smoking agreement signed on admission. Care directive dated 03/07/17 showed Resident #103 was admitted as non-smoker- notify LN immediately if noted to be smoking. Record review of a Smoking assessment dated [DATE] showed risk factor included medications currently prescribed. The assessment was negative for (did not indicate) cognitive patterns, body control, sensory issues, vision impairment and related [DIAGNOSES REDACTED]. The smoking assessment did not comprehensively assess all risk factors for safe smoking such as history of smoking violations issued. The assessment did not identify or analyze impact of upper and lower extremity weakness, sensory and cognitive impairments. Additionally, the assessment did not include fall risk and history of unsafe smoking attempts. No further reassessments were located. RESIDENT #95 Review of a Quarterly MDS dated [DATE], showed Resident #95 admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS showed the resident exhibited short and long term memory loss with impaired decision making skills, had unsteady balance and required the use of an electric wheelchair for mobility. Review of care plan dated 02/07/17 showed Resident #95 used tobacco products and had no desire to quit. Record review of an updated Smoking assessment dated [DATE], showed Resident #95 was cognitively intact, had no sensory impairments, and did not exhibit side effects of medications. The resident was asked if there was a history of unsafe smoking. Only the resident statement was listed. Additionally, the resident stated how much he smoked, (22 cigarettes a day), and how often (all hours). The assessment did not include fall risk. The resident was deemed safe as an independent smoker. The Smoking assessment did not comprehensively review all risk factors, was incomplete and inaccurate. RESIDENT #89 Record review of 01/02/17 Annual MDS, showed Resident #89 admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS also showed the resident exhibited short term memory loss, complained of difficulty focusing and concentrating, feeling depressed/down, little energy and pleasure to participate in activities of enjoyment, sleep disturbance, and rejected cares at times. Resident #89 required assistance for hygiene, transfers due to unsteady balance, dressing and used a wheelchair for mobility. Record review of care plan dated 09/09/16 showed Resident #89 had poor activity tolerance, was a fall risk, had a severe depression score, use of psychotropic and narcotic medication, pain, use of blood thinners, seizure disorder, and use of tobacco products with no desire to quit. Record review of document titled, Smoking Assessment, dated 05/18/16, showed the assessment was incomplete and inaccurately reflected the resident and history. [DIAGNOSES REDACTED]. All other questions were negative. Fall risk and history of unsafe smoking practices were not included in the assessment. Resident #89's record did not contain a current reassessment that addressed all current risk factors for Resident #89's ability to smoke safely. FACILITY EXIT DOORS AND DOOR ALARMS Record review of the facility Nursing Protocol dated effective 12/26/16 and titled SNF Security Procedure showed the following: -Daily at 2200 (10:00PM) the Evening shift supervisor will direct nursing staff to lock and alarm all exit doors with exception of main entrance door to Nursing Facility. -Once all doors are locked the alarm panel will be verified to show electronic monitoring is energized. -Daily at 0800 (8:00 AM) the Day shift supervisor will direct nursing staff to disarm and unlock all exit doors. Duties identified included: -Upon hearing a door alarm, staff will identify location and immediately notify staff working in that area and will report status to Shift supervisor. In an interview on 03/27/17 at 3:18 PM, Staff QQQ, Facility Plan Manager (FPM), stated he was not aware how many doors the building had, which doors alarmed, which ones locked, and did not have a facility blueprint available because the facility was in a transitioning process to a different system. Staff QQQ stated the doors were routinely checked, but not documented if there was an issue discovered. The alarms on the doors were not routinely checked, but staff let the department know if there was an issue. Staff QQ

Based on observation, interview and record review the facility failed to identify and immediately protect four of five Sampled Residents (#s 8, 17, 29 and 83) who were involved in resident interactions involving inappropriate sexual touching or physical altercations. Multiple staff failed to recognize abuse occurred when Resident #29 demonstrated repeat inappropriate, sexual behaviors toward females. Staff failed to immediately intervene to protect Resident #8 and Resident #17 from inappropriate touching, resulting in physical and psychological harm for both residents. Staff failure to implement interventions to manage repeated sexual behaviors led to a physical altercation between Resident #29 and Resident #83, when Resident #83 intervened to protect Resident #17 from inappropriate touching by Resident #29. This resulted in injury and had the potential to cause psychological harm for Resident #29, when Resident #83 hit him in the face. This failure caused psychological harm for Resident #83 who escalated emotionally and physically and also was hit in the face by Resident #29. Facility failures resulted in determination of Immediate Jeopardy on [DATE]. Immediate Jeopardy was removed on [DATE] included extensive staff training on abuse recognition and procedures to protect residents and one to one supervision for Resident #29 and Resident #8. Findings included . RESIDENT #29 An Admission Minimum Data Set (MDS, required comprehensive assessment tool) dated [DATE], showed Resident #29 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A History and Physical dated [DATE], showed the resident had a mood disorder and a history of alcohol dependence. The MDS showed Resident #29's Brief Interview of Mental Status (BIMS, cognitive assessment) score was 9, indicating the resident had moderate cognitive impairment. The MDS also showed the resident received medication to treat depression. The facility had knowledge that Resident #29 exhibited sexually inappropriate behaviors as evidenced by facility's care plan dated [DATE], and dated later reviewed on [DATE]. The care plan showed Resident #9 had alteration in behavior related to inappropriate sexually oriented comments/actions toward staff and female residents. The care plan goal showed the resident would not be inappropriate with staff and female residents for 90 days. Interventions on the same care plan included to: inform resident that sexually oriented advances/touch/comments were inappropriate and not tolerated and that he may forget and need information repeated to him. Another intervention listed for staff to notify the social worker of any inappropriate touching/comments. An undated aide directive (care plan for nursing aides) also contained interventions, if staff observed Resident #29 make inappropriate oriented comments or touch female staff, to report to licensed nurses. Resident #29 repeatedly demonstrated sexual and physical behaviors towards other female residents; Resident #8 on [DATE], [DATE] and [DATE], and twice toward Resident #17 on [DATE]. RESIDENT #8 An Admission MDS dated [DATE] showed Resident #8 admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated showed the resident used a wheelchair and had a BIMS score of 6, indicating severe cognitive impairment. A facility Care Conference Summary dated [DATE] showed Resident #8 had moderate to advanced dementia and had poor safety awareness. INCIDENTS INVOLVING RESIDENT #29 1. [DATE]: RESIDENT #29 and RESIDENT #8 A Social Service note dated [DATE], written by Staff N, Psychiatric Social Worker, (SW), showed Resident #8 did not object to holding hands at times with Resident #29. The note showed when Staff N asked the resident about other touching staff observed, such as touching her breast, Resident #8 stated that she does not like that type of touching in public. The note stated the resident also did not want that type of touching at all, nor does she want this with anyone as she is (verbalized her age.) The facility later called a report into the State regarding the episode of inappropriate touching occurred on [DATE]. Resident #8's record did not identify staff added any interventions to protect Resident #8 from further unwanted touching when the [DATE] incident occurred. No further incidents of inappropriate touching between residents were observed by the survey team during on site visits. 2. [DATE]: RESIDENT #8 and RESIDENT #13 A nursing progress note written [DATE] at 0:15 AM, showed Resident #8 removed her pants and tried to get into bed with another male resident. The note showed Resident #8 tried to sit down by the head of the other resident. The note showed Resident #8 slapped staff when they attempted to redirect her. Resident #13 did not awaken and slept through the incident. The progress note showed that staff placed Resident #8 on checks every 15 minutes. 3. [DATE]: RESIDENT #29 and RESIDENT #8 During observations on [DATE] at 3:51 p.m., Staff M, Social Service Assistant (SSA), pushed Resident #8 in a wheelchair. Resident #29 asked Staff M to stop. Staff M pushed Resident #8 up to Resident #29, who leaned toward Resident #8 and kissed her with open mouth. Resident #29 said I have not kissed a woman in years. During an interview on [DATE] at 4:06 PM, Staff L, Psychiatric Social Worker (SW), stated that both residents were consenting adults and were able to make their own decisions. Staff L said we monitor for public display of affection and ensure it does not get inappropriate for public viewing. Staff L stated we can't tell residents they can't have a sexual relationship as they are human beings. During the same interview, Staff L stated that because residents displayed poor insight in judgment at times, staff would monitor their interactions together. When asked if either resident had legal decision makers, Staff L stated that Resident #29 was own decision maker but could not speak for Resident #8 because she is not a resident in my direct care. During an interview on [DATE] at 4:36 PM, Staff N (SS), stated that Resident #8 had a power of attorney or a legal decision maker. When asked Staff N about resident's kissing, Staff N stated that I would think we would try to discourage that behavior. Staff N was asked if these residents should be left alone in a room, and stated no because if they were alone there would be no way for her (Resident #8) to ask for assistance in a timely way. During an interview on [DATE] at 4:06 PM, when asked if both residents were able to be alone with each other in their rooms if they chose, Staff L (SW), stated because neither one of them have been deemed by a court to be incapacitated they are able to make their own decisions. Staff L stated that nothing prevented them from being alone and Resident #8 was checked by staff every 15 minutes. A social service note dated [DATE] showed Staff N, SW, contacted Resident #8's power of attorney (POA). The note showed resident's POA stated that she noticed Resident #8 referred to male residents as a prior boyfriend she lived with for [AGE] years, or a deceased husband who passed away [AGE] years ago. The POA did not believe Resident #8 was aware of her actions and did want the resident to engage in physical contact with another male resident, other than hand holding. 4. [DATE]: TWO INCIDENTS INVOLVING RESIDENT #29 AND RESIDENT #17 RESIDENT #17 An Annual MDS dated [DATE] showed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Resident's Diagnosis list showed the resident had delusional disorders. The MDS showed Resident #17 required extensive assistance from one person to mobilize in a wheelchair. Record review of the resident's Care Plan dated [DATE] showed the following intervention: Family/POA (power of attorney) does not want male Resident #29 near Resident #17, within arm's reach if possible due to inappropriate touch. If male resident seen near (resident) move them apart and redirect one to one staffing may be needed for protection. Staff N, SS dated this intervention in the Social Services notes and the Care Directive as starting [DATE]. Surveyors were unable to identify when prior incidents may have occurred. A report called to the State agency by Staff F, Registered Nurse, Investigations (RN), on [DATE], showed Resident #29 inappropriately touched Resident #17 twice on the morning of [DATE]. The first incident was witnessed by Staff ZZZ, Nurse Aide (NAC) and the second by Resident #83. Following two previous incidents on [DATE] and [DATE] of inappropriately touching Resident #8, Resident #29 exhibited two more incidents of inappropriate sexual touching involving Resident #17 on [DATE]. A facility investigation report of the incident that occurred on [DATE], showed Resident #29 inappropriately touched Resident #17 twice on the morning of [DATE]. Undated witness statements by Staff ZZZ, NAC, described, that at 8:00 AM. Resident #29 sat next to Resident #17 by the dining room door. Staff ZZZ stated that Resident #29 placed his hand between Resident #17's thighs in her private area. Staff ZZZ told Resident #29, that is inappropriate, we don't touch other people like this, stopping him immediately. Staff ZZZ moved Resident #17 to an activity area and stated she did not report the incident to anyone and became involved in other duties. Resident #29 entered the activity room and then fondled Resident's #17's breasts. Staff who observed the first incident of inappropriate touching failed to immediately report and protect Resident #17 from inappropriate sexual touching by Resident #29 and further harm. 5. [DATE]: INCIDENT INVOLVING RESIDENT #29 AND RESIDENT #83 A Quarterly MDS dated [DATE] showed Resident # 83 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS showed Resident # 83 had a BIMS of 14, indicating the resident as cognitively intact. A hospital Behavioral Healthcare Report dated [DATE] showed Resident #83 had [MEDICAL CONDITION] from prior war experiences and took medication to help with his mood. An undated aide directive showed Resident #83 may get angry and defensive quickly if he feels he is being challenged. A care plan dated [DATE] titled, Psycho-social well-being; Dementia, agitation, [MEDICAL CONDITION] showed to provide quiet times during periods of increased agitation or restlessness and to encourage Resident #83 to practice energy conservation techniques when anxious. A care plan dated [DATE] titled [MEDICAL CONDITION], Affective Disorder contained a goal for staff to work with the resident to help decrease nightmares, anxiety, stress and phobia caused by [MEDICAL CONDITION]. Review of a facility investigation report for an incident on [DATE] involving Resident #29 and Resident #17, contained a Witness Statement form completed by Resident #83. The resident's statement described he observed Resident #17 in a wheelchair when Resident #29 approached her and blocked her view by moving his wheelchair in front of her. Resident #29 stared at Resident #17. Resident #83 saw Resident #29 had his hand under resident's blanket and his hand on her thigh area and Resident #83 told Resident #29 the lady did not like him doing that. Following that, Resident #29 swung and hit Resident #83 in the face. Resident #83 tried protecting himself by counteracting physically and hit Resident #29 about three times while the other resident put his hands up. Resident #29 was bleeding from impact. The facility investigation dated [DATE] contained Resident #17's response to the situation in a statement that read, He was touching the lady under the blanket. He was molesting her and it was obvious that she did not want that. I got up and told him to stop touching her, and he hit me, so I got him good. An undated witness statement in the report written by Staff G, Registered Nurse (RN) wrote Resident #83 had a scratch on his forehead. A undated witness statement in the report written by Staff L, Psychiatric Social Worker (PSW) wrote, Resident #29 did not have a lot to say following the incident stated he didn't know what happened. Resident #29 told Staff L he was just sitting there and the next thing I know I got punched in the face. Staff L wrote she saw Resident #29 bleeding on the left side of the forehead with some visible swelling. Resident #83, who has a history of [MEDICAL CONDITION], while attempting to protect Resident #17, became involved in an altercation with Resident #29 which had the potential to worsen this resident's symptoms. Failure to ensure staff immediately protected Resident #17, who was cognitively impaired, following the first and earlier incident of inappropriate, sexual touching, allowed Resident #29 to have a second opportunity to repeat inappropriate touching of Resident #17 the second time, resulting in psychological harm for this resident. Failure of staff to identify Resident #29 had escalating inappropriate sexual behaviors and provide interventions and level of supervision necessary to prevent the resident from continuing these behaviors, resulted in harm for Resident #29 when hit in the face during an altercation with Resident #83. 6. [DATE] RESIDENT #29 AND RESIDENT #8 Following two previous incidents known by facility staff that occurred on [DATE] and [DATE] of inappropriately touching Resident #8, and two incidents of inappropriately touching Resident #17 on [DATE], staff failed to implement additional interventions to protect residents and prevent repeated further abuse. Staff did not supervise and prevent Resident #29 from inappropriately, sexually touching Resident #8 during a repeated and later incident on [DATE]. A facility intake report (facility report to the State agency) dated [DATE], showed staff discovered Resident #8 had a bruise to the left breast area. The bruise, light brown in color measured approximately 2.5 cm x 3.5 cm. During an interview on [DATE] at 10:43 AM, Staff BB, Medical Director (MD), explained when he learned about the bruise he decided to do full examination of the resident. A second facility intake report dated [DATE] showed that in between 15 minute checks, staff observed Resident #29 placed his hand over Resident #8's groin area. The facility investigation report for Resident #29, logged [DATE], contained a witness statement written by Staff R, Licensed Nurse (LN)that stated Resident #8 tried to push Resident #29's hand away from her body. Staff R , LN, wrote Resident #8 was upset and told her, I just wanted to give his puppy to my granddaughter. This facility investigation report for this incident on [DATE] stated that staff placed Resident #29 on one to one continuous monitoring. The facility did not Increase monitoring of Resident #29's escalating behaviors until after four episodes of inappropriate touching occurred involving Resident #8 and Resident #17. During an interview on [DATE] at 6:39 PM, Staff D, Interim Director of Nursing (IDNS), could not provide evidence how the facility determined Resident #8 or Resident #29, both with cognitive impairment and dementia, were able to consent to physical contact, sexual in nature. The DNS stated had she known what Resident #29's prior history had been she would have initiated one to one monitoring of the resident earlier. On [DATE], at 9:18 PM, Staff RR, Nursing Assistant (NAC) provided one to one supervision of Resident #29. Staff RR state she thought it was still acceptable for Resident #29 to hold hands and kiss female residents. Staff RR, NAC did not acknowledge an understanding why Resident #29 and Resident #8 could not hold hands while he was on one to one staff monitoring. During an interview on [DATE] at 9:37 PM, Staff EEE, Registered Nurse (RN), stated that Resident #8 and Resident #29 had patient rights and thought staff should not stop them from kissing on the lips because they were boyfriend and girlfriend. Staff EEE, RN stated that if they had physically inappropriate touching of private parts she would separate them since it was in a public place. During a later interview on [DATE] at 6:39 PM, Staff D, Interim Director of Nursing (DNS) stated that Staff M (SSA) should not have allowed the kiss between Resident #29 and Resident #8 (on [DATE]) to happen. Staff D, DNS confirmed Resident #8 had a legal guardian. Licensed staff failed to immediately identify the need to protect Resident #8 and Resident #17 from inappropriate sexual behaviors by Resident #29, until after the fifth incident occurred which resulted in repeated incidents of psychosocial harm for both residents. The facility removed Immediate Jeopardy through extensive staff training on recognition of abuse and resident protection and implemented increased supervision of residents.

Based on observation, interview and record review the governing body failed to ensure the administrator demonstrated effective administration of resources, implemented established facility policies and ensured policies and systems were in place that met the specific needs of the resident population. The governing body failed to provide oversight of the facility's operations and support staffing structure to ensure residents received required care and services for frequency of physician visits, and licensed nursing staff completed assessments within required time frames utilizing the Minimum Data Set (MDS, federally required assessment tool); to address resident safety during smoking activities; safety needs of residents with risks for wandering and elopement; prevention of resident abuse and provision of medically related social services. Failures resulted in harm for Resident (#s 8 and 17) who were not protected from repeat incidents of inappropriate touching; for Resident #83 involved in a resident altercation; for Resident (#s 1, 73, 98 and 102) who experienced harm when not protected from wandering outside in cold weather without supervision; for Resident #26 who fell multiple times without effective changes in interventions and later experienced a fall with fracture; for Resident #25 who did not receive consistent interventions to prevent significant weight loss and for Resident #75 for use of a restraint device. Governing body's failure to provide oversight resulted in Immediate Jeopardies. Findings included . 1) Refer to 42CFR 483.12 F223 Free from Abuse and Neglect. Each resident has the right to be free from abuse, neglect. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff and other residents. Failure to implement measures to prevent abuse resulted in harm for Resident (#s 8, 17 and 83) related to inappropriate touching. Immediate jeopardy was determined on 04/03/17 and removed on 04/04/17 following extensive staff training on abuse recognition and procedures for protecting, notifications and investigating. Additional measures were added for increased supervision of Resident #8 and Resident #17. 2) Refer to 42CFR 483.25(d) F323 Accidents. The facility did not provide an environment that was free from accident hazards over which the facility had control and did not provide adequate supervision to ensure safety with smoking or avoid preventable, avoidable accidents for Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) in the resident smoking area and for Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98,102, 104, 106 and 108) with risks for wandering and/or exited the building without staff knowledge and falls. Exiting the building without staff supervision resulted in harm for Resident (#s 26, 73, 98 and 102). Failures as referenced in F323 represented Immediate Jeopardies for Sampled Residents (#s 19, 30, 48, 62, 89, 93, 95 and 103) related to safety with smoking; and for Sampled Residents (#s 1, 8, 25, 40, 41, 47, 60, 73, 98,102, 104, 106 and 108) for lack of supervision and system in place to ensure resident safety for those who wandered or were at risk for elopement and those with falls. This resulted in harm for Resident (#s 26, 73, 98, and 102). Immediate Jeopardy was determined on 03/23/27 for lack of safety during smoking and removed on 03/27/17 with increased staff monitoring and supervision and addition of an emergency call system and improved lighting in the smoking area. Immediate Jeopardy was determined on 03/27/17 for safety related concerns for failure to supervise residents who left the facility or were at risk for elopement. The facility also failed to ensure they had a system in place to alert staff when residents exited the building. Immediate Jeopardy was remove on 03/28/17 through activation of door alarm system; staff identification of residents at risk for elopement and increased staff monitoring and supervision of residents who wandered and continuous monitoring of exit doors and redirected exits and entrance through the main facility door. 3) Refer to 42CFR 83.12(2)F225 Report/Investigate Abuse and Neglect. The facility failed to report alleged violations or conduct a thorough investigation of all alleged violations for Sampled Residents (#s 1, 8, 17, 19, 21, 26, 29, 52, 73, 75, 79, 98, 99 and 102). The facility did not report abuse, or thoroughly investigate incidents to determine measures were implemented to prevent further incidents which resulted in harm for Resident #8 and Resident #17. 4) Refer to 42CFR 483.40(d) F250 Social Services. Medically related social services were not provided to ensure behavior management and assistance to prevent incidents of inappropriate touching which resulted in harm for Resident #8 and Resident #17. Social services failed to ensure grievances were resolved for Sampled Residents (#s 30, 49, 64, 69, 79 and 92); and Sampled Resident #69 received assistance with a hearing device and implemented an effective behavior management program for Sampled Residents (#s 29, 49 and 75) and ensures Sampled Resident #1 received Pre-Admission and Screening. Substandard Care was identified in the following: 42 CFR 483.12 Freedom from Abuse; 42 CFR 483.12(a)(3)(4)(c)(1)-(4) Investigate/report Allegations/Individuals 42 CFR 483.25(d)(1)(2) Accidents Prevention 42 CFR 483.40 (d) Behavioral Health Services

Based on observation, interview and record review, the facility failed to immediately report, protect and thoroughly investigate incidents of abuse, elopement, falls and injures of unknown origin for 15 of 16 Sampled Residents (#s 1, 8, 17, 19, 21, 26, 29, 52, 73, 75, 79, 98, 99 and 102) who were reviewed for either abuse, elopement, falls or injuries of unknown origin. Failure to report, protect and thoroughly investigate resulted in psychosocial and physical harm for Resident #8 and Resident #17 who experienced repeated unwanted touching; resulted in harm for Resident # 26 who experienced a fracture following multiple falls with decreased physical well-being and quality of life. Findings included . Refer to F 223 for failure to report and investigate incidents. ABUSE RELATED INCIDENTS The facility incident and investigation log did not contain evidence the facility immediately reported the following three incidents when they occurred to Administration or to the State agency within two hours as required. No evidence was found staff protected residents and conducted thorough investigations at the time the following incidents occurred: 1. INCIDENT 03/06/17 11:25 AM A Social Service note dated 03/06/17, written by Staff N, Psychiatric Social Worker, (SW), showed Staff N asked the resident about staff observation of a resident touching her breast, Resident #8 stated that she does not like that type of touching in public. The note stated the resident also did not want that type of touching at all, nor does she want this with anyone as she is (mentioned age.) Facility generated complaint intake report to the State agency showed the facility notified the State of incident that occurred on 03/06/17 on 04/05/17, a month after the incident occurred. The report identified Resident #29 touched Resident #8's breast. 2. INCIDENT 03/22/17 A nursing progress note written 03/22/17 at 12:15 AM, showed Resident #8 removed her pants and tried to get into bed with a male resident who slept. Staff removed the resident when the event occurred. Facility staff did not immediately report the incident to Administration or the State, initiate or complete an investigation. Facility generated State agency complaint intake reports showed the facility did not notify the State of this incident that occurred on 03/22/17 until 04/03/17, thirteen days later. 3. INCIDENT 03/28/17 During observations on 03/28/17 at 3:51 p.m., Staff M, Social Service Assistant (SSA), pushed Resident #8 in a wheelchair and positioned it close to Resident #29. Resident #29 leaned toward Resident #8 and they kissed with open mouths. Staff did not immediately report the incident to Administration or the State agency. State agency complaint intake reports showed the facility did not notify the State of incident that occurred on 03/28/17 until 04/03/17, seven days later. Since incidents of inappropriate touching on 03/06/17 and 03/28/17 were not reported or immediately investigated, the facility did not have opportunity to determine what interventions were necessary to protect residents from further abuse. 4. INCIDENTS 03/30/17 On 03/30/17, the facility contacted the State agency to report Resident #29 inappropriately touched Resident #17 twice that day. A State agency complaint intake follow up report dated 03/30/17 received at 10:30 AM, showed Resident #29 placed his hand between Resident #17's legs and genital area at 8:15 AM that morning. Staff did not report the incident to Administration when it occurred or ensure Resident #17 was immediately protected from further harm. Staff who observed this incident of inappropriate touching moved Resident #17 to a common area and left her. Resident #29 had opportunity to again inappropriately touch the same resident shortly after the first incident. Harm was determined for Resident #8 and Resident #17 ss a result of delayed reporting, protecting and investigation from prior incidents. Incidents on 03/30/17 were Resident #29's third incident of non-consensual inappropriate touching. The facility later contacted the State agency on 04/02/17 at 2:00 PM, to report Resident #29 again inappropriately touched Resident #8. Following this incident, staff placed Resident #29 on one to one monitoring. During an interview on 04/03/17 at 6:39 PM, Staff D, Director of Nursing Services, (DNS), stated that had she known what Resident #29's prior history had been, she would have initiated one to one monitoring of the resident (Resident #29) earlier. RESIDENT #26 FALL WITH FRACTURE Review of a Quarterly Miniimum Data Set (MDS. an assessment tool) dated 11/08/16, showed Resident #26 admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The MDS included an assessment that identified the resident had sever cognitive impairment. Review of incident investigations showed nine sequential falls over a time frame from 10/01/16 through 03/24/17. Eight falls were unwitnessed and one witnessed fall occurred on 10/31/16. Facility incident investigations below showed the following: 1). A facility incident investigation dated 10/01/16 fall at 1:30 AM, showed a non-injury fall from his bed. The investigation did not determine the time Resident #26 was last toileted, instead the incident report box was checked N/A (not applicable). The investigation did not identify if staff placed the mat on floor or how or why the resident moved the floor mat away from the bed and why the resident switches body positions from the head of the bed to the foot of the bed. 2). A facility incident investigation dated 10/03/16 fall at 4:20 AM, showed a non-injury fall from the bed. The investigation did not identify the time staff toileted last Resident #26. A documented staff interview/statement showed that the Resident was found on the floor with his back up against the bed with the bed in the lowest position. 3). A facility incident investigation dated 10/10/16 fall at 12:30 AM, showed a non-injury fall from the bed. The investigation did not determine the time Resident was last toileted and the incident report showed resident not recently toileted. Witness statement on 10/10/16 stated when answering Residents call light, found resident sitting on the floor mat with back against his bed. The investigation did not show how long it took the staff to answer the call light. Investigation was documented as to why the resident switched body positions from the head of the bed to the foot of the bed. 4). A facility incident investigation dated 10/31/16 fall at 5:00 AM, showed a witnessed fall from the wheel chair which resulted in a skin tear to the left hand. Investigation showed that resident #26 stated I don't know, I just slipped out of my chair. The investigation did not determine the time the Resident was last toileted. The witness statement does not clearly identify how the resident fell from the wheel chair. No documented evaluation or assessment of the wheel chair and or of the Roho type cushion (an air filled cushion for the resident to sit on when in the wheel chair) was not conducted to rule out any equipment issues that may have contributed to the fall. Interventions implemented included to remind Resident to keep seat belt on and to sit back his wheel chair. The investigation did not identify how this intervention would have prevented fall or further similar falls. 5). A facility incident investigation dated 11/05/16 showed Resident #26 fell at 12:00 AM from the bed with resulting skin tear to the left elbow. The investigation showed portions of the incident report incomplete and that the resident was found with the bed left in raised position and the floor mat in the middle of the floor. The Resident stated that he slipped out of bed. Resident #26 was found on the floor with blood noted on the wall and on the safety strips on the floor. The investigation did not determine how or why the resident's floor mat was in the middle of the floor and how or why the position of the bed was left up when the care plan indicated to place the high-low bed to be in proper position. 6). A facility incident investigation dated 11/16/16, showed Resident #26 had a fall at 6:45 PM and was found in the bathroom on the floor between his wheel chair and the toilet. The investigation did not identify how the resident got to the bathroom, or if the resident attempted to self-transfer on and off the toilet, or if staff assisted the resident onto the toilet and left him unattended. The investigation showed staff found wheelchair brakes locked, however, the investigation did not indicate if staff locked the wheel chair or if the resident had the cognitive ability to lock the brakes. The incident report did not show if the resident could self-propel the wheel chair to the bathroom without assistance. The investigation did not contain evidence interviews or statements were obtained from staff who provided direct resident care. The investigation showed on 11/22/16, staff discovered the resident had a broken right ankle bone days after the fall. The facility did not contact the State agency the resident had an unwitnessed incident with significant injury. Previous to the fall that resulted in an ankle fracture, the facility did not implement any prior interventions to ensure prevention of further falls from occurred that resulted in harm for Resident #26. 7). A facility incident investigation dated 12/27/16 fall at 12:55 AM, showed Resident #26 fell from the bed and had two skin tears on the right elbow. Investigation showed that Resident #26's progress note on 12/27/16 at 2:00 AM stated Resident was last seen prior to fall at 12:45 AM lying in bed with his head at the foot of the bed, he had turned around in bed as he does frequently. The investigation showed that the head of the bed was at a 90 degree angle and his feet were located at the head of the bed. The bed was in the lowest position with the floor mat in place. No further investigation was conducted as to why the resident switches body positions from the head of the bed to the foot of the bed. No new interventions were implemented or care planed after the fall. 8). A facility incident investigation dated 03/20/17 fall at 5:10 AM, showed Resident #26 had a non-injury fall from the wheel chair with the resident found sitting on the foot rests of his wheel chair. The investigation showed Resident received new medication with in the past seven days from the fall date due to status [REDACTED]. No new interventions were implemented or care planed after the fall. 9). A facility incident investigation dated 03/24/17 fall at 5:45 AM, showed Resident #26 had a fall from his wheel chair with a skin tear noted to left hand. The incident report showed portions of the report not completely filled out. The investigation showed Resident #26 was restless in bed and then transferred to his wheel chair and left unattended. Staff documented statement on 03/24/17 that identified the resident was sitting next to the privacy curtain in his room. After hearing a noise staff stated the resident had pulled the curtain causing the wheel chair to topple forward and was found lying on his side on top of the foot rests. No new interventions were implemented or care planned after this fall. During an interview on 03/31/17 at approximately 12:30pm Staff F, Registered Nurse, Quality Assurance/Investigations (RN) stated that she did not know why Resident #26 did not have the physician notified of postural [MEDICAL CONDITION] (drop in blood pressure while changing positions from laying to sitting) for the fall on 10/01/16 and thought the physician should have been notified. When asked what her expectations for completing incident investigations, Staff F, RN, stated expectations were for investigations to be 100% completed and new interventions identified and care planned after each fall, and appropriate goals put in place. RESIDENT #102 ELOPEMENT WITH FALL Record review of an Admission Minimum Data Set (MDS, a required assessment tool,) dated 11/01/16 showed Resident #102 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident has short term memory loss, required cues and physical assistance of one person for transfers, ambulation (with a walker or wheelchair), toileting and dressing. Record review of the October 2016 Incident and Accident Log showed Resident #102 sustained an unwitnessed fall outside the building, on 10/27/16 at 9:00 AM. Review of the incident report for the fall on 10/27/16, showed Staff X, Registered Nurse (RN), went outside to obtain items from a car and found Resident #102 on the ground outside in the Restorative parking lot, upright against a car, and Velcro seatbelt was dismantled. The resident stated he attempted to follow his granddaughter home, slipped out of his wheelchair and landed on the ground. The incident report showed it rained at the time of the fall, the sidewalk was wet, and the resident was not wearing a coat. A reddened area was discovered to the mid to upper back and the resident denied hitting his head. The investigation further showed Resident #102 was confused, a fall risk and, orthostatic blood pressures (BPs) were out of parameters. This was the resident's second fall within 24 hours. Staff made a referral to the safety committee, pharmacy for review and the physician. Neuros were not performed because the resident denied hitting his head. The investigation findings showed the fall was reasonably related to condition/event, abuse and neglect was ruled out, and the care plan was revised. Fall interventions already in place included 15 minute checks, easy release seatbelt, grab bar, bed against wall, Reacher bar and safety strips. New interventions included assessing for pain, review use of call light and toilet high risk fall patients early before and after meals. The effectiveness of the fall interventions in place were unclear. The investigation did not include the position of the wheelchair, car and resident when he was discovered; how the belt was released; how the resident fell ; the last time staff visualized Resident #102; how long the resident was outside; witness statements to determine if anyone observed the resident exit the building; if the resident followed someone out the door that looked like the family member or was headed to their home or the outside temperature and effects of the resident outside in the rain without a coat. The fall committee's comprehensive analysis of the fall, physician's orders [REDACTED]. On 03/27/17 at 12:50 PM, Staff F, RN, Investigation Nurse, stated the floor nurse would initiate the Resident Occurrence Report. Staff F said she would look at what the follow-up was, including if the physician notification, new physician orders, family notification, if a skin sheet was filled out, and any witness statements. Staff F filled out the story based on the resident statement, did it make sense, and did the resident and witness stories connect, what could be put in place to prevent future occurrences. We are currently working on getting better. Staff F stated Resident #102 was found in the parking log sitting up against a car. The resident denied hitting his head. Resident #102 said he followed someone that looked like his granddaughter outside or was going to find her. Staff F could not recall and did not include in the investigation, when the resident was last seen, if the resident was seen exiting the building, if a door alarm sounded, where the wheelchair was in relation to the resident after the fall, how the resident fall and when the seatbelt was disconnected, how long the resident had been outside, what the doctor's feedback or interventions were when he was notified after the fall, what the cause of the orthostatic BP's and the potential effect it had on the resident or if it contributed to the fall. Staff F investigated the fall and did not address the elopement. It was unclear if the fall could have been prevented without a thorough investigation. The root cause of the investigation was not determined to prevent future falls, elopements, or rule out abuse and neglect. RESIDENT #98 ELOPEMENT WITH FALL Record review of Quarterly MDS dated [DATE] revealed Resident #98 had [DIAGNOSES REDACTED]. The resident required assistance of staff for transfers, dressing, toileting and primary mobility was the use of the wheelchair. Record review of January 2017 Incident Accident Log showed Resident #98 sustained an unwitnessed fall with injury on 01/15/17, at 4:15 AM outside. Review of the incident report for the 01/15/17 fall showed Staff Y found Resident #98 outside, at the end of wing two, wearing a t-shirt, pants and shoes. The resident exited the sliding glass door located in the conference room, and the wheels of the walker got stuck in the tracks of the sliding glass door, which resulted in the fall. He sustained three skin tears to both elbows. The resident denied hitting his head. A referral was made to pharmacy for a medication review, the fall committee for interventions, and maintenance to address the sliding glass door. The resident stated, I was going outside. The last time the resident was seen was at 3:30 a.m. The location and what the resident was doing at the time was not including in the investigation, in addition to witness statements from the assigned aide, Staff Z, and licensed nurse (LN), Staff AA. Resident #98 had been on 15 minute checks, and unaccounted for since 3:30 AM. The fall was concluded reasonably related to the resident's condition and event. Interventions already in place included 15 minute checks for poor safety awareness and high fall risk, safety strips on the floor next to the bed. New interventions put in place after the fall were other special equipment, therapy evaluation, and assess for pain. The investigation did not address if Resident #98 needed to use the bathroom, was hungry or thirsty, why he was using a walker instead of the wheelchair, how long the resident had been outside in the cold, what the weather/temperature was, the elopement risk assessment score. On 03/27/17 at 12:14 PM, Staff F stated Resident #98 was very confused, and was a high risk for falls. The staff last saw the resident at 3:30 AM and provided cares, and was found at 4:30 AM outside on the patio. Staff did not hear him call for help, a door alarm did not sound, but saw the resident on the ground in the corner of their eye. Staff F did not recall if that was a usual time for the resident to be awake, as it was not included in the investigation. The resident had difficulty expressing his needs and wants, and was care planned for staff to anticipate his needs. When asked the results of the therapy evaluation, pharmacy review and fall committee analysis, Staff F stated she did not recall and was not included in the investigation. Though there was a potential for psychological harm, it was not assessed or included in the investigation. Root cause was not identified, the potential for reoccurrence remained, and abuse and neglect were not ruled out. RESIDENT #73 ELOPEMENT WITH FALL Record review of the Quarterly MDS dated [DATE] showed Resident #73 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had unclear speech, had difficulty communicating needs/wants, difficulty understanding others, short and long term memory impairment, and impaired decision making skills. The resident required the use of a wheelchair for mobility, assistance from staff for transfers, dressing and toileting. Record review of the February 2017 Incident and accident Log showed Resident # 73 sustained an unwitnessed fall with injuries, on 02/10/17 at 7:15 PM. Review of the incident report for the 02/10/17 showed the Resident #73 was sitting outside station two in his wheelchair at the end of the ramp. The resident stated his wheels got stuck in the mud. The resident also stated it was getting cold and wet, so he put himself on the sidewalk and scooted his way up the ramp into the building, approximately 15 feet before staff found him. Resident #73 sustained multiple abrasions and skin tears from scooting himself up the ramp on his hands and knees. The incident was determined not a fall, and the incident was unwitnessed. The resident recently had a medication change, which may have contributed to his poor safety awareness. No new interventions were initiated as it was not a fall. No blood sugar was documented at the time he was found. The investigation did not include if the resident had made it to the dining room for dinner, or if he was potentially outside, because the last time seen was not included. Resident #73 was a high risk for falls, exhibited confusion, and required supervision for safety. The investigation did not include if staff were aware that the resident was outside, how long he had been outside. The resident was not wearing a coat at the time he was found. The location of the wheelchair in the mud was not clear, as it was not documented in the investigation. The incident was determined to be equipment related. On 03/27/2017 12:50 PM, Staff F said the door that the resident exited the building was a main entrance for residents and visitors, who exited and entered several times a day, and was not locked until 9:30 PM. Staff F was not certain how long the resident was outside and did not get witness statements to determine the time frame. Staff F was not aware there was a noise on the door as people entered and exited, I must be desensitized to it. Staff F further stated Resident #73 was alert and oriented, independent, and did not require staff to go on appointments with him. Staff F was uncertain of the resident's elopement assessment score, or include the assessment in the investigation. A therapy referral was made, but the outcome, was unknown as it was not included in the investigation. Though the investigation did not include Resident #73's psychosocial well-being from being outside for an undetermined amount of time, the investigation was not comprehensively reviewed to assist with choosing effective interventions. The root cause of the incident was not identified and abuse and neglect was not ruled out. RESIDENT #1 ELOPEMENT Record review of Quarterly MDS dated [DATE], showed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident exhibited short and long term memory loss with impaired judgement, depressive signs and symptoms, required assistance for transfers, dressing, toileting and hygiene, occasionally rejected cares and utilized the wheelchair for a primary means of mobility. Record review of nursing progress notes dated 01/03/17, showed at approximately 8:30 PM, Resident #1 was unable to be located on the facility. An in house search was performed unsuccessfully and 911 contacted. The resident was found by the Administration building at approximately 9:30 PM, and identified was not to be outside alone due to extreme cold and safety concerns. Record review of the January 2017 Incident and Accident Log revealed no incident of elopement recorded. On 04/04/17 5:07 PM, Staff D, DNS, confirmed the elopement was not written up on an incident report or called in to the state agency. For the elopement that occurred on 01/03/17, the investigation was initiated 04/04/17. Record review of the investigation results showed the elopement was substantiated. Staff and DNS failed to recognize the elopement occurred when a missing resident was identified, and failed to report the incident to the state agency as required. RESIDENT# 21 FALL Review of the Quarterly Minimum Data Set (MDS, a required assessment tool,) dated 12/12/2016, showed Resident #21 admitted on [DATE] with multiple [DIAGNOSES REDACTED]. A cognitive assessment showed the resident severely impaired and never/rarely made decisions. During observation and interview on 04/05/17 at 4:27 PM, Resident #21 sat in his wheelchair watching TV with call light within reach. A footrest supported the resident's left leg with no signs of discomfort. When asked questions about comfort or pain, the resident could answer yes or no. Record review of Resident 21's Resident Occurrence Report (investigation) dated 03/10/17, identified the resident had an unwitnessed fall at 4:00 PM. Portions of the incident investigation report were not completed and no staff statements/interviews were conducted. During an interview on 04/05/17 at 8:07 AM, Staff F, Registered Nurse (RN), stated that she could not explain why the incident report was not completed. When asked if the incident report should be completely filled out including staff interviews conducted, Staff F answered yes, and stated that incident reports should be 100% completed and interviews should be conducted. During an interview on 04/05/17 at 8:27 AM, Staff D, Director of Nursing Services (DNS), could not explain why Resident #21's fall did not identify a root cause or why the investigation was not completed. Staff D also stated that expectations were for staff interviews to be conducted and that the incident report should absolutely be completely filled out and interventions care planed. RESIDENT #75 FALLS FALL 10/19/16 Record review of Quarterly MDS dated [DATE], revealed Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident exhibited short and long term memory loss with moderately impaired decision making skills, required assistance from staff to transfer, dressing, eating, toileting and mobility. Resident #75 required the use of a wheelchair for mobility, was a high fall risk, used a Velcro seatbelt to help reduce falls, and staff anticipated the resident's needs/wants. Record review of October 2016 Incident and Accident Log showed Resident #75 sustained an unwitnessed, non-injury fall on 10/19/16 at 2:30 PM. Record review of the investigation for the 10/19/17 fall, showed staff were alerted when Resident #75 was found on the floor in the middle of his room. The wheelchair was located a few feet away. Resident #75 stated, I was trying to get into bed. The call light was not used to notify staff. A neurological assessment was not initiated as there was no evidence of a head injury. The investigation determined the fall was reasonably related to the condition/event, the care plan was followed and abuse and neglect were ruled out. A pharmacy referral was made for a medication review. Interventions already in place included easy release seat belt while in the wheelchair, floor mat by bed when in bed, safety strips at bedside, and visual cues posted to remind the resident to use the call light for assistance. New interventions initiated after the 10/19/16 fall were review of the call light use with the resident and give the resident priority to lay down. The investigation did not include how Resident #75 got in his room, how long he had been in there, the time the resident last ate and was toileted, how long the resident was able to tolerate being up in a wheelchair and if pain was an issue, why the foot rests were removed from the wheelchair and if it potentially contributed to the fall, if the staff or resident released the seatbelt or if the seatbelt remained intact. A pharmacy review report was not included in the investigation. An interview was conducted on 03/30/17 at 5:23 PM, Staff F said she did not know how Resident #75 got to his room, believed he was tired, but the investigation did not explain. When asked the effectiveness of reminding a resident with cognitive impairments to use a call light, Staff F stated, Probably not the most effective intervention, but you have to try. The interventions in place were not evaluated for effectiveness, root cause was not identified, and abuse and neglect was not ruled out. Fall 01/20/17 Record review of January 2017 Incident and Accident Log revealed Resident #75 sustained an unwitnessed fall in his room on 01/20/17 at 2:45 AM. Record review of Incident report for the 01/20/17 fall revealed Resident #75 rolled out of bed and stated he was not certain how it happened. Staff KK discovered the resident on the floor during routine rounds, I just found him like that. The call light was in reach, but was not used. No additional witness statements were obtained to determine the last time the resident was seen, what position he was placed into bed to determine if his positioning was a factor, if the resident was hungry or had pain, last time the resident was changed or toileted, or what Resident #75's routine sleeping patterns were to see if a change had occurred and why. The investigation was determined not preventable, a referral was made to pharmacy for a medication review, and abuse and neglect were ruled out. The investigation did not include the pharmacy report, or how the fall was not preventable. In an interview on 04/03/17 at 4:04 PM, Staff D, DNS, stated, I would want to see exactly the position he was laying in, the last time he was checked and changed, if the resident had pain, time the last pain medication was given, statements from night shift, evening shift when they put him to bed, how he was positioned, to rule out neglect to ensure he was positioned properly, and if he was hungry or thirsty. I would have expected a head to toe skin assessment. Root cause of the fall was not identified, no new interventions were put in place after the fall, and abuse and neglect were not ruled out. RESIDENT #79 FALL Record review of Annual MDS dated [DATE], showed Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert and oriented, required the use of a wheelchair or walker for mobility due to impaired balance, depressive signs and symptoms that included feeling down, felt bad about himself, difficulty sleeping, and had little energy. The resident's mood and behavior worsened from last assessment period. Record review of November 2016 Incident and Accident log revealed Resident #79 sustained a fall at bedside on 11/05/16 at 3:40 AM, and a second fall on 11/15/16. 11/05/16 Fall Review of the incident report for the 11/05/16 fall, showed the resident wheeled himself up to the nurses' station. Upon observation, the resident was bleeding, had a laceration, hematoma and bruise above his right eyebrow, with an additional abrasion to his right temple. Resident #79 stated he did not recall what happened, woke up on the floor, and complained of neck and spine pain and weakness in his extremities. The resident was transported to the emergency department for further evaluation. Resident was diagnosed with [REDACTED]. The investigation reported the resident was wearing pajama pants, t-shirt and flip flop shoes when he self-propelled himself to the nurses' station. Witness statements obtained did not include the last time the resident was observed, what position the resident was in; if he

Based on observation, interview and record review the facility failed to provide social services interventions to protect, report and investigate intimate interactions between residents, monitor and identify psychosocial harm, and address the behaviors for three of five Sampled Residents (#'s 8, 17, & 29) reviewed for abuse. Failure to intervene and address resident needs resulted in psychosocial and physical harm for Resident #8 and Resident #17. Additionally, Social Services failed to ensure missing property and grievances were resolved for six of six Sampled Residents (#s 30, 49, 64, 69, 79, & 92), ensure hearing was evaluated and devices obtained for one of one Sampled Resident (#69), three of six Sampled Residents (#s 29, 49, & 75) were free from unnecessary medications, and a Level I Preadmission and Record Review (PASRR) was accurate and referred for Level II as indicated for one of six Sampled Residents (#49). Failure to ensure Social Services provided services to meet the physical, mental and psychosocial needs of the residents, had the potential to increase frequency and severity of resident behaviors, unidentified needs not being met, further decline in function, decreased quality of life, and/or continued abuse. Findings included . Refer to F223 for failure to immediately report, investigate and prevent further abuse. RESIDENT #8 The 01/30/17 Minimum Data Set (MDS), an assessment tool, showed Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The reisdent had short and long term memory loss, exhibited delusional thoughts and wandered. Record review of the Fall Risk assessment dated [DATE] showed Resident #8 was a high risk for falls. A notation on the form reads: If residents score 10 or above make sure you put safety intervention on the care plan. Record reivew of the document titled, The Elopement Risk Assessments (ELA), dated 03/23/17, resident was a high elopement risk. The assessment stated, Since her admit, (Resident #8), has had wandering episodes. She has gone into other residents rooms, but has not exited the building. She has been placed on alert with checks. Review of Social Service Progress Notes dated 03/23/17, showed Staff N documented, As requested by supervisor, social worker requested referral for transfer to Retsil Dementia Unit. Received response from Retsil that they declined this transfer. Supervisor informed. During the survey period from 3/21/17 through 4/6/17, Resident #8 was observed wandering throughout the building, entering into other residents rooms and exiting the building. On several occasions the resident was observed talking with Resident #29. On 03/28/17 at 3:51 PM, a surveyor observed Staff M pushing Resident #8 in a wheelchair. As Resident #8 approached Resident #29 sitting in his wheelchair in the hallway by Station 2, Resident #8 asked Staff M to stop. Resident #8 leaned in towards Resident #29, and Resident #29 leaned towards Resident #8, and kissed each other (he had his mouth open), on the mouth, when they greeted each other in the hallway. Both residents smiled and then shook hands. In response, Resident #29 stated, I have not kissed a woman in years. Both residents held hands for a while as they talked about warm clothing for the weather. Staff M then wheeled Resident #8 down the hall to another location. In an interview at 4:06 PM, Staff L, Psychiatric Social Worker (PSW), when asked is this a usual occurrence, said Yes, and it is care planed and we respect resident rights to be in a relationship. They are both consenting adults and we monitor displays of public display of affection and ensure that it does not get inappropriate for public viewing. When asked Is it allowed to get physical? Staff M said, We can't tell residents they can't have a sexual relationship as they are human beings. However, should they display physicality in public and we say it is not appropriate and try to cue them to cease inappropriate public behaviors. She denied knowledge of any residents in a sexual relationship in the facility. When asked if the residents were able to be alone with each other in their room, Staff M said, Because neither one of them have be deemed by a court to be incapacitated they are able to make their own decisions. However, because they have displayed poor insight in judgment at times staff monitors their interactions together. Staff M stated there was nothing preventing these residents from being alone, but Resident #8 was on 15 minute checks. If we saw them together alone, we would redirect her to a different location. She also stated when asked about resident POA that Resident #29 was his own decision maker but was unsure about Resident #8 because she was not a resident in my direct care. In an interview on 3/28/17 at 4:36 PM, Staff N, PSW, stated she did not have any knowledge of this type of occurrence between the residents. She said they do talk to each other a lot and sit close to each other doing lunch. When asked if the residents were allowed to kiss, Staff M said I suppose so but I would think we would try to discourage that behavior. She replied when asked if Resident #8 was her own decision maker, I am not sure, I would have to look that up. She does have a power of attorney for healthcare which is her daughter. Staff M said in response to the question, Would it be ok her to be alone with him in a room? I would say no because if they were alone there would be no way for her to ask for assistance in a timely way. If observed, staff would re-direct her out. Staff M said yes when asked if Resident #8 and Resident #29 were in a relationship. She replied when asked, Would it be ok for them to kiss and or to have a sexual relationship? I would have to think about that a little more. Kissing is ok if it was in an appropriate place but if it became more involved kissing with inappropriate touching then we would intervene and redirect. I don't think she truly knows who he really is. Staff M stated she had not talked to Resident #8's daughter about this and did not consider this an incident because Resident # 8 had a BIM's score of 6 and Resident #29 a score of 9. Both scores for the residents, however, indicate moderate to severe cognitive impairment. In Interview on 04/03/17 at 6:39 PM, Staff LLL, RN, CN Station 1, when asked about Resident #8's behaviors said, Yes, am aware of her man seek behaviors, she calls them her husband especially (Resident #29). She stated that she was in love with him. Family was aware of her thinking that he was her husband and they believed she thought she was identifying them to her boyfriends from her past. Resident #29 was placed on one to one (1:1) after he fondled (Resident #8) in her groin area 04/02/17. Police were notified of the incident. He had fondled an additional resident, (Resident #17) on 03/30/17, on the breast, and another resident got involved (Resident #83), because he felt it was inappropriate for him (Resident #29) to touch her private area. Staff LLL said (Resident # 8) went over there today to see (Resident #29) and was holding his hand. Staff are aware and the 1:1 stayed with them to ensure that they were not inappropriate. Staff LLL denied knowledge of the expectation to keep Resident #29 from other female residents saying, he had not been told that he could not be around other female residents. The resident had a 1:1 that was there to ensure that he was not inappropriate. Record review of the document titled, History and Physical Exam Note, dated 04/03/17, showed documentation of a Blue-green bruise on left upper-inner breast (2.5x 3.5 cm). In interview on 04/03/17 at 6:39 PM Staff E, Deputy Director (DD) and Staff D, Interim Director of Nursing (IDNS) were informed of observation of residents kissing in hallway. Staff D said Somebody said they saw them kissing so I said to find out what was going on. We got in touch with the family, and the daughter stated she only wanted hand holding by her mother. Staff D added that Resident #29 was put on alert for another incident and placed on 1:1 for inappropriate touching. Staff D agreed Staff M should not have allowed the kiss to happen, and no futher contact should occur between the residents following the incident, including holding hands. Staff D stated yes, social services and all other staff need additional training on this issue. In interview on 04/03/17 at 9:18 PM, Staff RR, Nursing Assistant (NAC) and Staff EEE, RN, stated it was appropriate for Resident #8 and Resident #29 to visit and hold hands because he had a 1:1 watching him. Staff EEE said They do have patient rights. I cannot stop them because they are boyfriend and girlfriend, but if they were to get physically inappropriate with touching of private parts, I would separate them because it is in a public place. Both staff stated they did not have any instruction or training related to these residents. Record review of Resident #25's clinical record, showed a social services progress note dated 03/06/17 at 11:25 AM, showed a conversation between Staff N, SW, and Resident #8. The note indicated the resident went to SW office and asked about getting money to buy treats. While the resident was there, Staff N asked the resident about male residents and touching. The note read: PSW also talked to (resident) about a male that she will hold hands with at times. Resident stated that 'yes, she does.' SW asked if she was ok with that and she said 'yes.' PSW asked her about other touching that staff have seen such as touching her breast and she said that she tells him 'No, she does not like that type of touching in public.' She also stated that she does not want that type of touching at all, nor does she want this with anyone as she is in her 90's. She is not interested in going someplace private. We let her know that the resident had asked SW about getting an apartment for himself and her. Resident reported that she does not want anything like that. She said that when the resident touches her breast, she tells him 'no' and that he is respectful of her wishes. In interview on 04/04/17 at 10:20 AM, Staff D was asked if she was aware of Staff N's previous knowledge of inappropriate touching of Resident #8 by Resident #29. She said no. Information was shared regarding the 03/06/17 note written by Staff N. The inappropriate touching and behavior by Resident #29 toward Resident #8 was known to Staff N as indicated in the 03/06/17 social services note. Interventions to prevent further behaviors was not implemented. Had these behaviors been reported and appropriate interventions initiated or attempted the incidents that occurred on 03/22/17, 03/28/17 and 04/02/17 that caused physical and psychological harm to these residents might have been avoided. The inaction on the part of social services prevented residents from being safe in their home. RESIDENT #17 Refer to F223 and F225 for further information about resident history and abuse. An Annual MDS dated [DATE] showed Resident #17 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had long and short term memory loss, impaired judgement and required cues/supervision for safety. Resident #17 required extensive assistance from one person for dressing, toileting, bathing and mobility. Record review of nursing progress notes dated 03/30/17, showed Resident #29 inappropriately touched Resident #17 twice on that morning. Both incidents were witnessed. Record review of investigation for the 03/30/17 incident, showed the staff that observed the first incident of inappropriate touch, failed to immediately report and protect Resident #17 from inappropriate sexual touching by Resident #29 and further harm. Social Services were aware Resident #29 had two previous incidents touching a female resident, and did not address or monitor the behaviors to initiate appropriate interventions to prevent the 03/30/17 occurrences. These incidents caused harm to Resident #17. RESIDENT #69 Refer to F313 for failure to refer for hearing devices. Social Services did not ensure Resident #69, that was hard of hearing, was offered and services were arranged to obtain an evaluation and hearing devices when needed, in addition to evaluating any alteration in psychosocial well-being related to impaired communication, with potential for an increase for social isolation and cognitive decline. RESIDENT #79 Refer to F166 for failure to resolve grievances. Social Services did not ensure the grievance process was a functional system, and that all staff were able to complete a grievance on any concern a resident had at any time. Grievances were to be completed and resolved in a timely manner, and that Resident #79 did not sustain any alteration in psychosocial well-being related to his missing property. RESIDENT #30 Refer to F166 for failure to resolve grievances. Social Services did not ensure the grievance process was a functional system, and all staff were able to complete a grievance on any concern a resident had at any time. Grievances were to be completed and resolved in a timely manner, and that Resident #30 did not sustain any alteration in psychosocial well-being related to his missing property and feeling his belongings were not safe. RESIDENT #64 Refer to F241 and F166 for failure to resolve grievances and maintain privacy Social Services did not ensure a grievance was identified when Resident #47 repeatedly entered Resident #64's room uninvited, handled appropriately, investigated thoroughly and resolved timely. Additionally, Social Services did not assess, evaluate the psychosocial well-being, ensure he was treated with dignity, or provide support to Resident #64 when the problem was identified and continued for almost a year. Resident #49 Refer to F329, F285 and F166 for failure to be free from unnecessary medications, resolve grievances and Preadmission Screen and Resident Review (PASRR) referral. Social Services did not ensure a grievance was identified when Resident #47 repeatedly entered Resident #49's room uninvited, handled appropriately, investigated thoroughly and resolved timely. Additionally, Social Services did not assess, evaluate the psychosocial well-being, ensure he was treated with dignity, or provide support to Resident #49 when the problem was identified and continued for almost a year. Social Services did not ensure Resident #49's behaviors were assessed to identify any unmet needs, revaluated comprehensively, and addressed with effective non-pharmacological interventions prior to medication for treatment. Social Services did not ensure a Level I PASRR was accurate and referred for a Level II evaluation when appropriate, potentially resulting in Resident #49's physical, mental and psychosocial needs not being met. RESIDENT #92 Refer to F 166 for failure to resolve grievances. Social Services did not ensure a grievance was identified, all staff were aware they could complete the report for a resident and the concern was investigated thoroughly to provide effective interventions to meet the needs of Resident #92 when he complained the room was too hot. The resident was not assessed or evaluated for potential alteration in psychosocial well-being when he expressed his discomfort. RESIDENT #29 Refer to F329 and F223 for failure to prevent resident abuse and behavior interventions. Social Services did not evaluate Resident #29's behavior, identify any unmet needs, comprehensively address all behaviors with mental health or counseling services, ensure staff were aware of what behaviors needed to be redirected, how to redirect with effective non-medical interventions and keep Resident #29 and other residents free from abuse. Social Services had knowledge that Resident #29 exhibited sexually inappropriate behaviors as evidenced by facility's care plan dated 08/08/16, 02/02/17, and various social service progress notes. Social Services failed to identify the escalation in in appropriate behaviors and address with appropriate resources including mental health, to redirect, reduce and/or eliminate the behaviors to ensure Resident #26, Resident 17, and Resident #8's safety. Social Services did not identify Resident #29's lack of effective family or support system, his inability to effectively communicate or demonstrate appropriate socialization skills, relationships, and the need for additional resources and support, to include a guardian, to help manage/support his everyday physical, mental and psychosocial needs. RESIDENT #75 See F329 and F221 for restraint use and address behaviors. Social Services did not ensure Resident #49's behaviors were assessed to identify any unmet needs, revaluated comprehensively, and addressed with effective non-pharmacological interventions to include the use of a lap belt, prior to medication or a potential restraint for treatment.

Based on observation, interview and record review the facility failed to timely refer for reassessment when weight loss occurred and consistently implemented interventions and utilize an Interdisciplinary Team (IDT) approach to evaluate if interventions were effective to address significant weight loss for one of four Sampled Residents (#25) reviewed for nutrition. These failures resulted in avoidable weight loss for Resident #25 and constituted harm. Findings included . Resident # 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a fall on 1/17/17 and sustained a fracture to the neck of the right femur with mild displacement and received scheduled and as needed narcotics for pain. She was also on comfort measures. The care plan identified on 1/25/17 the problem of a potential nutrition risk. The goals listed were: will consume >75% of most meals and maintain weight 133-143 pounds. The interventions were to monitor meal consumption and encourage the resident to consume >74% of most meals. Administer dietary supplements as ordered to assure adequate nutrition. Monitor weight as ordered and report significant change in weight to Registered Dietitian (RD) and physician(MD). Monitor diet preferences and offer substitutes of preferred foods. An observation on 3/29/17 at 9:50 AM, found Resident #25 sitting in bed drinking a cup of tea. She said she enjoyed tea. Breakfast was served anytime between 6:25 - 10:00 AM. Another observation on 3/30/17 at 9:44 AM the resident was in bed, the light was off in the room. The breakfast tray was on counter by sink. Visible was a used tea bag, the yogurt and milk had not been eaten. A piece of French toast was visible from underneath the lid. On 4/3/17 at 7:45 AM the resident was sitting on the side of bed with feet dangling off left side. The bed side tray was placed in front of Resident #25 with a bowl of oatmeal, cup of milk, and cup of juice, no tray. When asked what she was eating she said, I don't know, it was just there. The resident was not wearing her dentures. On 4/05/17 at 7:52 AM the breakfast tray was on the bedside table positioned over the bed in front of the resident. She was asleep. The plate was full and no food appeared to have been eaten. On 4/6/17 at 12:29 PM Resident #25 was seen sitting in the Main Rainier dining room during lunch. She was asleep at the table. Several observations during lunch showed her sitting in the same position, not moving, and not eating. No staff were seen attempting to wake the resident or assist her with the meal. Review of the Care Directive (undated) identified the resident's cognitive status to be impaired for memory-short and long term, to anticipate needs, and to cue for daily routine. The Significant Change Minimum Data Set (MDS) a required assessment tool, dated 1/24/17 recorded for meals, the resident required Supervision - oversight, encouragement or cueing and set up help. Undated nursing aide care directive, the guide for aide staff to know how to care for the resident, listed the resident as independent with meals. NUTRITIONAL SUPPLEMENT A Nutritional Assessment for a significant change dated 1/26/17 following Resident #25's fall with a fracture recorded the resident consumed 0-25% of meals, intake of fluid was poor, and reported a meal observation on 1/20/17 by the dietary supervisor of resident with the issue of pocketing food identified. The assessment concluded that the residents' diet was adequate, intake decreased probably due to pain and effects of pain medication, texture was now altered to mechanical soft, and recommended Plus 2 60 ml (milliliters) four times a day. Refer to RD <126>139 as continued weight loss is not desired. Staff TT recommended Plus 2 (calorie, protein supplement). Physician confirmed an order on 1/29/17 to provide the supplement. The January 2017 and February 2017 MAR indicated [REDACTED]. Without identifying amount of supplement consumed, the facility could not determine the effectiveness of the intervention or if alternating the times staff offered the supplement were needed. The facility did not address why Resident #25 refused the supplement for the month of February. Documentation for Plus 2 on the March 2017 MAR indicated [REDACTED].) by mouth 4 x daily at med pass Dx: weight loss (Document amount taken). Review of the order to increase the amount of the Plus 2 to 120 ml recorded on the April 2017 MAR indicated [REDACTED]. She consumed 120 ml for only 5 of the 24 scheduled servings. Documentation of intake on the March 2017 MAR indicated [REDACTED]. Evenings had no intake recorded and bedtime shows only refusals. Dietary note dated 3/28/17, 43 days after the noted weight gain, recorded the residents weight was down to 115.2 lbs., she was sleeping at meal times, and taking only few bites. The Plus 2 to be increased to 120 ml four times a day. MEAL MONITORING Tray monitoring, though listed as an intervention in the care plan on 1/25/17 was not done consistently. The February 2017 Tray Monitor sheet shows four (4) days of missed entries for breakfast with a start date of 2/6/27 for the month. All other entries note room with no intake recorded to know what and amounts of food eaten at breakfast for the month. Only three of these days included staff initials. Lunch monitoring for that same period included missed entries on eleven (11) days. Four (4) days record room, Eight days record amount of food eaten and fluid intake. Dinner monitoring for February showed missed entries on three days. Twelve days recorded room, with eight (8) days of intake recorded. A review of meal monitoring sheets and documentation of intake of Plus 2 on the March 2017 Medication Administration Record [REDACTED]. No documentation or report of notification given about this issue. On 4/06/17 at 12:34 PM the Meal Monitor sheet for March 2017 was requested from medical records. At 12:46 PM Staff HHH, medical records, said the meal monitoring sheets for March 2017 could not be found. The meal monitoring sheet for April 2017 that was on the door inside the resident's room on 4/6/17 could not be found when a copy was requested on 4/10/17. An interview on 3/31/17 at 10:46 AM Staff TT, RD, said the resident was discussed in the meeting that morning for weight loss and added the tracking was inconsistent because some notes were document in the paper chart and some on the computer. It was not easy to find information. Staff TT stated the resident had a fall in January with a fracture and was not surgical candidate. Resident #25, Staff TT said, was being treated with pain medications and positioning. A recent x-ray showed the fracture was not healing, the resident was not eating a lot, and was sleeping a lot and playing with her food rather than eating it. She said had asked Staff BB to assess the resident related to this concern and the nurse was concerned she may be getting too much [MEDICATION NAME] and not eating. Staff TT said Staff BB had increased the Plus 2 this week and added a Multivitamin with Minerals. Measures to prevent significant weight loss did not include assisting the resident with meals in her room, allowing the resident to eat in the assisted dining room where she could be cued to eat instead of sleeping through the meal was not done. A record of the residents intake could not be found for the month of March and the documentation started for the month of April could not be located although it was posted inside the residents room on door on 4/6/17 prior to exiting the facility on 4/7/17. Meal monitoring for February 2017 was incomplete and not conducted as per the 1/27/17 care plan. WEIGHT MONITORING The record contained no evidence the facility used an interdisciplinary approach to discuss the impact of pain medication affecting decreased food intake identified as a concern in the RD assessment on 1/26/17. The RD progress note dated 2/13/17 indicated for staff to refer for less than 120 lbs. The weight record showed on 3/8/17, Resident #25's weight decreased to 117 lbs. No evidence nursing referred or RD assessed the resident when weight decreased below 120 lbs. until 20 days later. Twenty days after residents weight decreased to less than 117 lbs., RD reassessed the resident and recommended to double portion of Plus 2 to 120 ml, four times a day. The next day on 3/29/17 facility weight records showed Resident #25 weighed 113 lbs. The resident weighed 125 lbs. on 2/26/17, approximately one month earlier. Between 2/2/27 and 3/29/17 the resident lost an additional 12 lbs. or 9.6 percent of body weight. PAIN MEDICATION The RD assessment dated [DATE] identified a potential concern with the use of pain medication impacted food intake. Resident record did not contain evidence staff addressed this concern using an interdisciplinary approach. An email written 3/21/17 by Staff TT, RD to the physician, stated, I know there is a very fine line between pain medication working and a person sleeping and I don't know where that line is. I know I don't want her in pain either. She does sleep through her meals and when awake seem to play in her food more than eating it. During an interview on 4/3/17 at 3:43 PM, Staff BB, Medical Director stated The weight meetings were cancelled every week, over and over. The facility failed to care plan to provide supervision and cueing with eating; address refusals of nutritional supplement provided; consistently monitor amount of food eaten or documented amount of supplement consumed to determine if interventions to prevent weight loss.

Based on observation, interview, and record review, the facility failed to ensure one of three Sampled Residents (R#75), reviewed for physical restraints were free from physical restraints. The facility failed to assess and reassess the use of a Velcro seat belt restraint, obtain informed consent, and ensure the restraint was the least restrictive alternative prior to implementation. This failure resulted in psychological harm and restriction of movement, as determined by a reasonable person, when staff repeatedly restrained the resident to his tilt and space wheel chair. Findings included . Record Review of 12/06/17 Quarterly Minimum Data Set (MDS), a required assessment tool, showed Resident #75 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observations various times throughout the day on 03/21/17 at 12:45 PM, 03/22/17 at 12:00 PM, 03/23/17 at 2:00 PM, 03/27/17 at 4:40 PM, 03/28/17 at 1:47 PM, 04/03/17 at 12:57 PM, and 04/05/17 at 11:54 AM, Resident #75 wore a Velcro seatbelt while in his tilt-and-space wheelchair. Observation on 03/21/17 at 11:00 AM and 03/22/17 at 2:15 PM, Resident #75 was sitting in his wheelchair in his room, facing the television. An interview was attempted, but the resident was not interviewable and could not follow directions. During an observation on 04/03/17 at 12:57 PM, Resident #75 sat in his wheelchair in the dining room, and wore a lap belt throughout the meal. When the resident was finished, one staff member released the seatbelt and two staff repositioned the resident in his wheelchair after which the belt was replaced. In an interview on 04/03/17 at 1:07 PM, Staff OO, NAC stated that she had not seen Resident #75 move around in his tilt and space chair. Staff OO stated that the purpose of the belt was for safety, I think. During an observation on 04/05/17 at 11:54 AM, Resident #75 sat in his wheelchair watching television in his room, not visible from the doorway. A Velcro seatbelt was in place across his lap in his wheelchair. When greeted, Resident #75 did not respond and looked down to the ground. In an interview on 03/23/17 at 2:08 PM, Resident #75's family member stated she was not aware the resident wore a lap belt or seat belt while in his wheelchair, and was visibly upset. Record review of a document titled, Informed Consent for Use of Device, dated 05/29/15 showed Resident #75 signed a consent for a Velcro seatbelt. The consent did not clarify if the resident consented or refused to allow the Velcro seat belt. The program was explained as an effort to reduce or use a less restrictive device or to discontinue the use of the device altogether. The documented reason for the seatbelt was for increased falls, which was not an appropriate intervention to prevent falls. The document was as signed by Staff F, Quality Assurance Nurse. Record review of a document titled, Device Assessment, dated 06/30/16, showed the only documentation found in the chart as an assessment for the use of the seatbelt. The assessment indicated the resident required the support of one or more staff to transfer, had poor body positioning, inability to reposition self, had contractures, was hard of hearing and had poor vision, and his condition was unstable and/or was experiencing an acute episode. The condition was not clarified. Fall risk assessment was scored a 30, which indicated a high risk for falls. The effect on the resident was marked, enable, as indicated by a checkmark in a box next to the word. No description was provided. Alternative interventions tried or attempted included, frequent repositioning. The assessment was reviewed on 08/31/16, 09/15/16, 12/06/16, and 01/31/16, as indicated reviewed, and Staff X's, Restorative Aide Supervisor (RAS) signature. The review dates did not include the resident's current response to the device, if the resident could still release the seatbelt when asked, if a less restrictive device was attempted, or ensure staff were applying the device properly. In an interview on 04/05/17 at 10:10 AM, Staff R and Staff JJJ stated Resident #75 had exhibited a significant decline in the last 2-3 months. He did not engage in conversation anymore and did not attempt to reposition himself as he did in the past. In interview on 04/05/17 at 1:19 PM, Staff X, RAS, stated the assessments were completed by Staff X, unless she was not available, then nursing staff would initiate. The assessment would be reviewed quarterly and as needed. It was important to review, for when someone had declined, but may no longer need the device, and may be considered at risk if a device was used. Residents needed the ability to remove safety devices off themselves, in order to benefit them. Staff X added, even if staff monitored the resident's carefully, there was always a chance the resident could become impulsive and remove the device. Staff X stated the device on Resident #75 was not used for staff convenience. Staff X stated the original reason written for the lap belt, increased falls, was not an appropriate reason for the use. Staff X stated the consent was not complete, and was unsure what enable meant under resident response. Staff X stated she was not certain Resident #75 could continue to release his seatbelt, which was considered a restraint. An additional interview was held on 04/05/17 at 1:24 PM, with both Staff X, RAS and Staff DD, MDS Coordinator (MDSC). Staff DD stated Resident #75 used to be able to take his lap belt off. The last time it was observed was approximately three months ago. Staff X stated she had interviewed staff involved in the interdisciplinary team (IDT) about Resident #75's use of the seatbelt on or about 04/05/17. During the interviews, most staff agreed that they had not seen him attempt to get up out of his wheelchair and continued to wear the Velcro seat belt as a restraint for staff convenience to prevent falls. Staff X stated Staff L, Social Services, was the only one not in agreement with the removal because Resident #75 occasionally attempted to get up to go to Resident #8 when he was in the activity room, as the activity room was not well supervised, still not understanding the fact that restraints can not be used as an intervention for fall prevention.

Based on observation, interview and record review it was determined that the facility failed to ensure staff were qualified and trained and demonstrated skills necessary to meet the needs of residents receiving wound care for 4 of 4 Sampled Residents (#s 1, 7, 9 & 10) review for wound care. This failure resulted in Immediate Jeopardy due either failure to prevent pressure ulcers or provide timely and consistent care and treatment. Findings include: Refer to F314 for staff failure to provide care for pressure injuries. QUALIFIED STAFF According to the National Pressure Ulcer Advisory Panel (NPUAP), Position Paper on Staging Pressure Ulcers, RNs are expected to assess the patient's skin, stage the wound and implement an individualized plan of care based on the patient needs. Due to licensed/vocational nurse and state practice act restrictions, wounds that have the appearance of a pressure ulcer should be inspected and described by these nurses. Additionally, the NPUAP supports the education of nurses to be able to accurately identify the anatomical location of a wound and its cause. During an interview on 3/2/17 at 1:05 p.m., Staff D, Medical Director, reported that a few months prior, the facility told nursing staff that LPNs were not to assess and stage pressure ulcers. Staff D stated, the problem with that was, after the LPNs were told not to do the assessments, there was no direction as to how the assessments would get done, and by who. Staff D stated because there was no direction, the weekly wound assessments were either not done, or the measurements from the previous week were just carried forward. During an interview on 3/3/17 at 4:10 p.m., Staff C, Quality Assurance and Investigation Nurse, reported she was not aware of any training related to wound assessment. Staff C also stated floor staff had reported they are not comfortable with the wound/pressure injury assessments. Review of training records with the staff development coordinator revealed, there was no evidence staff had received training related to ulcers since September 2014. The facility had two ulcer related trainings in 2014, one in March and one in September. Review of the class attendance sheets revealed many of the attendees were either nursing assistants or no longer worked in the facility. Review of the March training revealed there were 44 attendees. Further review of the attendees revealed only 9 were licensed nurses. Of the nine, four are nurses assigned to the medication/treatment carts, two that work on day shift and two that work evening shift. Review of the September training revealed there was 12 attendees. Of the 12, seven were licensed staff, four of those seven remain employed; two of those four worked on the medication/treatment carts, one on night shift and one on evening shift. During an interview on 3/7/17 at 11:50 a.m., Staff F, Staff Development, confirmed majority of wound treatments were done during the day shift by the day shift nurses assigned to the medication/treatment carts. Staff F confirmed the majority of day shift medication cart nurses had not attended the training. Staff F reviewed the full time day shift nursing staff and reported the licensed nurses who work the medication treatment carts are Staff V - worked at facility less than 1 year Staff W- worked at facility over one year, but less than 2 Staff X - worked at the facility for 1 week Staff Y- worked at the facility for less than 3 months Staff Z - approximately 1 month Staff N - less than one year. The facility had not provided training related to assessing and staging pressure injuries in almost three years. The facility failed to ensure the staff assigned to assess and stage wounds were trained and qualified. This failure placed residents at risk for decreased quality of wound care. HOW TO MEASURE: Review of the facility policy titled Identifying Skin Issues and Weekly Tracking dated 2/16/16 directed staff to measure the skin condition (length=head-toe, width=side to side) and make a note of the appearance. Observations on 3/1/17 at 12:00 p.m., revealed Staff AA, RN, did an assessment of a pressure wound on Resident #1's lateral hip. Staff AA measured from approximately the 2 o'clock area of the wound across to the 7 o'clock area of the wound, and then measured from the 9 o'clock to 3 o'clock. Staff AA reported his measurements units were 1 cm long by 0.8 cm wide. Staff AA was reminded by the surveyor he actually measured the wound with a ruler in inch increments and the wound measured 1 inch by 0.8 inches. When asked why Staff AA did not measure straight up and down for length he reported he was taught to measure the longest part of the wound that is in vertical plane, and then measure 90 degrees from that line. During an interview on 3/7/17 at 12:30 p.m., Staff S, Nurse Supervisor, reported that she was taught to measure the wound from head to toe (straight up and down) and then shoulder to shoulder. During an interview on 3/1/17 at 1130 a.m., Staff Y, LPN, was asked about her documentation on the weekly skin/wound tracking sheet. It was noted that some measurements were written numbers with cm indicating the measurements were done in centimeters, and some were written with mm indicating measurements were record in millimeters. Staff Y recorded numbers without indication of the unit of measurement. Staff Y reported her measurements were in inches. When asked about the unit of measure for the other documented weekly measurements, Staff Y reported she did not know what the unit of measure was. Staff Y was asked if she could tell be the documentation whether or not the wound was smaller of larger. Staff Y confirmed she did not know based on the documentation. The facility did not have a system in place to ensure staff were using consistent units of measurements, and that staff were measuring the same areas of the wounds. Without these systems in place, there was no reliable way to monitor the wounds progress or decline.

Based on observation, interview and record review it was determined that the facility failed to implement an effective Quality Assurance program that identified and corrected system wide deficiencies in resident care and services related to pressure ulcers, skin assessments and monitoring, implementation of physician orders for wound care, or maintain compliance of similar, previously cited deficiencies. These failures resulted in harm for Resident #1, Resident #7, Resident #9 and Resident #10 and constituted Immediate Jeopardy for all residents in the facility. Findings include: PRESSURE INJURIES Refer to 42CFR 483.25( c), F314: During an interview on 3/3/17 at 12:10 p.m., QA committee members reported they had identified in October 2016 they had an increase in facility acquired pressure ulcers. Staff C, Quality Assurance and Investigation Nurse, reported the facility had implemented a program for new shoes for diabetic residents, new individualized toileting schedules and new briefs with better absorbency. Additionally, Staff A, Administrator, and Staff C reported they had been monitoring the weekly wound assessment records and had identified staff were not consistently monitoring wounds. Staff A stated administration had made repeated attempts to correct and educate staff, however, the deficient practice continued. During an interview with Staff B on 3/2/17 at 12:30 p.m., Staff B, Director of Nursing, reported the facility had identified that the staff was deficient in tracking and assessing wounds each week. Staff B reported staff were counseled, however the practice continued. During an interview on 3/1/17 at 1:00 p.m., Staff D reported he had attempted to work with staff on measurements, however, staff had reported him for picking on them, so he no longer tries to educate staff. During an interview on 3/7/17 at 3/2/17 at 2:30 p.m., Staff S, Nurse Supervisor, reported nursing staff should complete a form title ulcer investigation form whenever there is a new ulcer, but she does not know what staff do with it after they complete it. Additionally, Staff S reported she did not know if staff were actually using the form. During an interview on 3/2/17 at 4:00 p.m., Staff C reported the ulcer investigation form does not go to the QA committee for review. PHYSICIAN ORDERED SKIN ASSESSMENTS AND TREATMENTS Refer to 42CFR 483.25 F309: Resident records indicate staff failed to complete weekly skin assessments and provide treatments as ordered by the physician. Review of previous abbreviated surveys since the last annual survey revealed the facility has received citations in F309 on two separate occasions on 5/24/16 and 9/30/16. Both prior F309 citations were related to failure to complete weekly skin checks and failure to provide treatments as ordered by the physician. During an interview on 3/3/17 at 12:10 p.m., Staff A reported the facility provided education to staff, but the issue has continued. Staff A reported the facility is doing weekly audits and continued to identify lapses in weekly skin assessments and treatments. Staff A stated administration continues to educate, however, the correction is short lived, and they may need to consider something else such as performance evaluation. The QAA committee identified quality deficiencies related to skin care, however, failed to ensure deficient practices were corrected and maintained.

Based on observation, interview and record review it was determined that the facility failed to identify when new wound conditions developed, thoroughly assess and monitor wounds or conduct consistent weekly skin checks for 11 of 11 Sampled Residents (#s 10, 1, 7, 9, 13, 14, 12, 16, 15, 8 & 11) reviewed for weekly treatment orders, including skin assessments. These failures placed residents at risk for delayed identification of new skin alterations, leading to a delay in treatment. Additionally, these failures placed residents at potential risk for decreased quality of care due to not having all prescribed treatments to promote healing of medical conditions. These failures also had the potential for unidentified skin conditions or worsening of skin conditions to occur for all residents. These failures resulted in harm for Resident #10, Resident #9, Resident #7 and Resident #1, all who had wounds that worsened, and constituted Immediate Jeopardy. Findings include: Review of the facility policy titled Identifying Skin Issues and Weekly Tracking dated 12/26/16 revealed directives to staff; -Upon admission and weekly thereafter, residents are to have a complete skin assessment, to identify new and chronic skin issues to ensure that proper treatment is in place to maintain and or resolve skin issues/wounds to provide comfort and decrease incident of infection as well as other complications that may arise. -Weekly on a residents bath day the licensed nurse with the assistance of the Nursing Assistant Certified (NAC), will conduct a thorough assessment of the residents current skin condition. Making note of any new or acute skin issues as well as the state of the chronic issues. -Both the Licensed Nurse as well as the NAC will indicate on the bath flow sheet that they have together assessed the resident's skin. -Upon finding a new or deteriorating chronic skin issue the licensed nurse will: measure the area, make note of the appearance, review the record for contributing factors, call the provider for treatment, complete weekly skin sheet and place on weekly skin tracking form, make a progress note of the area and add to the treatment sheet. -Weekly with skin assessment and tracking the Licensed Nurse will review the treatment in place for each resident and document healing progress. When no change or progress is being made the provider will be notified to obtain a new treatment WEEKLY SKIN ASSESSMENTS During an interview on 3/1/17 at 2:00 p.m., Staff U, NAC, reported, on resident bath days, the nurse will come into the shower room if the resident has a wound. Staff U reported if the resident does not have a chronic skin condition being followed by the nurse, then the nurse does not come into the shower room to complete a skin assessment. Staff U reported if the nursing assistant that is giving the shower finds a new skin condition, they will report it to the assigned licensed nurse, who will then come into the shower room to assess the new skin alteration. During an interview on 3/1/17 at 2:05 p.m., Licensed Staff N, LPN, reported that the licensed nurse should be doing a full skin assessment for each resident weekly, and the assessment is done on bath day. Staff N added, the weekly assessments are not always being done, as sometimes the bath day gets changed, or the assessment may get missed. Staff N stated the assessment definitely should be done if they are following a wound. During an interview on 3/1/17 at 2:30 p.m., Staff U and Staff M, NAC, both shower aides, were asked where they would document the assessment with the nurse that was done each week. Staff U and Staff M both reported they were unaware that shower aides documented skin assessments and did not know where to document the assessment. Nursing staff did not identify they conducted a full head to skin assessment weekly on each resident to ensure they timely identified new skin conditions. Record reviews of 11 Sampled Residents, identified staff failed to conduct consistent weekly skin checks for 10 residents, all except Resident #1. Resident #1's record identified staff conducted weekly skin checks but staff did not identify when a skin abrasion developed into an ulcer. RESIDENT #10 - WOUNDS Refer to F314 for further details. Review of Resident #10's record revealed physician orders dated 12/30/17 (likely meant to be 2016), directing staff to apply duoderm to sacrum, change every three days or if soiled for a [DIAGNOSES REDACTED]. Review of Resident #10's January 2017 Treatment Administration Record (TAR) revealed the dressing had not been changed after 1/21/17. Review of the February 2017 TAR revealed no documentation to support the treatment had been administered at all during the month. The medical record did not contain evidence the resident received dressing change for five continuous weeks. Review of wound measurements on 12/28/16 (two days prior to the new treatment order) revealed the sacral wound was 1.5 cm (centimeters) long, 1.5 cm wide and 1 cm deep. Further review of wound measurements revealed on 1/3/17, the wound increased in size to 2 cm long, 1.3 cm wide and 1.2 cm deep, indicating the wound was both longer and deeper. The wound worsened following 10 days of missed treatment. When reviewed on 3/2/17, the most recent wound measurements documented were obtained on 2/15/17. At this time the wound had increased in size again to 2.5 cm long, 2 cm wide and 1 cm deep, meaning the wound worsened in both length and width. During an interview on 3/1/17 at 10:45 a.m., Staff N, LPN, reported she had completed Resident #10's dressing change and the measurements listed in the record were accurate, confirming the wound increased in size. During an interview on 3/2/17 at 10:40 a.m., Resident #10 reported sometimes he has wound pain. Resident #10 declined to have surveyor observe the wound during dressing change. Staff failed to administer treatment to the wound as ordered by physician and the wound deteriorated, growing in length, width and depth. This failure caused harm to Resident #10. RESIDENT #10 - TREATMENTS Review of Resident #10 January 2017 TAR revealed orders dated 10/20/16 directed staff to do a weekly skin checks. There was no documentation on the TAR to support the skin check had been completed during the month of January. Review of the February 2017 TAR revealed only 2 of the scheduled 4 skin assessments were done. Further review of the January TAR revealed orders dated 10/20/16 to change catheter monthly, with no documentation to support it had been done. Additionally, the January TAR had orders dated 10/20/16 directing staff to change catheter tubing and drainage bag every two weeks. There was no documentation to evidence staff had carried out the orders during the month. Review of the February 2017 TAR revealed orders dated 10/20/16 directing staff to change the SVN (small volume nebulizer) tubing and set up weekly. Only one of the four scheduled changes was documented as being complete during February. During an interview on 3/2/17 at 2:30 p.m., Staff S, Nurse Supervisor, reviewed the TAR and confirmed not changing the SVN tubing placed the resident at increased risk of respiratory infections, and that not changing the catheter and its tubing/bag can potentially place the resident at increased risk for urinary tract infection. Staff S reported facility expectations are that staff complete each task on the TAR and document that it was done. If the treatment was not done, Staff S reported, she expects staff to document why it was not complete. None of the treatment records identified why treatments were not completed. RESIDENT #1 Refer to F314 for further details. Review of Resident #1's TAR revealed directives to staff to complete a weekly skin assessment. The resident's February TAR contained initials of staff each week to indicate they completed weekly skin checks. Observations on 3/1/17 at 12:00 noon, revealed Resident #1 had an open wound on his lateral knee. The wound was round, slightly larger than a silver dollar, with visible muscle tissue exposed. Review of a facility incident investigation indicated Resident #1 was observed on 2/8/17 to have an abrasion on his left lateral knee. During an interview on 3/1/17 at 11:30 a.m., Staff P, Charge Nurse, confirmed Resident #1 did have an abrasion. Staff P explained after the abrasion was noted on 2/8/17, it was not assessed again until 2/20/17 when it had worsened into pressure ulcer. Staff P was asked, since you documented you completed the weekly skin checks, why didn't you notice the resident's wound on the left knee during the assessments documented completed on 2/9/17 and 2/16/17? Staff P reported, the resident did not have a wound skin sheet to direct her to look at the resident's skin. During an interview on 3/2/17 at 6:55 p.m., Staff D, Medical Director, confirmed when he saw the ulcer on 2/20/17 the full thickness (complete loss of skin layers) of skin was gone, and the underlying muscle and tendon were exposed. Failure to monitor the skin alteration weekly led to failure to identify the worsening condition of the wound, thus leading to a full thickness pressure ulcer. The failure resulted in harm to Resident #1. RESIDENT #7 Resident #7 was currently hospitalized for [REDACTED]. Review of Resident #7's medical record revealed he had skin ulcerations on the left calf and left heel and right heel. Review of Resident #7's January TAR revealed orders dated 11/29/16 directing staff to complete weekly skin checks. The January TAR did not have documentation to support a skin check had been completed since 1/17/17 until 2/1/17, meaning there fifteen days passed between skin checks. During an interview on 3/2/17 at 1:05 p.m., Staff D confirmed staff were not monitoring Resident #7's skin or wounds adequately. Staff D reported that a few months prior the facility told nursing staff that LPNs were not to assess and stage pressure ulcers. Staff D stated, the problem with that was, after the LPNs were told not to do the assessments, there was no direction as to how the assessments would get done, and by who. Staff D stated because there was no direction, the weekly wound assessments were either not done, or the measurements from the previous week were just carried forward. Review of Resident #7's nursing skin tracking sheets from 1/24/17 through 2/20/17, the left and right heels and calf ulcer measurements, remained the same each week. According to physician notes, the difference in the measurements over a 12 day period, from 2/8/17 to 2/20/17, indicated the wound on the left heel had increased and the wound on the right heel had more than tripled in size. Resident #7's skin record did not identify the unit of measurement used when staff measured the heel wounds. During an interview on 3/1/17 at 11:30 a.m. , Staff Y, LPN, reported some staff measured wounds in inches, some in centimeters and some in millimeters. Staff Y reviewed the skin records and confirmed it was unclear what actual units were used for measurements documented. Review of Resident #7's admission skin assessment dated [DATE] indicated both great toes were black, non-blanchable. Review of Resident #7's skin tracking sheets revealed no further documentation related to the condition of his toes. During an interview on 3/2/17 at 12:40 p.m., Staff C, Quality Assurance and Investigation Nurse, reported she would have expected to see skin tracking sheets after blackened toes were identified. Although nursing notes consistently documented Resident #7's wound measured the same week to week, physician notes documented the resident's right heel measured 9 mm x 12 mm on 2/8/17. On 2/20/17, the physician documented the right heel measured 30 mm x 43 mm. Notes also identified the left heel wound increased in size during the same time period. RESIDENT #9 Resident #9 admitted to the facility in May 2016. Observations on 3/3/17 at 3:45 p.m., revealed Resident #9 sitting in his wheelchair. Resident #9's feet were both wrapped, however, and there was visible blood tinged drainage soaked into the wrap covering his left foot. Resident #9 complained of pain. Review of Resident #9's care plan revealed he was identified as being at risk for skin breakdown. Further review of the care plan revealed interventions in place to prevent skin breakdown, including; - Assess skin weekly and as needed - Administer treatments per orders Review of Resident #9's Treatment Administration Record (TAR) for January 2016 revealed an order dated 5/24/16 directing staff to complete a weekly skin check. The weekly skin check was documented completed only once during January, on 1/2/17, eight weeks earlier. Review of Resident #9's February 2017 TAR revealed no documentation to support the weekly skin check had been completed, meaning, when reviewed on 2/28/17, the skin check had not been done since 1/2/17. During an interview on 3/2/17 at 1:05 p.m., Staff D reported, Resident #9 was prone to injuring self. During an interview on 3/2/17 at 2:33 p.m., Staff S confirmed by not doing complete skin checks weekly, Resident #9 was at risk for having a skin alteration go unnoticed by staff, therefore resulting in a delay for treatment. Additionally, the January TAR listed a treatment order dated 1/9/17 directing staff to apply [MEDICATION NAME] dressing to a pressure area on Resident #9's right heel. There was no documentation between 1/20/17 and 1/29/17 (ten days) that the dressing change had been done. The same dressing order was also not documented as being done from 2/11/17 until 2/16/17, and was not documented after 2/23/17 on the February 2017 TAR. The January TAR also included an order dated 1/9/17 to check the placement of the heel dressing every shift. The January TAR indicated day shift did not document this as being done 9 times, evening shift did not document it as being done 13 times, and night shift did not document 19 times. The February TAR was reviewed on 2/28/17, and did not contain evidence staff did dressing checks since 1/31/17. During an interview on 3/2/17 at 2:33 p.m., Staff S confirmed not providing treatments as ordered placed residents at risk for worsening condition of the wound. RESIDENT #13 Observations on 3/2/17 at 3:30 p.m., revealed Resident #13 sitting in his wheelchair watching television. Review of Resident #13's January 2017 TAR revealed an order dated 4/28/16 directing staff to complete a weekly skin check. There was no documentation to evidence a skin check had been done during January. During an interview on 3/2/17 at 3:30 p.m., Resident #13 was asked if one of the nursing staff does a skin assessment on his shower days, or if nursing staff complete a head to toe skin assessment weekly. Resident #13 responded, No, and you would think that they should since I have a history of [MEDICAL CONDITION]. RESIDENT #14 Observations on 3/2/17 at 3:20 p.m., revealed Resident #14's right leg appeared reddened and swollen, with flaking skin. Review of Resident #14's January 2017 TAR revealed orders dated 8/5/16 directing staff to complete a weekly skin check. There was no documentation to support the skin check had been completed during the month. Further review of the January TAR revealed directives to staff to apply a medicated shampoo to Resident #14's face, scalp and body two times each week and to leave the treatment on for 5 minutes before rinsing off. Treatment records for January 2017 identified staff did not provide treatment five times. During February 2017, staff did not identify they provided treatments three times. Neither treatment record identified the length of time staff left the treatment on as per instructions indicated in the treatment record. RESIDENT #12 Review of Resident #12's January 2017 TAR revealed orders dated 1/6/17 directing staff to complete a weekly skin assessment. There was no documentation to support the weekly skin check had been done in January. Review of the February 2017 TAR also revealed directives for weekly skin checks had been continued, however, there was no documentation a skin check done during the month. RESIDENT #16 Resident #16 admitted to the facility 1/23/17. Observations on 3/2/17 at 2:20 p.m., revealed Resident #16 lying in bed. Resident #16 had visible dry, flaking, skin around his hair line. Review of Resident #16's February 2017 TAR revealed directives dated 1/23/17 for staff to complete a weekly skin check. The weekly check was documented as being done on 2/2/17 and 2/6/17. There was no skin check after 2/6/17 for the remainder of the month. The February TAR had orders dated 1/23/17 directing staff to apply a medicated shampoo to Resident #16's scalp twice a week. Documentation on the TAR indicated the shampoo was used one time, on 2/1/17, during the entire month. Additionally, the TAR had directives dated 1/23/17 for staff to flush his catheter daily. Resident #16's treatment record during February 2017, contained documentation staff completed only nine catheter flushes during 28 days of the month. RESIDENT #15 Review of Resident #15's record revealed he only had one treatment ordered, weekly skin checks. Review of Resident #15's January 2017 TAR revealed his skin check was completed only two times, on 1/1/17 & on 1/8/17. Review of the February 2017 TAR reveal no documentation to support the skin check had been done during the entire month, indicated Resident #15's skin had not been visualized by nursing staff for more than 7 weeks. RESIDENT #8 Review of Resident #8's January 2017 TAR revealed orders dated 3/23/16 directing staff to complete a skin check weekly. There was no documentation the skin was done during the month. RESIDENT #11 Review of Resident #11's medical record showed he had a stage II pressure injury on his coccyx and excoriation to his buttocks. Review of Resident #11's February 2017 TAR revealed orders dated 10/19/16 directing staff to apply a designated ointment topically to excoriated buttocks/sacrum with every incontinence change. There was no documentation to support the ointment had been applied during the entire month. In addition to the ointment, the February TAR listed orders dated 10/19/17 for mineral oil/petroleum to be applied topically with every incontinence change. There was no documentation on the TAR to support the treatment had be administered during the entire month. Additionally, the February TAR had an order dated 6/3/14 directing staff to apply a medicated lotion to the Resident #11's scalp weekly. Documentation indicated the lotion was applied one time in February, on 2/7/17. The February TAR also directed staff to complete a skin check weekly. There was no documentation to support the skin check had been done after 2/17/17 for the remainder of the month. Furthermore, the February TAR had directives for staff to monitor coccyx/sacrum OA (open area) weekly on bath day until resolved, and monitor shin abrasion every bath day until resolved. Neither of the two skin alterations were documented as being monitored from 2/17/17 through the remainder of the month. Facility staff failed to monitor resident's skin in order to monitor existing skin conditions and to identify new skin alterations. Additionally, staff failed to carry out all treatments as ordered by the physicians. The failures resulted in delayed identification of skin alterations, delayed identification of non-healing skin conditions and therefore, delayed healing, thus causing harm for Resident #1, Resident #7, Resident #9 and Resident #10.

Based on observation, interview and record review, it was determined that the facility failed to ensure residents did not develop pressure ulcers and failed to provide care and treatment for [REDACTED].#s 1, 7, 9 & 10) reviewed for pressure injury. These failures resulted in harm for Resident #1 due to development of an avoidable Stage III pressure ulcer. For Resident #7, Resident #9 and Resident #10, all three residents had worsening of pressure ulcers. The faciilty failed to timely act and self correct a system wide failure related to care and services for prevention, identification, assessment, monitoring and treatment of [REDACTED]. Findings include: Review of the National Pressure Ulcer Advisory Panel, pressure ulcers that reach full thickness, that is stage III or IV, deep tissue injury or those that are unstageable are considered never events; that is they should never happen. During an interview on 3/7/17 at 1:00 p.m., Staff C, Investigation Nurse, reported the facility does not do investigations after a resident develops a pressure ulcer while in the facility. During an interview on 3/7/17 at 12:30 p.m., Staff S, Nurse Supervisor, was asked if charge nurses completed an investigation when a pressure injury was discovered to determine the cause, or if the wound was avoidable. Staff S reported there is a form that should be completed, and presented a form titled Ulcer Investigation Form, however, she did not know if staff were using it. Staff S reported the staff member who identifies a new skin ulceration should complete the form. Staff S stated after the form is complete, she does not know what staff does with it. During an interview on 3/2/17 at 1:05 p.m., Staff D, Medical Director, reported that a few months prior the facility told nursing staff that LPNs were not to assess and stage pressure ulcers. Staff D stated, the problem with that was, after the LPNs were told not to do the assessments, there was no direction as to how the assessments would get done, and by who. Staff D stated because there was no direction, the weekly wound assessments were either not done, or the measurements from the previous week were just carried forward. RESIDENT #1 Review of Resident #1's record revealed he had a stage III pressure ulcer on his left lateral knee. During an interview on 3/1/17 at 11:30 a.m., Staff P, Charge Nurse, reported Resident #1's pressure injury started a small abrasion. Staff P stated she noted the abrasion on 2/8/17 and placed a bandaid on it. Staff P stated she then forgot about the wound until 2/20/17. Review of Resident #1's record revealed no documentation about the abrasion since 2/8/17 until 2/20/17, when the physician saw it and documented the wound was 2 centimeters (cm) long by 3.5 cm wide and .2 cm deep ulceration with necrotic (tissue that is dead and turns black) slough, visible muscle. Blanching [DIAGNOSES REDACTED] (redness on the surrounding skin) that measured 6 cm long by 8 cm wide. The wound was diagnosed as being a stage III pressure ulcer. During an interview on 3/1/17 at 1:00 p.m., Staff D reported the wound was avoidable had it been treated when it was still an abrasion. Review of Resident #1's record revealed the physician treated the wound on 2/20/17 and wrote a new order. Review of Resident #1's Treatment Administration Record (TAR) revealed the physician's treatment was completed on 2/21/17 and added to the record. However, the record identified staff missed the treatments during the next two days, and did not get done again until 2/24/17. Further review of Resident #1's TAR revealed documentation indicating staff had completed a weekly skin assessment on 2/9/17 and again on 2/26/17. There was no documentation to support the staff who completed the skin assessment noticed the wound on Resident #1's left outer knee. Review of Resident #1's care plan revealed he had been identified as being at risk for skin breakdown. Interventions in the care plan to prevent skin breakdown included weekly skin assessments, and providing skin treatments as ordered. Review of Resident #1's record revealed a Device Assessment form dated 5/19/16 and a form titled Assistive Device Checklist (Order Form) dated 8/14/16. Both forms indicated Resident #1 needed a specialty air mattress to prevent skin breakdown. During an interview on 2/28/17 at 9:55 a.m., Staff N, LPN, was asked if she knew how the original abrasion occurred. Staff N reported it was likely due to Resident #1's knee rubbing on the air mattress. During an interview on 3/2/17 at 10:40 a.m., Staff N was asked if she knew what the settings on the air mattress should be set at. Staff N reported the person (outside vendor) who brings in the air mattress sets it up and turns on the bed. Staff do not change the settings. During an interview on 3/2/17 at 10:25 a.m., Staff P reported the air bed settings should be directed in the physician's orders [REDACTED]. During an interview on 3/2/17 at 12:30 p.m., Staff B, Director of Nursing, confirmed the facility policy for air mattresses did not include information regarding the settings. Staff B reported the facility would be contacting the manufacturers of each air mattress. During an interview on 3/2/17 at 1:10 p.m., Staff D was informed of the lack of a system to ensure air mattress are set up correctly. Staff D confirmed the facility should not have a specialty device in use if the staff do not know how to use them. Staff had identified Resident #1 as being at risk for skin breakdown. The facility brought in a specialty air mattress to prevent skin breakdown, however did not get physician orders [REDACTED]. When a skin alteration did occur, staff failed to notify the physician and get orders for treatment of [REDACTED]. Staff did not address the wound for almost 2 weeks. Once the wound was seen by the physician, a treatment was ordered, and that treatment was not provided in a consistent manner. Staff failed to prevent skin breakdown. When skin breakdown did occur, staff failed to notify the physician and treat the wound appropriately. RESIDENT #7 Resident #7 was out of the facility undergoing vascular surgery. Review of Resident #7's record revealed a physician's note dated 2/20/17 which indicated he had bilateral heel pressure ulcers. Review of a physician's note dated 2/8/17 indicated the following: Right heel- 9 mm (millimeters) x 12 mm pressure ulcer with hard black eschar Left heel- 55 mm x 80 mm with hard black eschar Further review indicated the physician saw Resident #7 again on 2/20/17 when the following measurements were taken: Right heel 30 mm x 40 mm, hard black eschar Left heel- 65 mm x 70 mm The difference in the measurements over a 12 day period, from 2/8/17 to 2/20/17, indicated the wound on the left heel had increased and the wound on the right heel had more than tripled in size. During an interview on 3/2/17 at 1:05 p.m., Staff D was asked about why the resident was not seen by the physician during the timeframe when the wound declined. Staff D reported it had come to his attention that staff had been copying the measurements from the previous week instead of doing new measurements for Resident #7. Staff D was asked if Resident #7's wounds had been tracked closer could he have avoided vascular surgery. Staff D reported, Resident #7 may not have avoided the surgery, however, he would have been referred to a specialist much sooner and the wound decline been tracked and reported appropriately. Additionally, Staff D confirmed, although Resident #7 had vascular concerns, the wounds on his heels were pressure related. During an interview on 3/1/17 at 11:30 a.m., Staff Y, LPN, reviewed skin tracking sheet for wounds on Resident #7's left heel, right heel, and left calf. Staff Y was asked about the measurements she documented on 2/15/17. Staff Y confirmed the measurements she documented were two and a half times larger than the previous measurements. Staff Y confirmed she did not notify the physician wounds increased in size after taking the measurements. Staff Y was also asked about the measurements dated 2/19/17 that had lines drawn over them. Staff Y reported she was not sure why she documented the measurements, as she had not actually measured the wounds. During an interview on 3/7/17 at 2:30 p.m., Staff B was asked if an ulcer Investigation Form had been done related to Resident #7's ulcers decline. Staff B stated the ulcer investigation was not done. Staff failed to adequately monitor Resident #7's wounds. The wounds rapidly declined. RESIDENT #10 Review of Resident #10's record revealed a weekly skin record which indicated staff were monitoring a pressure wound on the Resident's right gluteal fold (the area where the top of the thigh meet the buttocks) and a pressure wound on his right heel. Review of Resident #10's TAR an order treat the resident's heel, an order to treat the right ischial wound, and an order to treat the sacrum (the area where the spine meets the buttocks), and an order to treat the right ischial wound. During an interview on 3/1/17 at 10:00 a.m., Staff N reviewed the chart and confirmed there were treatments listed for three different areas, however, there was only documentation of monitoring of two wounds. Staff N confirmed the weekly skin tracking form did not include the sacral wound, and there was no documentation to support the size or depth of the wound. When Resident #10's record was reviewed the following day, on 3/2/17, there was still no skin tracking sheet for the sacral wound. There had not been tracking of the wounds on the heel or the gluteal fold since 2/15/17, more than two weeks prior, and after bringing it to staff attention the day prior. During an interview on 3/2/17 at 1:05 p.m., Staff D reported concerns related to the care of the sacral wound. Staff D stated the wound was almost completely healed, and then went to a stage III ulcer. Review of the skin tracking record for the gluteal fold revealed the wound was a stage IV. The tracking showed there was not measurement/assessment for a 2 week period between 1/10/17 and 1/24/17. The tracking sheet indicated the wound increased in size during that time. During an interview on 3/7/17 at 2:30 p.m., Staff B was asked if an ulcer investigation had been done related to the cause of Resident #10's wounds. Staff B stated the investigation was not done. Staff failed to document and monitor the sacral wound that was nearly healed, and then became a Stage III ulcer. Additionally, staff were not consistently measuring and assessing Resident #10's gluteal and heel ulcer, both of which increased in size and depth. RESIDENT #9 Observations on 3/3/17 at 3:45 p.m., revealed Resident #9 sitting in his wheelchair. Resident #9's feet were both wrapped, however, there was visible blood tinged drainage soaked into the wrap covering his left foot. Resident #9 complained of pain. Review of Resident #9's care plan revealed interventions in place to prevent skin breakdown, including; - Assess skin weekly and as needed - Administer treatments per orders The January TAR listed a treatment order dated 1/9/17 directing staff to apply [MEDICATION NAME] dressing to the pressure area on Resident #9's right heel. There was no documentation between 1/20/17 and 1/29/17 (ten days) that the dressing change had been done. The same dressing order was also not documented as being done from 2/11/17 until 2/16/17, and was not documented after 2/23/17 on the February 2017 TAR. Staff failed to treat pressure injuries as ordered by the physician. Staff treated wounds without a physician's orders [REDACTED]. Staff failed to accurately measure and record wounds. These failures caused avoidable wounds and caused existing wounds to deteriorate.

Based on observation, interview and record review it was determined that the facility failed to ensure the services provided met professional standards of practices for Sampled Residents 10, 1, 7, 9, 13, 14, 12, 16, 15, 8 & 11. Nursing staff failed notify the physician after deterioration of resident wounds for Residents (#s 1, 7 & 9) reviewed for decline in wound condition. Staff failed to implement physician treatment orders for Residents #s 10, 1, 7, 9, 13, 14, 12, 16, 15, 8 & 11. Additionally, facility staff failed to provide care treatment for [REDACTED].#s 1, 7, 10 & 9 reviewed for pressure injury. These failures caused harm for Resident #1, Resident #7 and Resident #10, resulting in immediate jeopardy. Findings include: Refer to F309 and F314 IMPLEMENTING PHYSICIAN TREATMENT ORDERS According to Clinical Nursing Skills, Smith & Duell, sixth edition, page 4, standards of the nurse practice act include administering medications and treatments per the physician's orders [REDACTED].>RESIDENT #10 Resident #10's record revealed physician orders [REDACTED]. Review of Resident #10's January 2017 Treatment Administration Record (TAR) revealed the dressing had not been changed after 1/21/17. Review of the February 2017 TAR revealed no documentation to support the treatment had been administered at all during the month. Review of Resident #10 January 2017 TAR revealed orders dated 10/20/16 directing staff to do a weekly skin check. There was no documentation on the TAR to support the skin check had been completed during the month. Review of the February 2017 TAR revealed only 2 of the scheduled 4 skin assessments were done. Further review of the January TAR revealed orders dated 10/20/16 to change catheter monthly, with no documentation to support it had been done. Additionally, the January TAR had orders dated 10/20/16 directing staff to change exit tubing and drainage bag every two weeks. There was no documentation to evidence staff had carried out the orders during the month. Review of the February 2017 TAR revealed orders dated 10/20/16 directing staff to change the SVN (small volume nebulizer) tubing and set up weekly. Only one of the four scheduled changes was documented as being complete. During an interview on 3/2/17 at 2:30 p.m., Staff S, Nurse Supervisor, reviewed the TAR and confirmed not changing the SVN tubing placed the resident at increased risk of respiratory infections, and that not changing the catheter and its tubing/bag can potentially place the resident at increased risk for urinary tract infection. Staff S reported facility expectations are that staff complete each task on the TAR and document that it was done. If the treatment was not done, Staff S reported, she expects staff to document why it was not complete. RESIDENT #1 Review of a facility investigation dated 2/24/16 revealed Resident #1 had developed a stage III pressure injury to his lateral knee. During an interview on 3/1/17 at 11:30 a.m., Staff P, Charge Nurse, reported she noted Resident #1 had an abrasion on his knee that she covered with a bandaid. Staff P stated she forgot to notify the physician and forgot about the abrasion until 2/20/17 when it had developed into a stage III pressure injury. Staff P provided a treatment without a physician's orders [REDACTED]. Additionally, Staff P failed to monitor the skin alteration. The decline in the wound condition went unnoticed for 12 days. RESIDENT #7 Review of Resident #7's January TAR revealed orders dated 11/29/16 directing staff to complete weekly skin checks. The January TAR did not have documentation to support a skin check had been completed since 1/17/17, meaning there was fifteen days passed before the next skin check on 2/1/17. During an interview on 3/2/17 at 1:05 p.m., Staff D, Medical Director, confirmed staff were not monitoring Resident #7's per care standards. RESIDENT #9 Review of Resident #9's Treatment Administration Record (TAR) for January 2016 revealed an order dated 5/24/16 directing staff to complete a weekly skin check. The weekly skin check was documented one time in January, on 1/2/17, eight weeks prior. Review of Resident #9's February 2017 TAR revealed no documentation to support the weekly skin check had been completed, meaning, when reviewed on 2/28/17, the skin check had not been done since 1/2/17. Additionally, the January TAR listed a treatment order dated 1/9/17 directing staff to apply [MEDICATION NAME] dressing to the pressure area on Resident #9's right heel. There was no documentation between 1/20/17 and 1/29/17 (ten days) that the dressing change had been done. The same dressing order was also not documented as being done from 2/11/17 until 2/16/17, and was not documented after 2/23/17 on the February 2017 TAR. The January TAR also included an order dated 1/9/17 to check the placement of the heel dressing every shift. The January TAR indicated day shift did not document this as being done 9 times, evening shift did not document it as being done 13 times, and night shift did not document 19 times. The February TAR was reviewed on 2/28/17, and revealed the check had not been documented as every being done on all three shifts. RESIDENT #13 Review of Resident #13's January 2017 TAR revealed an order dated 4/28/16 directing staff to complete a weekly skin check. There was no documentation to evidence a skin check had been done in January. RESIDENT #14 Review of Resident #14's January 2017 TAR revealed orders dated 8/5/16 directing staff to complete a weekly skin check. There was no documentation to support the skin check had been completed during the month. RESIDENT #12 Review of Resident #12's January 2017 TAR revealed orders dated 1/6/17 directing staff to complete a weekly skin assessment. There was no documentation to support the weekly skin check had been done in January. Review of the February 2017 TAR also revealed directives for weekly skin checks had been continued, however, there was no documentation a skin check done during the month. The documentation on the TAR indicated the medicated shampoo had only been applied 4 of the 9 scheduled applications for January. Review of the February TAR indicated the medicated shampoo had been administered five of the eight scheduled applications. RESIDENT #16 Review of Resident #16's February 2017 TAR revealed directives dated 1/23/17 for staff to complete a weekly skin check. The weekly check was documented as being done on 2/2/17 and 2/6/17. There was no skin check after 2/6/17 for the remainder of the month. The February TAR had orders dated 1/23/17 directing staff to apply a medicated shampoo to Resident #16's scalp twice a week. Documentation on the TAR indicated the shampoo was used one time during the entire month. Additionally, the TAR had directives dated 1/23/17 for staff to flush his catheter daily. The flush was documented 9 of the 28 days. RESIDENT #15 Review of Resident #15's record revealed he only had one treatment ordered, weekly skin checks. Review of Resident #15's January 2017 TAR revealed his skin check was completed only two times, on 1/1/17 & on 1/8/17. Review of the February 2017 TAR reveal no documentation to support the skin check had been done during the entire month, indicated Resident #15's skin had not been visualized by nursing staff for more than 7 weeks. RESIDENT #8 Review of Resident #8's January 2017 TAR revealed orders dated 3/23/16 directing staff to complete a skin check weekly. There was no documentation the skin was done during the month. RESIDENT #11 Review of Resident #11's February 2017 TAR revealed orders dated 10/19/16 directing staff to apply a designated ointment topically to excoriated buttocks/sacrum with every incontinence change. There was no documentation to support the ointment had been applied during the entire month. In addition to the ointment, the February TAR listed orders dated 10/19/17 for mineral oil/petroleum to be applied topically with every incontinence change. There was no documentation on the TAR to support the treatment had be administered during the entire month. Additionally, the February TAR had an order dated 6/3/14 directing staff to apply a medicated lotion to the Resident #11's scalp weekly. Documentation indicated the lotion was applied one time in February, on 2/7/17. The February TAR also directed staff to complete a skin check weekly. There was no documentation to support the skin check had been done after 2/17/17 for the remainder of the month. Failure to follow orders to complete weekly skin assessments placed residents at risk for delay in identification of skin alterations, therefore, delaying treatments. Failure to administer treatments as ordered placed residents at risk for delayed healing. Administering treatments without a physician's orders [REDACTED]. .

Based on observation, interview and record review, the facility failed to ensure each resident received care and services to prevent skin breakdown; failed to provide treatments as ordered by the physician and failed to complete weekly skin assessments as ordered by the physician and as directed in the care plans for 11 of 11 Sampled Residents (#s 1, 10, 7, 9, 13, 14 12, 16, 15, 8 & 11) reviewed for skin care. This failure resulted in harm for Resident #1, Resident #10 and Resident #7, as evidenced by the increased size and severity of their wounds. Findings include: Refer to F309 related to nursing services for failure to provide care as outlined in the resident's care plan and as ordered by the physician. Review of the facility policy Abuse Reporting dated 1/9/17 revealed the facility definition of neglect is a pattern of conduct or inaction by a person or entity with a duty of care that fails to provide goods and services that maintain physical or mental health of a vulnerable adult; or (b) an act or omission by a person or entity with a duty of care that demonstrates a serious disregard of consequences of such a magnitude as to constitute a clear and present danger to the vulnerable adult's health. RESIDENT #1 Review of a facility investigation dated 2/24/17 revealed on 2/8/17 Staff P, Charge Nurse, identified a skin abrasion on Resident #1's outer knee. Staff P treated the abrasion with a bandaid without an order from the physician. The investigation indicated Staff P did not notify the physician, did not notify the next shift, or other staff and did not document the skin alteration. The investigation indicated the skin abrasion was not treated again until 2/20/17. During an interview on 3/1/17 at 1:10p.m., Staff D, Medical Director, confirmed the wound had not been cared for nearly two weeks when it came to the attention of the physician. Staff D confirmed failure to report the wound, failure to treat the wound added to the wounds deterioration, which did meet the definition of neglect. Staff D reported the resident cannot get treatment if their condition is not reported to the physician. Staff D stated the failure to report Resident #1's condition resulted in his wound not being treated. RESIDENT #10 Review of Resident #10's record revealed staff did not provide care to wounds as ordered by the physician. The resident's wounds increased in size. Additionally, documentation did not support weekly skin assessments were done as outlined in the plan of care. RESIDENT #7 Review of Resident #7's medical record revealed nursing staff fail to monitor his skin and wounds weekly as directed in the plan of care. Resident #7's wound increased in size. RESIDENT #9 Review of Resident #9's record revealed documentation did not support that weekly skin assessments were being done by nursing staff as outlined in the resident's plan of care. Additionally, records indicated the resident's heel was not receiving treatment as ordered by the physician. RESIDENT #13 Review of Resident #13's medical record revealed documentation did not support weekly skin assessments had been done by nursing staff as outlined in the plan of care. RESIDENT #14 Review of Resident #14's medical record revealed nursing staff did not document weekly skin checks were being done, and did not provide treatment as ordered by the physician. RESIDENT #12 Review of Resident #12's medical record revealed there was no documentation to support nursing staff had completed weekly skin checks as outlined in the plan of care. Additionally, documentation did not support nursing staff were providing treatments as ordered by the physician. RESIDENT #16 Review of Resident #16's record revealed documentation did not support weekly skin checks were being done as outlined in the plan of care. Additionally, documentation did not support all treatments were being given as ordered by the physician. RESIDENT #15 Review of Resident #15's record revealed documentation did not support nursing staff had completed weekly skin assessments as outline in the plan of care. RESIDENT #8 Review of Resident #8's medical record revealed documentation did not support nursing staff had completed the weekly skin assessments as outline in the resident's plan of care. RESIDENT #11 Review of Resident #11's record revealed documentation did not support that nursing staff had provided skin treatments as ordered by the physician, had provided medicated shampoo as ordered by the physician, and had not performed skin checks as outlined in the plan of care. Failure of the nursing staff to provide care and services met the facility's definition of neglect.

Based on observation, interview and record review it was determined that the facility failed to notify the physician when there was a change in resident condition for 3 of 4 Sampled Residents (#s 1, 7 & 9) reviewed for decline in wound condition. This failure resulted in a delay in treatment and caused deteriorating wound status and a delay in starting antibiotic treatment for [REDACTED].#1, Resident #7 and Resident #9. Findings include: Review of the facility policy Identifying Skin Issues and Weekly Tracking dated 12/26/16 revealed; -Upon finding a new or deteriorating chronic skin issue the licensed nurse will: call the provider -When no change or progress is being made the provider will be notified to obtain a new treatment if deemed necessary by the provider. RESIDENT #1 Observations on 3/1/17 at 12:00 p.m., revealed a wound on Resident #1's left outer knee. The wound was open for the full thickness of the wound extending to the underlying muscle and tendon. During an interview on 3/2/17 at 1:05 p.m., Staff D, Medical Director, confirmed he was notified of the abrasion, and in fact, he was not notified there had been a skin alteration until 2/20/17, when Resident #1 was diagnosed with [REDACTED]. Staff D confirmed had he been notified when the abrasion was identified on 2/8/17, he would not have ordered the treatment provided by staff. Staff D confirmed the severity of the wound could have been avoided had staff notified him timely so treatment could be started. Failure to notify the physician and get orders for treatment when the abrasion was identified resulted in a wound deep enough to expose the underlying muscle and tendons, harming Resident #1. RESIDENT #7 Resident #7 was out of the facility. Review of Resident #7's medical record revealed skin/wound tracking flow sheets. During an interview on 3/1/17 at 11:30 a.m., Staff Y, LPN, reviewed skin tracking sheet for wounds on Resident #7's left heel, right heel, and left calf. Staff Y was asked about the measurements she documented on 2/15/17. Staff Y confirmed the measurements she documented were two and half times larger than the previous measurements. Staff Y confirmed she did not notify the physician after taking the measurements. During an interview on 3/2/17 at 1:05 p.m., Staff D, Medical Director, reported measurements for the pressure areas on Resident #7's skin tracking sheets were documented from the week before, not actually measured each week. Staff D stated this contributed to the unnoticed increase in size. Staff D stated he was not informed of the increased sized timely. Staff D, Medical Director, was asked if Resident #7's treatment plan would have been changed had he been notified of the increasing wound size. Staff D stated had he been notified earlier, he would have referred Resident #7 to a specialist earlier. Failure not notify the physician of Resident #7's increase in size of wounds resulted in a delay in receiving treatment from a specialist. RESIDENT #9 Observations on 3/3/17 at 3:45 p.m., revealed Resident #9 in wheelchair with dressing covering her left foot. The dressing had red tinged drainage soaked into it over the toe area. Review of Resident #9's record revealed a progress note dated 2/16/17 at 9:00 a.m., indicating staff noted a 1.5 cm x 1 cm scabbed abrasion on left 2nd toes; area cleansed with normal saline and antibiotic ointment and bandaid applied. There was no documentation or evidence the physician had been notified by staff, or that the physician ordered the antibiotic ointment and bandaid. Further review of progress notes revealed a note dated 2/17/17 that indicated the same toe had an open area and redness of the skin around it. The doctor was then notified. During an interview on 3/3/17 at 3:55 p.m., Staff Q, Charge Nurse, confirmed the resident developed an infection in the wound on his left 2nd toe. During an interview on 3/1/17 at 1:00 p.m., Staff D reported he was not aware of the toe injury until it became infected. The failure to notify the physician when the wound developed resulted in a delay in treatment. The wound was not being monitored by the physician and then became infected.

Based on record review and interview, the facility failed to ensure 1 of 6 residents (Former Resident #10) reviewed for change of condition had evidence of ongoing monitoring of the medical condition. The facility failed to provide evidence Resident #10's respiratory status was consistently monitored and actions taken to improve oxygen saturation levels following an initial assessment of respiratory distress with an oxygen saturation level of 74%. This failure resulted in harm to Resident #10 who required intubation by emergency service personnel and hospitalization for further treatment. The facility also failed to ensure necessary care was provided related to provision of an intravenous antibiotic for 1 of 5 residents (#1) reviewed for necessary care and services upon admission to the facility. This failure placed Resident #1 at risk for ineffective treatment of [REDACTED]. Findings include: 1. Record review revealed Resident #10 admitted to the facility during 10/2011 for medical [DIAGNOSES REDACTED]. Review of the record showed the resident had a history of [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of nursing progress notes dated 7/27/12 at 9:15 p.m. showed the resident complained he was having trouble breathing. Oxygen saturation level at that time was 81%; oxygen was administered at 4 liters/minute to keep oxygen saturation levels above 90%. Recorded vital signs included respirations at 30. Review of the resident's baseline respirations for three days prior showed average 18 to 20. The physician was notified and ordered a chest x-ray and a nebulizer breathing treatment. There was no further evidence of monitoring of the resident's medical condition between 9:15 p.m. and 1:20 a.m. at which time Staff F (LPN) noted the resident's oxygen saturation level was 74% after a nebulizer treatment. The note indicated the x-ray showed a left lobe infiltrate and "the resident wanted to go to the hospital"; the physician was notified and agreed. Continued review of nursing progress notes indicated twenty five minutes later at 1:45 a.m. oxygen was increased to 5 liters; oxygen saturation "rebounded to 80%" and "contacted ambulance for transport requesting advanced life support due to resident's condition". There was no further evidence of monitoring the resident and/or vital signs/oxygen saturation levels for the 30 minute period between 1:45 a.m. and 2:15 a.m. when documentation revealed the resident was "getting non-responsive" and ambulance staff was with the resident. Review of the resident's emergency room record dated 7/28/12 revealed reference to emergency service personnel finding Resident #1 "in extremis" (in grave or extreme circumstances) and "tripoding" (struggling to breathe, using accessory chest muscles to breathe).The resident had a breathing tube inserted to assist with breathing and was transported to the hospital. During interview on 8/17/12 at 3:15 p.m., the investigator inquired if there was additional evidence of monitoring of Resident #10 during the resident's respiratory distress. On 8/20/12 the investigator received a statement signed by Staff F which did not provide additional evidence to support ongoing monitoring of Resident #1. 2. Record review revealed Resident #1 admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Review of Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation revealed evidence the resident did not receive the dose scheduled for 6:00 p.m. on 8/6/12 or the doses scheduled for midnight, 6:00 a.m. & noon on 8/7/12. Interview with Staff E (RN) on 8/16/12 at 3:05 p.m. revealed the IV antibiotic was not ordered prior to her ordering it during the evening shift on 8/6/12. Staff E stated the resident did not receive the antibiotic as ordered for 24 hours.